life work safety · 2018. 11. 30. · bethesda healthcare system 6 code red • code red is the...
TRANSCRIPT
Bethesda Healthcare System 1
Life Work Safety
Rev 62018
Bethesda Healthcare System 2
Introduction
Physical Danger Codes
Red Pink Orange Yellow Strong Gamma
MRI Safety
Medical Codes
Blue BEE Team Grey HIT
Incident Reporting
Hazardous Materials
Biomedical Waste
Chemical
Radioactive
Biological
TB
HIVAIDS
Flu Season
MENU
Bethesda Healthcare System 3
Introduction
As soon as a patient enters the hospital we are responsible for their
safety It is a vital part of our business
This CBL will cover basic safety issues that come from potential
sources within the hospital such as fire electrical hazards hazardous
materials etc
The Disaster CBL covers basic safety issues that arise from sources
outside the hospital such as hurricanes major storms biological
attacks and chemical spills
Bethesda Healthcare System 4
General Safety Tips
bull The following general safety tips are reminders to be aware of safety wherever you are
ndash Parking lots
bull watch for cars backing out of parking spots
bull always lock your car
bull do not leave valuables in plain sight in your car
bull have your keys ready when approaching your car and check the back seat before getting in
bull if you feel uncomfortable walking to your car at night call security at BHE ext 84199 or at BHW ext 70160 to escort you
bull In the parking garage DO NOT
ndash walk on the ramp
ndash make a left turn on the ramps
ndash Offices
bull secure valuables out of sight
bull use proper body mechanics when lifting heavy objects
bull open only one file drawer at a time in the same file cabinet
Bethesda Healthcare System 5
General Safety Tips continued
bull Hallways
ndash wipe up small watercoffee spills
ndash pick up trash
ndash be careful rounding corners watch for others
ndash open ldquoblindrdquo doors gently donrsquot crash through
bull Yourself
ndash get enough sleep
ndash concentrate on work while at work
ndash never use illegal or inappropriate drugs
ndash always think of yourself as working within a team
Bethesda Healthcare System 6
CODE RED
bull Code Red is the code for fire If you discover a fire or smoke you must carry out the following steps in their exact order
bull Rescue
bull Activate Alarm
bull Contain Fire
bull Extinguish fire (if safe to do so) or Evacuate
bull If you hear ldquoCode Redrdquo over the hospital paging system you must pause to listen for the location of the fire Then follow your department fire plan
bull If you work at Health City Service Center or the Plaza Click Here for fire procedures
Bethesda Healthcare System 7
1 Rescue
Rescue patientspersons in immediate danger In this initial step
remove the person from the room the fire is in
This is a temporary safety measure It is critical that you get to
the next step (Activate Alarm) as quickly as possible
If you need to progress to the Evacuate step then you must
remove all people in the endangered smoke compartment to the
next smoke compartment on the same floor This is called
horizontal evacuation Removing the patient from a patient room
does not remove the patient from the smoke compartment
Bethesda Healthcare System 8
2 Alarm ndash Pull it Then Call it
bull Pull the nearest alarm To activate the alarm ndash In Bethesda EAST push the handle in and pull it down In Bethesda WEST just pull the handle down Do this as quickly as possible The alarm not only alerts the fire department it also shuts down the air handlers that may be helping to spread the fire
bull Then call the operator at 855 at the East hospital or 755 at the West hospital and report the fire and its location
bull The operator will announce the Code Red then call 911
ndash After office hours (nights weekend and holidays) the operator will also contact the Director of Engineering Asst Director of Engineering and the Administrator on-call
bull When the fire is out the operator will announce ldquoCode Red all clearrdquo three times
bull The Operator will only accept an all clear from a member of the fire response team
Bethesda Healthcare System 9
3 Contain
Contain the firesmoke by closing windows and doors after all
persons are out (remember to check bathrooms)
All other staff in the vicinity of the fire (not involved in the initial
discoveryresponse) are to report to the nursersquos station to
receive assignments closing all doors and windows along
the way and removing all obstacles from the hallways
All staff throughout the hospital will respond by closing all doors
and remaining on the alert for further instructions They
should not enter the fire location unless they are members of
the fire response team
Bethesda Healthcare System 10
4 Extinguish (If safe to do so)
We have many types of fire extinguishers
ABC ndash Marked with an ABC and can be used on all types of fires
Carbon Dioxide ndash used mainly for electrical fires around large pieces of
equipment
Halon Suppression Systems used on sensitive electronic equipment
K Extinguishers ndash Used on grease fires
Water Mist Extinguisher ndash Found in ORLampD best choice for protection
of hospital environments books documents and clean room facilities
To use a fire Extinguisher
P ndash pull the safety pin
A ndash aim the fire extinguisher
S ndash squeeze the handle
S ndash sweep the base of the fire with the spray
Bethesda Healthcare System 11
5 Evacuate
bull Evacuate all persons you are responsible for plus yourself to the next adjacent smoke compartment on the same floor (horizontal evacuation)
bull The charge nurse or designee will prioritize each patientrsquos evacuationcategory
bull Charge nurse or designee ensures that bag valve mask is at bedside of all ventilator dependent patients and oxygen for oxygen dependent patients
bull Staff will be assigned to conduct a methodical room-by-room search accounting for all visitors and leading all patients and visitors to safety A rubber glove will be placed on the doorknobs of all vacated rooms
bull All Emergency equipment is to be plugged into red outlets
bull Station someone at the elevator to prohibit elevator use
bull In some cases relocating patients to another floor may become necessary This is called Vertical Evacuation
Bethesda Healthcare System 12
Fire Drills
bull All staff members will actively participate in hospital-wide fire
drills The Fire Response Team is made up of specific people
throughout the hospital They have additional duties during
each fire drill and fire event
bull Each department has a fire plan Each staff member is
responsible to know that plan
bull Staff will stay alert to the fire situation until the end of the drill
when ldquoCode Red All Clearrdquo is announced three times
Bethesda Healthcare System 13
Oxygen
bull Oxygen is one of the primary ingredients of fire Special care
must be taken during a fire concerning oxygen being delivered
to patients
ndash ZONE OXYGEN valves shall only be turned off by
engineering after consultation with nursing or the nursing
supervisor (new policy 2013)
ndash Bedside oxygen may be turned off by trained employees
bull The hospital is divided into smoke compartments When the fire
alarm sounds the doors of the smoke compartments will
automatically close Do not block these doors which are the
heavy doors in the hallways Patient room doors are not smoke
compartment doors
bull Another source of free air flow in a fire is the elevator shaft
DO NOT USE ELEVATORS DURING A FIRE or FIRE ALARM
Bethesda Healthcare System 14
Electricity
bull In the event of a power outage an emergency power system will
activate within 10 seconds The emergency system will only
power emergency outlets (red outlets) switches and certain
emergency lighting (on all the time with no onoff switches)
bull Use the red outlets (emergency outlets) for ALL life sustaining
equipment
Bethesda Healthcare System 15
Electrical Hazards
bull Electricity is such a common part of our everyday lives that we
sometimes forget the hazards of using this form of energy Signs of
potential electrical hazard are
ndash frayed or damaged cords
ndash loose connections
ndash cords or connections in or near liquids
ndash electrical tools that spark shock or smoke due to damage or defect
ndash loss or lack of grounding electrical equipment
bull Extension cords are to be used only on a temporary basis and must
be approved by Engineering
bull Any appliances brought from home MUST by approved by Biomedical
Maintenance
Bethesda Healthcare System 16
Electrical Hazards
Make it common practice
bull When unplugging electrical cords from the wall outlet
bull DO NOT TO PULL or YANK on the cord when
removing ELECTRICAL CORDS FROM OUTLETS This may result in damage to the wiring and has been known to
cause a spark or a shock to the user
bull Bend (at the knees)
bull Grab the electrical cord by the plug ONLY
bull Carefully pull and ease it out from the outlet
Bethesda Healthcare System 17
Lock outTag Out
bull If you discover a problem with an electrical devise contact Biomedical Maintenance and remove the item from service Always submit a work order Try to be as detailed and specific as possible about how the equipment is malfunctioning You will find the form on the Intranet page under Links called EngBio Work orders
bull When an appliance or devise has been taken out of service (lock out or tag out) you may not use it again until it has been approved by Biomedical Maintenance
bull These rules were made for your safety Do not endanger yourself or your patient by using faulty equipment
Bethesda Healthcare System 18
Downtime Status Codes for eCOS amp SCM Systems
The following codes pertain to eCOS and SCM and will be
utilized when these systems are down These codes are
announced overhead
ldquoStatus 1rdquo = System will be unavailable for up to 1 hour
ldquoStatus 2rdquo = System will be unavailable for up to 2 hours
ldquoStatus 3rdquo = System will be unavailable for more than 2 hours
ldquoSystem is now availablerdquo = System is back up and running
Bethesda Healthcare System 19
Your Environment
bull As with any home or office place occasionally there will be a
broken or poorly functioning plumbing appliance damage to
walls floors or ceiling broken furniture or other damage to the
hospital
bull Report any damage you find to the Engineering Department In
a real crisis situation call Engineering to initially report the
problem In all situations submit an engineering work order
You will find the form on the Intranet page under Links called
EngBio Work orders Fill out the form and submit it
bull Any broken furniture should be labeled with the problem
ldquoBrokenrdquo is not especially helpful for the people trying to fix the
problem
Bethesda Healthcare System 20
Utility Failure OR 1600 Appendix G
The Utility Management Plan applies to all employees and
departments of the hospital and to the following systems
bull electrical power amp emergency power
bull natural gas medical gases vacuum
bull steam and condensation systems
bull heating and ventilation heating ventilation and air
conditioning systems
bull water (including domestic and fire protection) sewage
plumbing
bull horizontal and vertical transport systems alarm systems
(including fire) diesel fuel and
bull communicationsdata systems
Bethesda Healthcare System 21
Emergency Power
bull BHE currently have two 10000-gallon fuel tanks They are
underground with the tops about 24 feet above sea level
Therefore flooding is not likely to be the cause of a fuel tank
failure
bull A fifth generator was added with the addition of the Bethesda
Heart Hospital doubled our generating capability The new
generator is located in a separate hurricane enclosure at least 8
feet higher than the existing generators The new generator is
dedicated to air conditioning and ventilation loads but still has
the capability to carry critical loads if the need arises
bull BHW has two generators with 2 above ground 10000 gallon
fuel tanks
Bethesda Healthcare System 22
Internal Power Failure
INTERNAL POWER FAILURE
bull In the event of a power outage the red outlets would be switched to
emergency generator power
bull Life Safety lighting will be provided which will provide marginal
lighting throughout Flashlights and other portable lights are
maintained in individual departments
bull At the time of an outage persons in charge should check all red
outlets in their areas to make sure only items critical to patient care
are connected Toasters coffee pots etc should never be plugged
into red outlets
Bethesda Healthcare System 23
Red Outlets
bull To ensure life safety equipment is maintained in the event of a
power failure the only equipment that should be plugged into
ldquored emergency outletsrdquo is that equipment which is necessary to
provide appropriate care of the patient ie life safety
equipment communications equipment diagnostic information
physiological monitoring lighting etc
bull Computers are the only other acceptable pieces of equipment
that may be used in the red emergency outlets because of their
relatively low power consumption
bull Radios televisions fans etc should only be plugged into the
white normal power outlets
Bethesda Healthcare System 24
Water and Sewer
bull Water and sewer are supplied by the Local Municipal Water
Company Water comes into the building from different points
They can be isolated from one another and all are not needed
at the same time There are booster pumps to increase city
water pressure when needed If the City cannot provide water
the Engineering Department has a written procedure to connect
the irrigation well to the Hospital water supply if needed
bull Water samples are collected for testing of Legionella bacterium
annually
Bethesda Healthcare System 25
HVAC ndash Air Quality
bull Air quality throughout the building is monitored by
computer Filter changes on air handlers and isolation fans are
performed by maintenance schedules Critical care air handlers
controls pumps and fans are connected to the emergency
power system
bull Ultraviolet lighting is also used for more thorough filtration in
areas where invasive procedures are done
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 2
Introduction
Physical Danger Codes
Red Pink Orange Yellow Strong Gamma
MRI Safety
Medical Codes
Blue BEE Team Grey HIT
Incident Reporting
Hazardous Materials
Biomedical Waste
Chemical
Radioactive
Biological
TB
HIVAIDS
Flu Season
MENU
Bethesda Healthcare System 3
Introduction
As soon as a patient enters the hospital we are responsible for their
safety It is a vital part of our business
This CBL will cover basic safety issues that come from potential
sources within the hospital such as fire electrical hazards hazardous
materials etc
The Disaster CBL covers basic safety issues that arise from sources
outside the hospital such as hurricanes major storms biological
attacks and chemical spills
Bethesda Healthcare System 4
General Safety Tips
bull The following general safety tips are reminders to be aware of safety wherever you are
ndash Parking lots
bull watch for cars backing out of parking spots
bull always lock your car
bull do not leave valuables in plain sight in your car
bull have your keys ready when approaching your car and check the back seat before getting in
bull if you feel uncomfortable walking to your car at night call security at BHE ext 84199 or at BHW ext 70160 to escort you
bull In the parking garage DO NOT
ndash walk on the ramp
ndash make a left turn on the ramps
ndash Offices
bull secure valuables out of sight
bull use proper body mechanics when lifting heavy objects
bull open only one file drawer at a time in the same file cabinet
Bethesda Healthcare System 5
General Safety Tips continued
bull Hallways
ndash wipe up small watercoffee spills
ndash pick up trash
ndash be careful rounding corners watch for others
ndash open ldquoblindrdquo doors gently donrsquot crash through
bull Yourself
ndash get enough sleep
ndash concentrate on work while at work
ndash never use illegal or inappropriate drugs
ndash always think of yourself as working within a team
Bethesda Healthcare System 6
CODE RED
bull Code Red is the code for fire If you discover a fire or smoke you must carry out the following steps in their exact order
bull Rescue
bull Activate Alarm
bull Contain Fire
bull Extinguish fire (if safe to do so) or Evacuate
bull If you hear ldquoCode Redrdquo over the hospital paging system you must pause to listen for the location of the fire Then follow your department fire plan
bull If you work at Health City Service Center or the Plaza Click Here for fire procedures
Bethesda Healthcare System 7
1 Rescue
Rescue patientspersons in immediate danger In this initial step
remove the person from the room the fire is in
This is a temporary safety measure It is critical that you get to
the next step (Activate Alarm) as quickly as possible
If you need to progress to the Evacuate step then you must
remove all people in the endangered smoke compartment to the
next smoke compartment on the same floor This is called
horizontal evacuation Removing the patient from a patient room
does not remove the patient from the smoke compartment
Bethesda Healthcare System 8
2 Alarm ndash Pull it Then Call it
bull Pull the nearest alarm To activate the alarm ndash In Bethesda EAST push the handle in and pull it down In Bethesda WEST just pull the handle down Do this as quickly as possible The alarm not only alerts the fire department it also shuts down the air handlers that may be helping to spread the fire
bull Then call the operator at 855 at the East hospital or 755 at the West hospital and report the fire and its location
bull The operator will announce the Code Red then call 911
ndash After office hours (nights weekend and holidays) the operator will also contact the Director of Engineering Asst Director of Engineering and the Administrator on-call
bull When the fire is out the operator will announce ldquoCode Red all clearrdquo three times
bull The Operator will only accept an all clear from a member of the fire response team
Bethesda Healthcare System 9
3 Contain
Contain the firesmoke by closing windows and doors after all
persons are out (remember to check bathrooms)
All other staff in the vicinity of the fire (not involved in the initial
discoveryresponse) are to report to the nursersquos station to
receive assignments closing all doors and windows along
the way and removing all obstacles from the hallways
All staff throughout the hospital will respond by closing all doors
and remaining on the alert for further instructions They
should not enter the fire location unless they are members of
the fire response team
Bethesda Healthcare System 10
4 Extinguish (If safe to do so)
We have many types of fire extinguishers
ABC ndash Marked with an ABC and can be used on all types of fires
Carbon Dioxide ndash used mainly for electrical fires around large pieces of
equipment
Halon Suppression Systems used on sensitive electronic equipment
K Extinguishers ndash Used on grease fires
Water Mist Extinguisher ndash Found in ORLampD best choice for protection
of hospital environments books documents and clean room facilities
To use a fire Extinguisher
P ndash pull the safety pin
A ndash aim the fire extinguisher
S ndash squeeze the handle
S ndash sweep the base of the fire with the spray
Bethesda Healthcare System 11
5 Evacuate
bull Evacuate all persons you are responsible for plus yourself to the next adjacent smoke compartment on the same floor (horizontal evacuation)
bull The charge nurse or designee will prioritize each patientrsquos evacuationcategory
bull Charge nurse or designee ensures that bag valve mask is at bedside of all ventilator dependent patients and oxygen for oxygen dependent patients
bull Staff will be assigned to conduct a methodical room-by-room search accounting for all visitors and leading all patients and visitors to safety A rubber glove will be placed on the doorknobs of all vacated rooms
bull All Emergency equipment is to be plugged into red outlets
bull Station someone at the elevator to prohibit elevator use
bull In some cases relocating patients to another floor may become necessary This is called Vertical Evacuation
Bethesda Healthcare System 12
Fire Drills
bull All staff members will actively participate in hospital-wide fire
drills The Fire Response Team is made up of specific people
throughout the hospital They have additional duties during
each fire drill and fire event
bull Each department has a fire plan Each staff member is
responsible to know that plan
bull Staff will stay alert to the fire situation until the end of the drill
when ldquoCode Red All Clearrdquo is announced three times
Bethesda Healthcare System 13
Oxygen
bull Oxygen is one of the primary ingredients of fire Special care
must be taken during a fire concerning oxygen being delivered
to patients
ndash ZONE OXYGEN valves shall only be turned off by
engineering after consultation with nursing or the nursing
supervisor (new policy 2013)
ndash Bedside oxygen may be turned off by trained employees
bull The hospital is divided into smoke compartments When the fire
alarm sounds the doors of the smoke compartments will
automatically close Do not block these doors which are the
heavy doors in the hallways Patient room doors are not smoke
compartment doors
bull Another source of free air flow in a fire is the elevator shaft
DO NOT USE ELEVATORS DURING A FIRE or FIRE ALARM
Bethesda Healthcare System 14
Electricity
bull In the event of a power outage an emergency power system will
activate within 10 seconds The emergency system will only
power emergency outlets (red outlets) switches and certain
emergency lighting (on all the time with no onoff switches)
bull Use the red outlets (emergency outlets) for ALL life sustaining
equipment
Bethesda Healthcare System 15
Electrical Hazards
bull Electricity is such a common part of our everyday lives that we
sometimes forget the hazards of using this form of energy Signs of
potential electrical hazard are
ndash frayed or damaged cords
ndash loose connections
ndash cords or connections in or near liquids
ndash electrical tools that spark shock or smoke due to damage or defect
ndash loss or lack of grounding electrical equipment
bull Extension cords are to be used only on a temporary basis and must
be approved by Engineering
bull Any appliances brought from home MUST by approved by Biomedical
Maintenance
Bethesda Healthcare System 16
Electrical Hazards
Make it common practice
bull When unplugging electrical cords from the wall outlet
bull DO NOT TO PULL or YANK on the cord when
removing ELECTRICAL CORDS FROM OUTLETS This may result in damage to the wiring and has been known to
cause a spark or a shock to the user
bull Bend (at the knees)
bull Grab the electrical cord by the plug ONLY
bull Carefully pull and ease it out from the outlet
Bethesda Healthcare System 17
Lock outTag Out
bull If you discover a problem with an electrical devise contact Biomedical Maintenance and remove the item from service Always submit a work order Try to be as detailed and specific as possible about how the equipment is malfunctioning You will find the form on the Intranet page under Links called EngBio Work orders
bull When an appliance or devise has been taken out of service (lock out or tag out) you may not use it again until it has been approved by Biomedical Maintenance
bull These rules were made for your safety Do not endanger yourself or your patient by using faulty equipment
Bethesda Healthcare System 18
Downtime Status Codes for eCOS amp SCM Systems
The following codes pertain to eCOS and SCM and will be
utilized when these systems are down These codes are
announced overhead
ldquoStatus 1rdquo = System will be unavailable for up to 1 hour
ldquoStatus 2rdquo = System will be unavailable for up to 2 hours
ldquoStatus 3rdquo = System will be unavailable for more than 2 hours
ldquoSystem is now availablerdquo = System is back up and running
Bethesda Healthcare System 19
Your Environment
bull As with any home or office place occasionally there will be a
broken or poorly functioning plumbing appliance damage to
walls floors or ceiling broken furniture or other damage to the
hospital
bull Report any damage you find to the Engineering Department In
a real crisis situation call Engineering to initially report the
problem In all situations submit an engineering work order
You will find the form on the Intranet page under Links called
EngBio Work orders Fill out the form and submit it
bull Any broken furniture should be labeled with the problem
ldquoBrokenrdquo is not especially helpful for the people trying to fix the
problem
Bethesda Healthcare System 20
Utility Failure OR 1600 Appendix G
The Utility Management Plan applies to all employees and
departments of the hospital and to the following systems
bull electrical power amp emergency power
bull natural gas medical gases vacuum
bull steam and condensation systems
bull heating and ventilation heating ventilation and air
conditioning systems
bull water (including domestic and fire protection) sewage
plumbing
bull horizontal and vertical transport systems alarm systems
(including fire) diesel fuel and
bull communicationsdata systems
Bethesda Healthcare System 21
Emergency Power
bull BHE currently have two 10000-gallon fuel tanks They are
underground with the tops about 24 feet above sea level
Therefore flooding is not likely to be the cause of a fuel tank
failure
bull A fifth generator was added with the addition of the Bethesda
Heart Hospital doubled our generating capability The new
generator is located in a separate hurricane enclosure at least 8
feet higher than the existing generators The new generator is
dedicated to air conditioning and ventilation loads but still has
the capability to carry critical loads if the need arises
bull BHW has two generators with 2 above ground 10000 gallon
fuel tanks
Bethesda Healthcare System 22
Internal Power Failure
INTERNAL POWER FAILURE
bull In the event of a power outage the red outlets would be switched to
emergency generator power
bull Life Safety lighting will be provided which will provide marginal
lighting throughout Flashlights and other portable lights are
maintained in individual departments
bull At the time of an outage persons in charge should check all red
outlets in their areas to make sure only items critical to patient care
are connected Toasters coffee pots etc should never be plugged
into red outlets
Bethesda Healthcare System 23
Red Outlets
bull To ensure life safety equipment is maintained in the event of a
power failure the only equipment that should be plugged into
ldquored emergency outletsrdquo is that equipment which is necessary to
provide appropriate care of the patient ie life safety
equipment communications equipment diagnostic information
physiological monitoring lighting etc
bull Computers are the only other acceptable pieces of equipment
that may be used in the red emergency outlets because of their
relatively low power consumption
bull Radios televisions fans etc should only be plugged into the
white normal power outlets
Bethesda Healthcare System 24
Water and Sewer
bull Water and sewer are supplied by the Local Municipal Water
Company Water comes into the building from different points
They can be isolated from one another and all are not needed
at the same time There are booster pumps to increase city
water pressure when needed If the City cannot provide water
the Engineering Department has a written procedure to connect
the irrigation well to the Hospital water supply if needed
bull Water samples are collected for testing of Legionella bacterium
annually
Bethesda Healthcare System 25
HVAC ndash Air Quality
bull Air quality throughout the building is monitored by
computer Filter changes on air handlers and isolation fans are
performed by maintenance schedules Critical care air handlers
controls pumps and fans are connected to the emergency
power system
bull Ultraviolet lighting is also used for more thorough filtration in
areas where invasive procedures are done
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 3
Introduction
As soon as a patient enters the hospital we are responsible for their
safety It is a vital part of our business
This CBL will cover basic safety issues that come from potential
sources within the hospital such as fire electrical hazards hazardous
materials etc
The Disaster CBL covers basic safety issues that arise from sources
outside the hospital such as hurricanes major storms biological
attacks and chemical spills
Bethesda Healthcare System 4
General Safety Tips
bull The following general safety tips are reminders to be aware of safety wherever you are
ndash Parking lots
bull watch for cars backing out of parking spots
bull always lock your car
bull do not leave valuables in plain sight in your car
bull have your keys ready when approaching your car and check the back seat before getting in
bull if you feel uncomfortable walking to your car at night call security at BHE ext 84199 or at BHW ext 70160 to escort you
bull In the parking garage DO NOT
ndash walk on the ramp
ndash make a left turn on the ramps
ndash Offices
bull secure valuables out of sight
bull use proper body mechanics when lifting heavy objects
bull open only one file drawer at a time in the same file cabinet
Bethesda Healthcare System 5
General Safety Tips continued
bull Hallways
ndash wipe up small watercoffee spills
ndash pick up trash
ndash be careful rounding corners watch for others
ndash open ldquoblindrdquo doors gently donrsquot crash through
bull Yourself
ndash get enough sleep
ndash concentrate on work while at work
ndash never use illegal or inappropriate drugs
ndash always think of yourself as working within a team
Bethesda Healthcare System 6
CODE RED
bull Code Red is the code for fire If you discover a fire or smoke you must carry out the following steps in their exact order
bull Rescue
bull Activate Alarm
bull Contain Fire
bull Extinguish fire (if safe to do so) or Evacuate
bull If you hear ldquoCode Redrdquo over the hospital paging system you must pause to listen for the location of the fire Then follow your department fire plan
bull If you work at Health City Service Center or the Plaza Click Here for fire procedures
Bethesda Healthcare System 7
1 Rescue
Rescue patientspersons in immediate danger In this initial step
remove the person from the room the fire is in
This is a temporary safety measure It is critical that you get to
the next step (Activate Alarm) as quickly as possible
If you need to progress to the Evacuate step then you must
remove all people in the endangered smoke compartment to the
next smoke compartment on the same floor This is called
horizontal evacuation Removing the patient from a patient room
does not remove the patient from the smoke compartment
Bethesda Healthcare System 8
2 Alarm ndash Pull it Then Call it
bull Pull the nearest alarm To activate the alarm ndash In Bethesda EAST push the handle in and pull it down In Bethesda WEST just pull the handle down Do this as quickly as possible The alarm not only alerts the fire department it also shuts down the air handlers that may be helping to spread the fire
bull Then call the operator at 855 at the East hospital or 755 at the West hospital and report the fire and its location
bull The operator will announce the Code Red then call 911
ndash After office hours (nights weekend and holidays) the operator will also contact the Director of Engineering Asst Director of Engineering and the Administrator on-call
bull When the fire is out the operator will announce ldquoCode Red all clearrdquo three times
bull The Operator will only accept an all clear from a member of the fire response team
Bethesda Healthcare System 9
3 Contain
Contain the firesmoke by closing windows and doors after all
persons are out (remember to check bathrooms)
All other staff in the vicinity of the fire (not involved in the initial
discoveryresponse) are to report to the nursersquos station to
receive assignments closing all doors and windows along
the way and removing all obstacles from the hallways
All staff throughout the hospital will respond by closing all doors
and remaining on the alert for further instructions They
should not enter the fire location unless they are members of
the fire response team
Bethesda Healthcare System 10
4 Extinguish (If safe to do so)
We have many types of fire extinguishers
ABC ndash Marked with an ABC and can be used on all types of fires
Carbon Dioxide ndash used mainly for electrical fires around large pieces of
equipment
Halon Suppression Systems used on sensitive electronic equipment
K Extinguishers ndash Used on grease fires
Water Mist Extinguisher ndash Found in ORLampD best choice for protection
of hospital environments books documents and clean room facilities
To use a fire Extinguisher
P ndash pull the safety pin
A ndash aim the fire extinguisher
S ndash squeeze the handle
S ndash sweep the base of the fire with the spray
Bethesda Healthcare System 11
5 Evacuate
bull Evacuate all persons you are responsible for plus yourself to the next adjacent smoke compartment on the same floor (horizontal evacuation)
bull The charge nurse or designee will prioritize each patientrsquos evacuationcategory
bull Charge nurse or designee ensures that bag valve mask is at bedside of all ventilator dependent patients and oxygen for oxygen dependent patients
bull Staff will be assigned to conduct a methodical room-by-room search accounting for all visitors and leading all patients and visitors to safety A rubber glove will be placed on the doorknobs of all vacated rooms
bull All Emergency equipment is to be plugged into red outlets
bull Station someone at the elevator to prohibit elevator use
bull In some cases relocating patients to another floor may become necessary This is called Vertical Evacuation
Bethesda Healthcare System 12
Fire Drills
bull All staff members will actively participate in hospital-wide fire
drills The Fire Response Team is made up of specific people
throughout the hospital They have additional duties during
each fire drill and fire event
bull Each department has a fire plan Each staff member is
responsible to know that plan
bull Staff will stay alert to the fire situation until the end of the drill
when ldquoCode Red All Clearrdquo is announced three times
Bethesda Healthcare System 13
Oxygen
bull Oxygen is one of the primary ingredients of fire Special care
must be taken during a fire concerning oxygen being delivered
to patients
ndash ZONE OXYGEN valves shall only be turned off by
engineering after consultation with nursing or the nursing
supervisor (new policy 2013)
ndash Bedside oxygen may be turned off by trained employees
bull The hospital is divided into smoke compartments When the fire
alarm sounds the doors of the smoke compartments will
automatically close Do not block these doors which are the
heavy doors in the hallways Patient room doors are not smoke
compartment doors
bull Another source of free air flow in a fire is the elevator shaft
DO NOT USE ELEVATORS DURING A FIRE or FIRE ALARM
Bethesda Healthcare System 14
Electricity
bull In the event of a power outage an emergency power system will
activate within 10 seconds The emergency system will only
power emergency outlets (red outlets) switches and certain
emergency lighting (on all the time with no onoff switches)
bull Use the red outlets (emergency outlets) for ALL life sustaining
equipment
Bethesda Healthcare System 15
Electrical Hazards
bull Electricity is such a common part of our everyday lives that we
sometimes forget the hazards of using this form of energy Signs of
potential electrical hazard are
ndash frayed or damaged cords
ndash loose connections
ndash cords or connections in or near liquids
ndash electrical tools that spark shock or smoke due to damage or defect
ndash loss or lack of grounding electrical equipment
bull Extension cords are to be used only on a temporary basis and must
be approved by Engineering
bull Any appliances brought from home MUST by approved by Biomedical
Maintenance
Bethesda Healthcare System 16
Electrical Hazards
Make it common practice
bull When unplugging electrical cords from the wall outlet
bull DO NOT TO PULL or YANK on the cord when
removing ELECTRICAL CORDS FROM OUTLETS This may result in damage to the wiring and has been known to
cause a spark or a shock to the user
bull Bend (at the knees)
bull Grab the electrical cord by the plug ONLY
bull Carefully pull and ease it out from the outlet
Bethesda Healthcare System 17
Lock outTag Out
bull If you discover a problem with an electrical devise contact Biomedical Maintenance and remove the item from service Always submit a work order Try to be as detailed and specific as possible about how the equipment is malfunctioning You will find the form on the Intranet page under Links called EngBio Work orders
bull When an appliance or devise has been taken out of service (lock out or tag out) you may not use it again until it has been approved by Biomedical Maintenance
bull These rules were made for your safety Do not endanger yourself or your patient by using faulty equipment
Bethesda Healthcare System 18
Downtime Status Codes for eCOS amp SCM Systems
The following codes pertain to eCOS and SCM and will be
utilized when these systems are down These codes are
announced overhead
ldquoStatus 1rdquo = System will be unavailable for up to 1 hour
ldquoStatus 2rdquo = System will be unavailable for up to 2 hours
ldquoStatus 3rdquo = System will be unavailable for more than 2 hours
ldquoSystem is now availablerdquo = System is back up and running
Bethesda Healthcare System 19
Your Environment
bull As with any home or office place occasionally there will be a
broken or poorly functioning plumbing appliance damage to
walls floors or ceiling broken furniture or other damage to the
hospital
bull Report any damage you find to the Engineering Department In
a real crisis situation call Engineering to initially report the
problem In all situations submit an engineering work order
You will find the form on the Intranet page under Links called
EngBio Work orders Fill out the form and submit it
bull Any broken furniture should be labeled with the problem
ldquoBrokenrdquo is not especially helpful for the people trying to fix the
problem
Bethesda Healthcare System 20
Utility Failure OR 1600 Appendix G
The Utility Management Plan applies to all employees and
departments of the hospital and to the following systems
bull electrical power amp emergency power
bull natural gas medical gases vacuum
bull steam and condensation systems
bull heating and ventilation heating ventilation and air
conditioning systems
bull water (including domestic and fire protection) sewage
plumbing
bull horizontal and vertical transport systems alarm systems
(including fire) diesel fuel and
bull communicationsdata systems
Bethesda Healthcare System 21
Emergency Power
bull BHE currently have two 10000-gallon fuel tanks They are
underground with the tops about 24 feet above sea level
Therefore flooding is not likely to be the cause of a fuel tank
failure
bull A fifth generator was added with the addition of the Bethesda
Heart Hospital doubled our generating capability The new
generator is located in a separate hurricane enclosure at least 8
feet higher than the existing generators The new generator is
dedicated to air conditioning and ventilation loads but still has
the capability to carry critical loads if the need arises
bull BHW has two generators with 2 above ground 10000 gallon
fuel tanks
Bethesda Healthcare System 22
Internal Power Failure
INTERNAL POWER FAILURE
bull In the event of a power outage the red outlets would be switched to
emergency generator power
bull Life Safety lighting will be provided which will provide marginal
lighting throughout Flashlights and other portable lights are
maintained in individual departments
bull At the time of an outage persons in charge should check all red
outlets in their areas to make sure only items critical to patient care
are connected Toasters coffee pots etc should never be plugged
into red outlets
Bethesda Healthcare System 23
Red Outlets
bull To ensure life safety equipment is maintained in the event of a
power failure the only equipment that should be plugged into
ldquored emergency outletsrdquo is that equipment which is necessary to
provide appropriate care of the patient ie life safety
equipment communications equipment diagnostic information
physiological monitoring lighting etc
bull Computers are the only other acceptable pieces of equipment
that may be used in the red emergency outlets because of their
relatively low power consumption
bull Radios televisions fans etc should only be plugged into the
white normal power outlets
Bethesda Healthcare System 24
Water and Sewer
bull Water and sewer are supplied by the Local Municipal Water
Company Water comes into the building from different points
They can be isolated from one another and all are not needed
at the same time There are booster pumps to increase city
water pressure when needed If the City cannot provide water
the Engineering Department has a written procedure to connect
the irrigation well to the Hospital water supply if needed
bull Water samples are collected for testing of Legionella bacterium
annually
Bethesda Healthcare System 25
HVAC ndash Air Quality
bull Air quality throughout the building is monitored by
computer Filter changes on air handlers and isolation fans are
performed by maintenance schedules Critical care air handlers
controls pumps and fans are connected to the emergency
power system
bull Ultraviolet lighting is also used for more thorough filtration in
areas where invasive procedures are done
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 4
General Safety Tips
bull The following general safety tips are reminders to be aware of safety wherever you are
ndash Parking lots
bull watch for cars backing out of parking spots
bull always lock your car
bull do not leave valuables in plain sight in your car
bull have your keys ready when approaching your car and check the back seat before getting in
bull if you feel uncomfortable walking to your car at night call security at BHE ext 84199 or at BHW ext 70160 to escort you
bull In the parking garage DO NOT
ndash walk on the ramp
ndash make a left turn on the ramps
ndash Offices
bull secure valuables out of sight
bull use proper body mechanics when lifting heavy objects
bull open only one file drawer at a time in the same file cabinet
Bethesda Healthcare System 5
General Safety Tips continued
bull Hallways
ndash wipe up small watercoffee spills
ndash pick up trash
ndash be careful rounding corners watch for others
ndash open ldquoblindrdquo doors gently donrsquot crash through
bull Yourself
ndash get enough sleep
ndash concentrate on work while at work
ndash never use illegal or inappropriate drugs
ndash always think of yourself as working within a team
Bethesda Healthcare System 6
CODE RED
bull Code Red is the code for fire If you discover a fire or smoke you must carry out the following steps in their exact order
bull Rescue
bull Activate Alarm
bull Contain Fire
bull Extinguish fire (if safe to do so) or Evacuate
bull If you hear ldquoCode Redrdquo over the hospital paging system you must pause to listen for the location of the fire Then follow your department fire plan
bull If you work at Health City Service Center or the Plaza Click Here for fire procedures
Bethesda Healthcare System 7
1 Rescue
Rescue patientspersons in immediate danger In this initial step
remove the person from the room the fire is in
This is a temporary safety measure It is critical that you get to
the next step (Activate Alarm) as quickly as possible
If you need to progress to the Evacuate step then you must
remove all people in the endangered smoke compartment to the
next smoke compartment on the same floor This is called
horizontal evacuation Removing the patient from a patient room
does not remove the patient from the smoke compartment
Bethesda Healthcare System 8
2 Alarm ndash Pull it Then Call it
bull Pull the nearest alarm To activate the alarm ndash In Bethesda EAST push the handle in and pull it down In Bethesda WEST just pull the handle down Do this as quickly as possible The alarm not only alerts the fire department it also shuts down the air handlers that may be helping to spread the fire
bull Then call the operator at 855 at the East hospital or 755 at the West hospital and report the fire and its location
bull The operator will announce the Code Red then call 911
ndash After office hours (nights weekend and holidays) the operator will also contact the Director of Engineering Asst Director of Engineering and the Administrator on-call
bull When the fire is out the operator will announce ldquoCode Red all clearrdquo three times
bull The Operator will only accept an all clear from a member of the fire response team
Bethesda Healthcare System 9
3 Contain
Contain the firesmoke by closing windows and doors after all
persons are out (remember to check bathrooms)
All other staff in the vicinity of the fire (not involved in the initial
discoveryresponse) are to report to the nursersquos station to
receive assignments closing all doors and windows along
the way and removing all obstacles from the hallways
All staff throughout the hospital will respond by closing all doors
and remaining on the alert for further instructions They
should not enter the fire location unless they are members of
the fire response team
Bethesda Healthcare System 10
4 Extinguish (If safe to do so)
We have many types of fire extinguishers
ABC ndash Marked with an ABC and can be used on all types of fires
Carbon Dioxide ndash used mainly for electrical fires around large pieces of
equipment
Halon Suppression Systems used on sensitive electronic equipment
K Extinguishers ndash Used on grease fires
Water Mist Extinguisher ndash Found in ORLampD best choice for protection
of hospital environments books documents and clean room facilities
To use a fire Extinguisher
P ndash pull the safety pin
A ndash aim the fire extinguisher
S ndash squeeze the handle
S ndash sweep the base of the fire with the spray
Bethesda Healthcare System 11
5 Evacuate
bull Evacuate all persons you are responsible for plus yourself to the next adjacent smoke compartment on the same floor (horizontal evacuation)
bull The charge nurse or designee will prioritize each patientrsquos evacuationcategory
bull Charge nurse or designee ensures that bag valve mask is at bedside of all ventilator dependent patients and oxygen for oxygen dependent patients
bull Staff will be assigned to conduct a methodical room-by-room search accounting for all visitors and leading all patients and visitors to safety A rubber glove will be placed on the doorknobs of all vacated rooms
bull All Emergency equipment is to be plugged into red outlets
bull Station someone at the elevator to prohibit elevator use
bull In some cases relocating patients to another floor may become necessary This is called Vertical Evacuation
Bethesda Healthcare System 12
Fire Drills
bull All staff members will actively participate in hospital-wide fire
drills The Fire Response Team is made up of specific people
throughout the hospital They have additional duties during
each fire drill and fire event
bull Each department has a fire plan Each staff member is
responsible to know that plan
bull Staff will stay alert to the fire situation until the end of the drill
when ldquoCode Red All Clearrdquo is announced three times
Bethesda Healthcare System 13
Oxygen
bull Oxygen is one of the primary ingredients of fire Special care
must be taken during a fire concerning oxygen being delivered
to patients
ndash ZONE OXYGEN valves shall only be turned off by
engineering after consultation with nursing or the nursing
supervisor (new policy 2013)
ndash Bedside oxygen may be turned off by trained employees
bull The hospital is divided into smoke compartments When the fire
alarm sounds the doors of the smoke compartments will
automatically close Do not block these doors which are the
heavy doors in the hallways Patient room doors are not smoke
compartment doors
bull Another source of free air flow in a fire is the elevator shaft
DO NOT USE ELEVATORS DURING A FIRE or FIRE ALARM
Bethesda Healthcare System 14
Electricity
bull In the event of a power outage an emergency power system will
activate within 10 seconds The emergency system will only
power emergency outlets (red outlets) switches and certain
emergency lighting (on all the time with no onoff switches)
bull Use the red outlets (emergency outlets) for ALL life sustaining
equipment
Bethesda Healthcare System 15
Electrical Hazards
bull Electricity is such a common part of our everyday lives that we
sometimes forget the hazards of using this form of energy Signs of
potential electrical hazard are
ndash frayed or damaged cords
ndash loose connections
ndash cords or connections in or near liquids
ndash electrical tools that spark shock or smoke due to damage or defect
ndash loss or lack of grounding electrical equipment
bull Extension cords are to be used only on a temporary basis and must
be approved by Engineering
bull Any appliances brought from home MUST by approved by Biomedical
Maintenance
Bethesda Healthcare System 16
Electrical Hazards
Make it common practice
bull When unplugging electrical cords from the wall outlet
bull DO NOT TO PULL or YANK on the cord when
removing ELECTRICAL CORDS FROM OUTLETS This may result in damage to the wiring and has been known to
cause a spark or a shock to the user
bull Bend (at the knees)
bull Grab the electrical cord by the plug ONLY
bull Carefully pull and ease it out from the outlet
Bethesda Healthcare System 17
Lock outTag Out
bull If you discover a problem with an electrical devise contact Biomedical Maintenance and remove the item from service Always submit a work order Try to be as detailed and specific as possible about how the equipment is malfunctioning You will find the form on the Intranet page under Links called EngBio Work orders
bull When an appliance or devise has been taken out of service (lock out or tag out) you may not use it again until it has been approved by Biomedical Maintenance
bull These rules were made for your safety Do not endanger yourself or your patient by using faulty equipment
Bethesda Healthcare System 18
Downtime Status Codes for eCOS amp SCM Systems
The following codes pertain to eCOS and SCM and will be
utilized when these systems are down These codes are
announced overhead
ldquoStatus 1rdquo = System will be unavailable for up to 1 hour
ldquoStatus 2rdquo = System will be unavailable for up to 2 hours
ldquoStatus 3rdquo = System will be unavailable for more than 2 hours
ldquoSystem is now availablerdquo = System is back up and running
Bethesda Healthcare System 19
Your Environment
bull As with any home or office place occasionally there will be a
broken or poorly functioning plumbing appliance damage to
walls floors or ceiling broken furniture or other damage to the
hospital
bull Report any damage you find to the Engineering Department In
a real crisis situation call Engineering to initially report the
problem In all situations submit an engineering work order
You will find the form on the Intranet page under Links called
EngBio Work orders Fill out the form and submit it
bull Any broken furniture should be labeled with the problem
ldquoBrokenrdquo is not especially helpful for the people trying to fix the
problem
Bethesda Healthcare System 20
Utility Failure OR 1600 Appendix G
The Utility Management Plan applies to all employees and
departments of the hospital and to the following systems
bull electrical power amp emergency power
bull natural gas medical gases vacuum
bull steam and condensation systems
bull heating and ventilation heating ventilation and air
conditioning systems
bull water (including domestic and fire protection) sewage
plumbing
bull horizontal and vertical transport systems alarm systems
(including fire) diesel fuel and
bull communicationsdata systems
Bethesda Healthcare System 21
Emergency Power
bull BHE currently have two 10000-gallon fuel tanks They are
underground with the tops about 24 feet above sea level
Therefore flooding is not likely to be the cause of a fuel tank
failure
bull A fifth generator was added with the addition of the Bethesda
Heart Hospital doubled our generating capability The new
generator is located in a separate hurricane enclosure at least 8
feet higher than the existing generators The new generator is
dedicated to air conditioning and ventilation loads but still has
the capability to carry critical loads if the need arises
bull BHW has two generators with 2 above ground 10000 gallon
fuel tanks
Bethesda Healthcare System 22
Internal Power Failure
INTERNAL POWER FAILURE
bull In the event of a power outage the red outlets would be switched to
emergency generator power
bull Life Safety lighting will be provided which will provide marginal
lighting throughout Flashlights and other portable lights are
maintained in individual departments
bull At the time of an outage persons in charge should check all red
outlets in their areas to make sure only items critical to patient care
are connected Toasters coffee pots etc should never be plugged
into red outlets
Bethesda Healthcare System 23
Red Outlets
bull To ensure life safety equipment is maintained in the event of a
power failure the only equipment that should be plugged into
ldquored emergency outletsrdquo is that equipment which is necessary to
provide appropriate care of the patient ie life safety
equipment communications equipment diagnostic information
physiological monitoring lighting etc
bull Computers are the only other acceptable pieces of equipment
that may be used in the red emergency outlets because of their
relatively low power consumption
bull Radios televisions fans etc should only be plugged into the
white normal power outlets
Bethesda Healthcare System 24
Water and Sewer
bull Water and sewer are supplied by the Local Municipal Water
Company Water comes into the building from different points
They can be isolated from one another and all are not needed
at the same time There are booster pumps to increase city
water pressure when needed If the City cannot provide water
the Engineering Department has a written procedure to connect
the irrigation well to the Hospital water supply if needed
bull Water samples are collected for testing of Legionella bacterium
annually
Bethesda Healthcare System 25
HVAC ndash Air Quality
bull Air quality throughout the building is monitored by
computer Filter changes on air handlers and isolation fans are
performed by maintenance schedules Critical care air handlers
controls pumps and fans are connected to the emergency
power system
bull Ultraviolet lighting is also used for more thorough filtration in
areas where invasive procedures are done
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 5
General Safety Tips continued
bull Hallways
ndash wipe up small watercoffee spills
ndash pick up trash
ndash be careful rounding corners watch for others
ndash open ldquoblindrdquo doors gently donrsquot crash through
bull Yourself
ndash get enough sleep
ndash concentrate on work while at work
ndash never use illegal or inappropriate drugs
ndash always think of yourself as working within a team
Bethesda Healthcare System 6
CODE RED
bull Code Red is the code for fire If you discover a fire or smoke you must carry out the following steps in their exact order
bull Rescue
bull Activate Alarm
bull Contain Fire
bull Extinguish fire (if safe to do so) or Evacuate
bull If you hear ldquoCode Redrdquo over the hospital paging system you must pause to listen for the location of the fire Then follow your department fire plan
bull If you work at Health City Service Center or the Plaza Click Here for fire procedures
Bethesda Healthcare System 7
1 Rescue
Rescue patientspersons in immediate danger In this initial step
remove the person from the room the fire is in
This is a temporary safety measure It is critical that you get to
the next step (Activate Alarm) as quickly as possible
If you need to progress to the Evacuate step then you must
remove all people in the endangered smoke compartment to the
next smoke compartment on the same floor This is called
horizontal evacuation Removing the patient from a patient room
does not remove the patient from the smoke compartment
Bethesda Healthcare System 8
2 Alarm ndash Pull it Then Call it
bull Pull the nearest alarm To activate the alarm ndash In Bethesda EAST push the handle in and pull it down In Bethesda WEST just pull the handle down Do this as quickly as possible The alarm not only alerts the fire department it also shuts down the air handlers that may be helping to spread the fire
bull Then call the operator at 855 at the East hospital or 755 at the West hospital and report the fire and its location
bull The operator will announce the Code Red then call 911
ndash After office hours (nights weekend and holidays) the operator will also contact the Director of Engineering Asst Director of Engineering and the Administrator on-call
bull When the fire is out the operator will announce ldquoCode Red all clearrdquo three times
bull The Operator will only accept an all clear from a member of the fire response team
Bethesda Healthcare System 9
3 Contain
Contain the firesmoke by closing windows and doors after all
persons are out (remember to check bathrooms)
All other staff in the vicinity of the fire (not involved in the initial
discoveryresponse) are to report to the nursersquos station to
receive assignments closing all doors and windows along
the way and removing all obstacles from the hallways
All staff throughout the hospital will respond by closing all doors
and remaining on the alert for further instructions They
should not enter the fire location unless they are members of
the fire response team
Bethesda Healthcare System 10
4 Extinguish (If safe to do so)
We have many types of fire extinguishers
ABC ndash Marked with an ABC and can be used on all types of fires
Carbon Dioxide ndash used mainly for electrical fires around large pieces of
equipment
Halon Suppression Systems used on sensitive electronic equipment
K Extinguishers ndash Used on grease fires
Water Mist Extinguisher ndash Found in ORLampD best choice for protection
of hospital environments books documents and clean room facilities
To use a fire Extinguisher
P ndash pull the safety pin
A ndash aim the fire extinguisher
S ndash squeeze the handle
S ndash sweep the base of the fire with the spray
Bethesda Healthcare System 11
5 Evacuate
bull Evacuate all persons you are responsible for plus yourself to the next adjacent smoke compartment on the same floor (horizontal evacuation)
bull The charge nurse or designee will prioritize each patientrsquos evacuationcategory
bull Charge nurse or designee ensures that bag valve mask is at bedside of all ventilator dependent patients and oxygen for oxygen dependent patients
bull Staff will be assigned to conduct a methodical room-by-room search accounting for all visitors and leading all patients and visitors to safety A rubber glove will be placed on the doorknobs of all vacated rooms
bull All Emergency equipment is to be plugged into red outlets
bull Station someone at the elevator to prohibit elevator use
bull In some cases relocating patients to another floor may become necessary This is called Vertical Evacuation
Bethesda Healthcare System 12
Fire Drills
bull All staff members will actively participate in hospital-wide fire
drills The Fire Response Team is made up of specific people
throughout the hospital They have additional duties during
each fire drill and fire event
bull Each department has a fire plan Each staff member is
responsible to know that plan
bull Staff will stay alert to the fire situation until the end of the drill
when ldquoCode Red All Clearrdquo is announced three times
Bethesda Healthcare System 13
Oxygen
bull Oxygen is one of the primary ingredients of fire Special care
must be taken during a fire concerning oxygen being delivered
to patients
ndash ZONE OXYGEN valves shall only be turned off by
engineering after consultation with nursing or the nursing
supervisor (new policy 2013)
ndash Bedside oxygen may be turned off by trained employees
bull The hospital is divided into smoke compartments When the fire
alarm sounds the doors of the smoke compartments will
automatically close Do not block these doors which are the
heavy doors in the hallways Patient room doors are not smoke
compartment doors
bull Another source of free air flow in a fire is the elevator shaft
DO NOT USE ELEVATORS DURING A FIRE or FIRE ALARM
Bethesda Healthcare System 14
Electricity
bull In the event of a power outage an emergency power system will
activate within 10 seconds The emergency system will only
power emergency outlets (red outlets) switches and certain
emergency lighting (on all the time with no onoff switches)
bull Use the red outlets (emergency outlets) for ALL life sustaining
equipment
Bethesda Healthcare System 15
Electrical Hazards
bull Electricity is such a common part of our everyday lives that we
sometimes forget the hazards of using this form of energy Signs of
potential electrical hazard are
ndash frayed or damaged cords
ndash loose connections
ndash cords or connections in or near liquids
ndash electrical tools that spark shock or smoke due to damage or defect
ndash loss or lack of grounding electrical equipment
bull Extension cords are to be used only on a temporary basis and must
be approved by Engineering
bull Any appliances brought from home MUST by approved by Biomedical
Maintenance
Bethesda Healthcare System 16
Electrical Hazards
Make it common practice
bull When unplugging electrical cords from the wall outlet
bull DO NOT TO PULL or YANK on the cord when
removing ELECTRICAL CORDS FROM OUTLETS This may result in damage to the wiring and has been known to
cause a spark or a shock to the user
bull Bend (at the knees)
bull Grab the electrical cord by the plug ONLY
bull Carefully pull and ease it out from the outlet
Bethesda Healthcare System 17
Lock outTag Out
bull If you discover a problem with an electrical devise contact Biomedical Maintenance and remove the item from service Always submit a work order Try to be as detailed and specific as possible about how the equipment is malfunctioning You will find the form on the Intranet page under Links called EngBio Work orders
bull When an appliance or devise has been taken out of service (lock out or tag out) you may not use it again until it has been approved by Biomedical Maintenance
bull These rules were made for your safety Do not endanger yourself or your patient by using faulty equipment
Bethesda Healthcare System 18
Downtime Status Codes for eCOS amp SCM Systems
The following codes pertain to eCOS and SCM and will be
utilized when these systems are down These codes are
announced overhead
ldquoStatus 1rdquo = System will be unavailable for up to 1 hour
ldquoStatus 2rdquo = System will be unavailable for up to 2 hours
ldquoStatus 3rdquo = System will be unavailable for more than 2 hours
ldquoSystem is now availablerdquo = System is back up and running
Bethesda Healthcare System 19
Your Environment
bull As with any home or office place occasionally there will be a
broken or poorly functioning plumbing appliance damage to
walls floors or ceiling broken furniture or other damage to the
hospital
bull Report any damage you find to the Engineering Department In
a real crisis situation call Engineering to initially report the
problem In all situations submit an engineering work order
You will find the form on the Intranet page under Links called
EngBio Work orders Fill out the form and submit it
bull Any broken furniture should be labeled with the problem
ldquoBrokenrdquo is not especially helpful for the people trying to fix the
problem
Bethesda Healthcare System 20
Utility Failure OR 1600 Appendix G
The Utility Management Plan applies to all employees and
departments of the hospital and to the following systems
bull electrical power amp emergency power
bull natural gas medical gases vacuum
bull steam and condensation systems
bull heating and ventilation heating ventilation and air
conditioning systems
bull water (including domestic and fire protection) sewage
plumbing
bull horizontal and vertical transport systems alarm systems
(including fire) diesel fuel and
bull communicationsdata systems
Bethesda Healthcare System 21
Emergency Power
bull BHE currently have two 10000-gallon fuel tanks They are
underground with the tops about 24 feet above sea level
Therefore flooding is not likely to be the cause of a fuel tank
failure
bull A fifth generator was added with the addition of the Bethesda
Heart Hospital doubled our generating capability The new
generator is located in a separate hurricane enclosure at least 8
feet higher than the existing generators The new generator is
dedicated to air conditioning and ventilation loads but still has
the capability to carry critical loads if the need arises
bull BHW has two generators with 2 above ground 10000 gallon
fuel tanks
Bethesda Healthcare System 22
Internal Power Failure
INTERNAL POWER FAILURE
bull In the event of a power outage the red outlets would be switched to
emergency generator power
bull Life Safety lighting will be provided which will provide marginal
lighting throughout Flashlights and other portable lights are
maintained in individual departments
bull At the time of an outage persons in charge should check all red
outlets in their areas to make sure only items critical to patient care
are connected Toasters coffee pots etc should never be plugged
into red outlets
Bethesda Healthcare System 23
Red Outlets
bull To ensure life safety equipment is maintained in the event of a
power failure the only equipment that should be plugged into
ldquored emergency outletsrdquo is that equipment which is necessary to
provide appropriate care of the patient ie life safety
equipment communications equipment diagnostic information
physiological monitoring lighting etc
bull Computers are the only other acceptable pieces of equipment
that may be used in the red emergency outlets because of their
relatively low power consumption
bull Radios televisions fans etc should only be plugged into the
white normal power outlets
Bethesda Healthcare System 24
Water and Sewer
bull Water and sewer are supplied by the Local Municipal Water
Company Water comes into the building from different points
They can be isolated from one another and all are not needed
at the same time There are booster pumps to increase city
water pressure when needed If the City cannot provide water
the Engineering Department has a written procedure to connect
the irrigation well to the Hospital water supply if needed
bull Water samples are collected for testing of Legionella bacterium
annually
Bethesda Healthcare System 25
HVAC ndash Air Quality
bull Air quality throughout the building is monitored by
computer Filter changes on air handlers and isolation fans are
performed by maintenance schedules Critical care air handlers
controls pumps and fans are connected to the emergency
power system
bull Ultraviolet lighting is also used for more thorough filtration in
areas where invasive procedures are done
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 6
CODE RED
bull Code Red is the code for fire If you discover a fire or smoke you must carry out the following steps in their exact order
bull Rescue
bull Activate Alarm
bull Contain Fire
bull Extinguish fire (if safe to do so) or Evacuate
bull If you hear ldquoCode Redrdquo over the hospital paging system you must pause to listen for the location of the fire Then follow your department fire plan
bull If you work at Health City Service Center or the Plaza Click Here for fire procedures
Bethesda Healthcare System 7
1 Rescue
Rescue patientspersons in immediate danger In this initial step
remove the person from the room the fire is in
This is a temporary safety measure It is critical that you get to
the next step (Activate Alarm) as quickly as possible
If you need to progress to the Evacuate step then you must
remove all people in the endangered smoke compartment to the
next smoke compartment on the same floor This is called
horizontal evacuation Removing the patient from a patient room
does not remove the patient from the smoke compartment
Bethesda Healthcare System 8
2 Alarm ndash Pull it Then Call it
bull Pull the nearest alarm To activate the alarm ndash In Bethesda EAST push the handle in and pull it down In Bethesda WEST just pull the handle down Do this as quickly as possible The alarm not only alerts the fire department it also shuts down the air handlers that may be helping to spread the fire
bull Then call the operator at 855 at the East hospital or 755 at the West hospital and report the fire and its location
bull The operator will announce the Code Red then call 911
ndash After office hours (nights weekend and holidays) the operator will also contact the Director of Engineering Asst Director of Engineering and the Administrator on-call
bull When the fire is out the operator will announce ldquoCode Red all clearrdquo three times
bull The Operator will only accept an all clear from a member of the fire response team
Bethesda Healthcare System 9
3 Contain
Contain the firesmoke by closing windows and doors after all
persons are out (remember to check bathrooms)
All other staff in the vicinity of the fire (not involved in the initial
discoveryresponse) are to report to the nursersquos station to
receive assignments closing all doors and windows along
the way and removing all obstacles from the hallways
All staff throughout the hospital will respond by closing all doors
and remaining on the alert for further instructions They
should not enter the fire location unless they are members of
the fire response team
Bethesda Healthcare System 10
4 Extinguish (If safe to do so)
We have many types of fire extinguishers
ABC ndash Marked with an ABC and can be used on all types of fires
Carbon Dioxide ndash used mainly for electrical fires around large pieces of
equipment
Halon Suppression Systems used on sensitive electronic equipment
K Extinguishers ndash Used on grease fires
Water Mist Extinguisher ndash Found in ORLampD best choice for protection
of hospital environments books documents and clean room facilities
To use a fire Extinguisher
P ndash pull the safety pin
A ndash aim the fire extinguisher
S ndash squeeze the handle
S ndash sweep the base of the fire with the spray
Bethesda Healthcare System 11
5 Evacuate
bull Evacuate all persons you are responsible for plus yourself to the next adjacent smoke compartment on the same floor (horizontal evacuation)
bull The charge nurse or designee will prioritize each patientrsquos evacuationcategory
bull Charge nurse or designee ensures that bag valve mask is at bedside of all ventilator dependent patients and oxygen for oxygen dependent patients
bull Staff will be assigned to conduct a methodical room-by-room search accounting for all visitors and leading all patients and visitors to safety A rubber glove will be placed on the doorknobs of all vacated rooms
bull All Emergency equipment is to be plugged into red outlets
bull Station someone at the elevator to prohibit elevator use
bull In some cases relocating patients to another floor may become necessary This is called Vertical Evacuation
Bethesda Healthcare System 12
Fire Drills
bull All staff members will actively participate in hospital-wide fire
drills The Fire Response Team is made up of specific people
throughout the hospital They have additional duties during
each fire drill and fire event
bull Each department has a fire plan Each staff member is
responsible to know that plan
bull Staff will stay alert to the fire situation until the end of the drill
when ldquoCode Red All Clearrdquo is announced three times
Bethesda Healthcare System 13
Oxygen
bull Oxygen is one of the primary ingredients of fire Special care
must be taken during a fire concerning oxygen being delivered
to patients
ndash ZONE OXYGEN valves shall only be turned off by
engineering after consultation with nursing or the nursing
supervisor (new policy 2013)
ndash Bedside oxygen may be turned off by trained employees
bull The hospital is divided into smoke compartments When the fire
alarm sounds the doors of the smoke compartments will
automatically close Do not block these doors which are the
heavy doors in the hallways Patient room doors are not smoke
compartment doors
bull Another source of free air flow in a fire is the elevator shaft
DO NOT USE ELEVATORS DURING A FIRE or FIRE ALARM
Bethesda Healthcare System 14
Electricity
bull In the event of a power outage an emergency power system will
activate within 10 seconds The emergency system will only
power emergency outlets (red outlets) switches and certain
emergency lighting (on all the time with no onoff switches)
bull Use the red outlets (emergency outlets) for ALL life sustaining
equipment
Bethesda Healthcare System 15
Electrical Hazards
bull Electricity is such a common part of our everyday lives that we
sometimes forget the hazards of using this form of energy Signs of
potential electrical hazard are
ndash frayed or damaged cords
ndash loose connections
ndash cords or connections in or near liquids
ndash electrical tools that spark shock or smoke due to damage or defect
ndash loss or lack of grounding electrical equipment
bull Extension cords are to be used only on a temporary basis and must
be approved by Engineering
bull Any appliances brought from home MUST by approved by Biomedical
Maintenance
Bethesda Healthcare System 16
Electrical Hazards
Make it common practice
bull When unplugging electrical cords from the wall outlet
bull DO NOT TO PULL or YANK on the cord when
removing ELECTRICAL CORDS FROM OUTLETS This may result in damage to the wiring and has been known to
cause a spark or a shock to the user
bull Bend (at the knees)
bull Grab the electrical cord by the plug ONLY
bull Carefully pull and ease it out from the outlet
Bethesda Healthcare System 17
Lock outTag Out
bull If you discover a problem with an electrical devise contact Biomedical Maintenance and remove the item from service Always submit a work order Try to be as detailed and specific as possible about how the equipment is malfunctioning You will find the form on the Intranet page under Links called EngBio Work orders
bull When an appliance or devise has been taken out of service (lock out or tag out) you may not use it again until it has been approved by Biomedical Maintenance
bull These rules were made for your safety Do not endanger yourself or your patient by using faulty equipment
Bethesda Healthcare System 18
Downtime Status Codes for eCOS amp SCM Systems
The following codes pertain to eCOS and SCM and will be
utilized when these systems are down These codes are
announced overhead
ldquoStatus 1rdquo = System will be unavailable for up to 1 hour
ldquoStatus 2rdquo = System will be unavailable for up to 2 hours
ldquoStatus 3rdquo = System will be unavailable for more than 2 hours
ldquoSystem is now availablerdquo = System is back up and running
Bethesda Healthcare System 19
Your Environment
bull As with any home or office place occasionally there will be a
broken or poorly functioning plumbing appliance damage to
walls floors or ceiling broken furniture or other damage to the
hospital
bull Report any damage you find to the Engineering Department In
a real crisis situation call Engineering to initially report the
problem In all situations submit an engineering work order
You will find the form on the Intranet page under Links called
EngBio Work orders Fill out the form and submit it
bull Any broken furniture should be labeled with the problem
ldquoBrokenrdquo is not especially helpful for the people trying to fix the
problem
Bethesda Healthcare System 20
Utility Failure OR 1600 Appendix G
The Utility Management Plan applies to all employees and
departments of the hospital and to the following systems
bull electrical power amp emergency power
bull natural gas medical gases vacuum
bull steam and condensation systems
bull heating and ventilation heating ventilation and air
conditioning systems
bull water (including domestic and fire protection) sewage
plumbing
bull horizontal and vertical transport systems alarm systems
(including fire) diesel fuel and
bull communicationsdata systems
Bethesda Healthcare System 21
Emergency Power
bull BHE currently have two 10000-gallon fuel tanks They are
underground with the tops about 24 feet above sea level
Therefore flooding is not likely to be the cause of a fuel tank
failure
bull A fifth generator was added with the addition of the Bethesda
Heart Hospital doubled our generating capability The new
generator is located in a separate hurricane enclosure at least 8
feet higher than the existing generators The new generator is
dedicated to air conditioning and ventilation loads but still has
the capability to carry critical loads if the need arises
bull BHW has two generators with 2 above ground 10000 gallon
fuel tanks
Bethesda Healthcare System 22
Internal Power Failure
INTERNAL POWER FAILURE
bull In the event of a power outage the red outlets would be switched to
emergency generator power
bull Life Safety lighting will be provided which will provide marginal
lighting throughout Flashlights and other portable lights are
maintained in individual departments
bull At the time of an outage persons in charge should check all red
outlets in their areas to make sure only items critical to patient care
are connected Toasters coffee pots etc should never be plugged
into red outlets
Bethesda Healthcare System 23
Red Outlets
bull To ensure life safety equipment is maintained in the event of a
power failure the only equipment that should be plugged into
ldquored emergency outletsrdquo is that equipment which is necessary to
provide appropriate care of the patient ie life safety
equipment communications equipment diagnostic information
physiological monitoring lighting etc
bull Computers are the only other acceptable pieces of equipment
that may be used in the red emergency outlets because of their
relatively low power consumption
bull Radios televisions fans etc should only be plugged into the
white normal power outlets
Bethesda Healthcare System 24
Water and Sewer
bull Water and sewer are supplied by the Local Municipal Water
Company Water comes into the building from different points
They can be isolated from one another and all are not needed
at the same time There are booster pumps to increase city
water pressure when needed If the City cannot provide water
the Engineering Department has a written procedure to connect
the irrigation well to the Hospital water supply if needed
bull Water samples are collected for testing of Legionella bacterium
annually
Bethesda Healthcare System 25
HVAC ndash Air Quality
bull Air quality throughout the building is monitored by
computer Filter changes on air handlers and isolation fans are
performed by maintenance schedules Critical care air handlers
controls pumps and fans are connected to the emergency
power system
bull Ultraviolet lighting is also used for more thorough filtration in
areas where invasive procedures are done
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 7
1 Rescue
Rescue patientspersons in immediate danger In this initial step
remove the person from the room the fire is in
This is a temporary safety measure It is critical that you get to
the next step (Activate Alarm) as quickly as possible
If you need to progress to the Evacuate step then you must
remove all people in the endangered smoke compartment to the
next smoke compartment on the same floor This is called
horizontal evacuation Removing the patient from a patient room
does not remove the patient from the smoke compartment
Bethesda Healthcare System 8
2 Alarm ndash Pull it Then Call it
bull Pull the nearest alarm To activate the alarm ndash In Bethesda EAST push the handle in and pull it down In Bethesda WEST just pull the handle down Do this as quickly as possible The alarm not only alerts the fire department it also shuts down the air handlers that may be helping to spread the fire
bull Then call the operator at 855 at the East hospital or 755 at the West hospital and report the fire and its location
bull The operator will announce the Code Red then call 911
ndash After office hours (nights weekend and holidays) the operator will also contact the Director of Engineering Asst Director of Engineering and the Administrator on-call
bull When the fire is out the operator will announce ldquoCode Red all clearrdquo three times
bull The Operator will only accept an all clear from a member of the fire response team
Bethesda Healthcare System 9
3 Contain
Contain the firesmoke by closing windows and doors after all
persons are out (remember to check bathrooms)
All other staff in the vicinity of the fire (not involved in the initial
discoveryresponse) are to report to the nursersquos station to
receive assignments closing all doors and windows along
the way and removing all obstacles from the hallways
All staff throughout the hospital will respond by closing all doors
and remaining on the alert for further instructions They
should not enter the fire location unless they are members of
the fire response team
Bethesda Healthcare System 10
4 Extinguish (If safe to do so)
We have many types of fire extinguishers
ABC ndash Marked with an ABC and can be used on all types of fires
Carbon Dioxide ndash used mainly for electrical fires around large pieces of
equipment
Halon Suppression Systems used on sensitive electronic equipment
K Extinguishers ndash Used on grease fires
Water Mist Extinguisher ndash Found in ORLampD best choice for protection
of hospital environments books documents and clean room facilities
To use a fire Extinguisher
P ndash pull the safety pin
A ndash aim the fire extinguisher
S ndash squeeze the handle
S ndash sweep the base of the fire with the spray
Bethesda Healthcare System 11
5 Evacuate
bull Evacuate all persons you are responsible for plus yourself to the next adjacent smoke compartment on the same floor (horizontal evacuation)
bull The charge nurse or designee will prioritize each patientrsquos evacuationcategory
bull Charge nurse or designee ensures that bag valve mask is at bedside of all ventilator dependent patients and oxygen for oxygen dependent patients
bull Staff will be assigned to conduct a methodical room-by-room search accounting for all visitors and leading all patients and visitors to safety A rubber glove will be placed on the doorknobs of all vacated rooms
bull All Emergency equipment is to be plugged into red outlets
bull Station someone at the elevator to prohibit elevator use
bull In some cases relocating patients to another floor may become necessary This is called Vertical Evacuation
Bethesda Healthcare System 12
Fire Drills
bull All staff members will actively participate in hospital-wide fire
drills The Fire Response Team is made up of specific people
throughout the hospital They have additional duties during
each fire drill and fire event
bull Each department has a fire plan Each staff member is
responsible to know that plan
bull Staff will stay alert to the fire situation until the end of the drill
when ldquoCode Red All Clearrdquo is announced three times
Bethesda Healthcare System 13
Oxygen
bull Oxygen is one of the primary ingredients of fire Special care
must be taken during a fire concerning oxygen being delivered
to patients
ndash ZONE OXYGEN valves shall only be turned off by
engineering after consultation with nursing or the nursing
supervisor (new policy 2013)
ndash Bedside oxygen may be turned off by trained employees
bull The hospital is divided into smoke compartments When the fire
alarm sounds the doors of the smoke compartments will
automatically close Do not block these doors which are the
heavy doors in the hallways Patient room doors are not smoke
compartment doors
bull Another source of free air flow in a fire is the elevator shaft
DO NOT USE ELEVATORS DURING A FIRE or FIRE ALARM
Bethesda Healthcare System 14
Electricity
bull In the event of a power outage an emergency power system will
activate within 10 seconds The emergency system will only
power emergency outlets (red outlets) switches and certain
emergency lighting (on all the time with no onoff switches)
bull Use the red outlets (emergency outlets) for ALL life sustaining
equipment
Bethesda Healthcare System 15
Electrical Hazards
bull Electricity is such a common part of our everyday lives that we
sometimes forget the hazards of using this form of energy Signs of
potential electrical hazard are
ndash frayed or damaged cords
ndash loose connections
ndash cords or connections in or near liquids
ndash electrical tools that spark shock or smoke due to damage or defect
ndash loss or lack of grounding electrical equipment
bull Extension cords are to be used only on a temporary basis and must
be approved by Engineering
bull Any appliances brought from home MUST by approved by Biomedical
Maintenance
Bethesda Healthcare System 16
Electrical Hazards
Make it common practice
bull When unplugging electrical cords from the wall outlet
bull DO NOT TO PULL or YANK on the cord when
removing ELECTRICAL CORDS FROM OUTLETS This may result in damage to the wiring and has been known to
cause a spark or a shock to the user
bull Bend (at the knees)
bull Grab the electrical cord by the plug ONLY
bull Carefully pull and ease it out from the outlet
Bethesda Healthcare System 17
Lock outTag Out
bull If you discover a problem with an electrical devise contact Biomedical Maintenance and remove the item from service Always submit a work order Try to be as detailed and specific as possible about how the equipment is malfunctioning You will find the form on the Intranet page under Links called EngBio Work orders
bull When an appliance or devise has been taken out of service (lock out or tag out) you may not use it again until it has been approved by Biomedical Maintenance
bull These rules were made for your safety Do not endanger yourself or your patient by using faulty equipment
Bethesda Healthcare System 18
Downtime Status Codes for eCOS amp SCM Systems
The following codes pertain to eCOS and SCM and will be
utilized when these systems are down These codes are
announced overhead
ldquoStatus 1rdquo = System will be unavailable for up to 1 hour
ldquoStatus 2rdquo = System will be unavailable for up to 2 hours
ldquoStatus 3rdquo = System will be unavailable for more than 2 hours
ldquoSystem is now availablerdquo = System is back up and running
Bethesda Healthcare System 19
Your Environment
bull As with any home or office place occasionally there will be a
broken or poorly functioning plumbing appliance damage to
walls floors or ceiling broken furniture or other damage to the
hospital
bull Report any damage you find to the Engineering Department In
a real crisis situation call Engineering to initially report the
problem In all situations submit an engineering work order
You will find the form on the Intranet page under Links called
EngBio Work orders Fill out the form and submit it
bull Any broken furniture should be labeled with the problem
ldquoBrokenrdquo is not especially helpful for the people trying to fix the
problem
Bethesda Healthcare System 20
Utility Failure OR 1600 Appendix G
The Utility Management Plan applies to all employees and
departments of the hospital and to the following systems
bull electrical power amp emergency power
bull natural gas medical gases vacuum
bull steam and condensation systems
bull heating and ventilation heating ventilation and air
conditioning systems
bull water (including domestic and fire protection) sewage
plumbing
bull horizontal and vertical transport systems alarm systems
(including fire) diesel fuel and
bull communicationsdata systems
Bethesda Healthcare System 21
Emergency Power
bull BHE currently have two 10000-gallon fuel tanks They are
underground with the tops about 24 feet above sea level
Therefore flooding is not likely to be the cause of a fuel tank
failure
bull A fifth generator was added with the addition of the Bethesda
Heart Hospital doubled our generating capability The new
generator is located in a separate hurricane enclosure at least 8
feet higher than the existing generators The new generator is
dedicated to air conditioning and ventilation loads but still has
the capability to carry critical loads if the need arises
bull BHW has two generators with 2 above ground 10000 gallon
fuel tanks
Bethesda Healthcare System 22
Internal Power Failure
INTERNAL POWER FAILURE
bull In the event of a power outage the red outlets would be switched to
emergency generator power
bull Life Safety lighting will be provided which will provide marginal
lighting throughout Flashlights and other portable lights are
maintained in individual departments
bull At the time of an outage persons in charge should check all red
outlets in their areas to make sure only items critical to patient care
are connected Toasters coffee pots etc should never be plugged
into red outlets
Bethesda Healthcare System 23
Red Outlets
bull To ensure life safety equipment is maintained in the event of a
power failure the only equipment that should be plugged into
ldquored emergency outletsrdquo is that equipment which is necessary to
provide appropriate care of the patient ie life safety
equipment communications equipment diagnostic information
physiological monitoring lighting etc
bull Computers are the only other acceptable pieces of equipment
that may be used in the red emergency outlets because of their
relatively low power consumption
bull Radios televisions fans etc should only be plugged into the
white normal power outlets
Bethesda Healthcare System 24
Water and Sewer
bull Water and sewer are supplied by the Local Municipal Water
Company Water comes into the building from different points
They can be isolated from one another and all are not needed
at the same time There are booster pumps to increase city
water pressure when needed If the City cannot provide water
the Engineering Department has a written procedure to connect
the irrigation well to the Hospital water supply if needed
bull Water samples are collected for testing of Legionella bacterium
annually
Bethesda Healthcare System 25
HVAC ndash Air Quality
bull Air quality throughout the building is monitored by
computer Filter changes on air handlers and isolation fans are
performed by maintenance schedules Critical care air handlers
controls pumps and fans are connected to the emergency
power system
bull Ultraviolet lighting is also used for more thorough filtration in
areas where invasive procedures are done
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 8
2 Alarm ndash Pull it Then Call it
bull Pull the nearest alarm To activate the alarm ndash In Bethesda EAST push the handle in and pull it down In Bethesda WEST just pull the handle down Do this as quickly as possible The alarm not only alerts the fire department it also shuts down the air handlers that may be helping to spread the fire
bull Then call the operator at 855 at the East hospital or 755 at the West hospital and report the fire and its location
bull The operator will announce the Code Red then call 911
ndash After office hours (nights weekend and holidays) the operator will also contact the Director of Engineering Asst Director of Engineering and the Administrator on-call
bull When the fire is out the operator will announce ldquoCode Red all clearrdquo three times
bull The Operator will only accept an all clear from a member of the fire response team
Bethesda Healthcare System 9
3 Contain
Contain the firesmoke by closing windows and doors after all
persons are out (remember to check bathrooms)
All other staff in the vicinity of the fire (not involved in the initial
discoveryresponse) are to report to the nursersquos station to
receive assignments closing all doors and windows along
the way and removing all obstacles from the hallways
All staff throughout the hospital will respond by closing all doors
and remaining on the alert for further instructions They
should not enter the fire location unless they are members of
the fire response team
Bethesda Healthcare System 10
4 Extinguish (If safe to do so)
We have many types of fire extinguishers
ABC ndash Marked with an ABC and can be used on all types of fires
Carbon Dioxide ndash used mainly for electrical fires around large pieces of
equipment
Halon Suppression Systems used on sensitive electronic equipment
K Extinguishers ndash Used on grease fires
Water Mist Extinguisher ndash Found in ORLampD best choice for protection
of hospital environments books documents and clean room facilities
To use a fire Extinguisher
P ndash pull the safety pin
A ndash aim the fire extinguisher
S ndash squeeze the handle
S ndash sweep the base of the fire with the spray
Bethesda Healthcare System 11
5 Evacuate
bull Evacuate all persons you are responsible for plus yourself to the next adjacent smoke compartment on the same floor (horizontal evacuation)
bull The charge nurse or designee will prioritize each patientrsquos evacuationcategory
bull Charge nurse or designee ensures that bag valve mask is at bedside of all ventilator dependent patients and oxygen for oxygen dependent patients
bull Staff will be assigned to conduct a methodical room-by-room search accounting for all visitors and leading all patients and visitors to safety A rubber glove will be placed on the doorknobs of all vacated rooms
bull All Emergency equipment is to be plugged into red outlets
bull Station someone at the elevator to prohibit elevator use
bull In some cases relocating patients to another floor may become necessary This is called Vertical Evacuation
Bethesda Healthcare System 12
Fire Drills
bull All staff members will actively participate in hospital-wide fire
drills The Fire Response Team is made up of specific people
throughout the hospital They have additional duties during
each fire drill and fire event
bull Each department has a fire plan Each staff member is
responsible to know that plan
bull Staff will stay alert to the fire situation until the end of the drill
when ldquoCode Red All Clearrdquo is announced three times
Bethesda Healthcare System 13
Oxygen
bull Oxygen is one of the primary ingredients of fire Special care
must be taken during a fire concerning oxygen being delivered
to patients
ndash ZONE OXYGEN valves shall only be turned off by
engineering after consultation with nursing or the nursing
supervisor (new policy 2013)
ndash Bedside oxygen may be turned off by trained employees
bull The hospital is divided into smoke compartments When the fire
alarm sounds the doors of the smoke compartments will
automatically close Do not block these doors which are the
heavy doors in the hallways Patient room doors are not smoke
compartment doors
bull Another source of free air flow in a fire is the elevator shaft
DO NOT USE ELEVATORS DURING A FIRE or FIRE ALARM
Bethesda Healthcare System 14
Electricity
bull In the event of a power outage an emergency power system will
activate within 10 seconds The emergency system will only
power emergency outlets (red outlets) switches and certain
emergency lighting (on all the time with no onoff switches)
bull Use the red outlets (emergency outlets) for ALL life sustaining
equipment
Bethesda Healthcare System 15
Electrical Hazards
bull Electricity is such a common part of our everyday lives that we
sometimes forget the hazards of using this form of energy Signs of
potential electrical hazard are
ndash frayed or damaged cords
ndash loose connections
ndash cords or connections in or near liquids
ndash electrical tools that spark shock or smoke due to damage or defect
ndash loss or lack of grounding electrical equipment
bull Extension cords are to be used only on a temporary basis and must
be approved by Engineering
bull Any appliances brought from home MUST by approved by Biomedical
Maintenance
Bethesda Healthcare System 16
Electrical Hazards
Make it common practice
bull When unplugging electrical cords from the wall outlet
bull DO NOT TO PULL or YANK on the cord when
removing ELECTRICAL CORDS FROM OUTLETS This may result in damage to the wiring and has been known to
cause a spark or a shock to the user
bull Bend (at the knees)
bull Grab the electrical cord by the plug ONLY
bull Carefully pull and ease it out from the outlet
Bethesda Healthcare System 17
Lock outTag Out
bull If you discover a problem with an electrical devise contact Biomedical Maintenance and remove the item from service Always submit a work order Try to be as detailed and specific as possible about how the equipment is malfunctioning You will find the form on the Intranet page under Links called EngBio Work orders
bull When an appliance or devise has been taken out of service (lock out or tag out) you may not use it again until it has been approved by Biomedical Maintenance
bull These rules were made for your safety Do not endanger yourself or your patient by using faulty equipment
Bethesda Healthcare System 18
Downtime Status Codes for eCOS amp SCM Systems
The following codes pertain to eCOS and SCM and will be
utilized when these systems are down These codes are
announced overhead
ldquoStatus 1rdquo = System will be unavailable for up to 1 hour
ldquoStatus 2rdquo = System will be unavailable for up to 2 hours
ldquoStatus 3rdquo = System will be unavailable for more than 2 hours
ldquoSystem is now availablerdquo = System is back up and running
Bethesda Healthcare System 19
Your Environment
bull As with any home or office place occasionally there will be a
broken or poorly functioning plumbing appliance damage to
walls floors or ceiling broken furniture or other damage to the
hospital
bull Report any damage you find to the Engineering Department In
a real crisis situation call Engineering to initially report the
problem In all situations submit an engineering work order
You will find the form on the Intranet page under Links called
EngBio Work orders Fill out the form and submit it
bull Any broken furniture should be labeled with the problem
ldquoBrokenrdquo is not especially helpful for the people trying to fix the
problem
Bethesda Healthcare System 20
Utility Failure OR 1600 Appendix G
The Utility Management Plan applies to all employees and
departments of the hospital and to the following systems
bull electrical power amp emergency power
bull natural gas medical gases vacuum
bull steam and condensation systems
bull heating and ventilation heating ventilation and air
conditioning systems
bull water (including domestic and fire protection) sewage
plumbing
bull horizontal and vertical transport systems alarm systems
(including fire) diesel fuel and
bull communicationsdata systems
Bethesda Healthcare System 21
Emergency Power
bull BHE currently have two 10000-gallon fuel tanks They are
underground with the tops about 24 feet above sea level
Therefore flooding is not likely to be the cause of a fuel tank
failure
bull A fifth generator was added with the addition of the Bethesda
Heart Hospital doubled our generating capability The new
generator is located in a separate hurricane enclosure at least 8
feet higher than the existing generators The new generator is
dedicated to air conditioning and ventilation loads but still has
the capability to carry critical loads if the need arises
bull BHW has two generators with 2 above ground 10000 gallon
fuel tanks
Bethesda Healthcare System 22
Internal Power Failure
INTERNAL POWER FAILURE
bull In the event of a power outage the red outlets would be switched to
emergency generator power
bull Life Safety lighting will be provided which will provide marginal
lighting throughout Flashlights and other portable lights are
maintained in individual departments
bull At the time of an outage persons in charge should check all red
outlets in their areas to make sure only items critical to patient care
are connected Toasters coffee pots etc should never be plugged
into red outlets
Bethesda Healthcare System 23
Red Outlets
bull To ensure life safety equipment is maintained in the event of a
power failure the only equipment that should be plugged into
ldquored emergency outletsrdquo is that equipment which is necessary to
provide appropriate care of the patient ie life safety
equipment communications equipment diagnostic information
physiological monitoring lighting etc
bull Computers are the only other acceptable pieces of equipment
that may be used in the red emergency outlets because of their
relatively low power consumption
bull Radios televisions fans etc should only be plugged into the
white normal power outlets
Bethesda Healthcare System 24
Water and Sewer
bull Water and sewer are supplied by the Local Municipal Water
Company Water comes into the building from different points
They can be isolated from one another and all are not needed
at the same time There are booster pumps to increase city
water pressure when needed If the City cannot provide water
the Engineering Department has a written procedure to connect
the irrigation well to the Hospital water supply if needed
bull Water samples are collected for testing of Legionella bacterium
annually
Bethesda Healthcare System 25
HVAC ndash Air Quality
bull Air quality throughout the building is monitored by
computer Filter changes on air handlers and isolation fans are
performed by maintenance schedules Critical care air handlers
controls pumps and fans are connected to the emergency
power system
bull Ultraviolet lighting is also used for more thorough filtration in
areas where invasive procedures are done
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 9
3 Contain
Contain the firesmoke by closing windows and doors after all
persons are out (remember to check bathrooms)
All other staff in the vicinity of the fire (not involved in the initial
discoveryresponse) are to report to the nursersquos station to
receive assignments closing all doors and windows along
the way and removing all obstacles from the hallways
All staff throughout the hospital will respond by closing all doors
and remaining on the alert for further instructions They
should not enter the fire location unless they are members of
the fire response team
Bethesda Healthcare System 10
4 Extinguish (If safe to do so)
We have many types of fire extinguishers
ABC ndash Marked with an ABC and can be used on all types of fires
Carbon Dioxide ndash used mainly for electrical fires around large pieces of
equipment
Halon Suppression Systems used on sensitive electronic equipment
K Extinguishers ndash Used on grease fires
Water Mist Extinguisher ndash Found in ORLampD best choice for protection
of hospital environments books documents and clean room facilities
To use a fire Extinguisher
P ndash pull the safety pin
A ndash aim the fire extinguisher
S ndash squeeze the handle
S ndash sweep the base of the fire with the spray
Bethesda Healthcare System 11
5 Evacuate
bull Evacuate all persons you are responsible for plus yourself to the next adjacent smoke compartment on the same floor (horizontal evacuation)
bull The charge nurse or designee will prioritize each patientrsquos evacuationcategory
bull Charge nurse or designee ensures that bag valve mask is at bedside of all ventilator dependent patients and oxygen for oxygen dependent patients
bull Staff will be assigned to conduct a methodical room-by-room search accounting for all visitors and leading all patients and visitors to safety A rubber glove will be placed on the doorknobs of all vacated rooms
bull All Emergency equipment is to be plugged into red outlets
bull Station someone at the elevator to prohibit elevator use
bull In some cases relocating patients to another floor may become necessary This is called Vertical Evacuation
Bethesda Healthcare System 12
Fire Drills
bull All staff members will actively participate in hospital-wide fire
drills The Fire Response Team is made up of specific people
throughout the hospital They have additional duties during
each fire drill and fire event
bull Each department has a fire plan Each staff member is
responsible to know that plan
bull Staff will stay alert to the fire situation until the end of the drill
when ldquoCode Red All Clearrdquo is announced three times
Bethesda Healthcare System 13
Oxygen
bull Oxygen is one of the primary ingredients of fire Special care
must be taken during a fire concerning oxygen being delivered
to patients
ndash ZONE OXYGEN valves shall only be turned off by
engineering after consultation with nursing or the nursing
supervisor (new policy 2013)
ndash Bedside oxygen may be turned off by trained employees
bull The hospital is divided into smoke compartments When the fire
alarm sounds the doors of the smoke compartments will
automatically close Do not block these doors which are the
heavy doors in the hallways Patient room doors are not smoke
compartment doors
bull Another source of free air flow in a fire is the elevator shaft
DO NOT USE ELEVATORS DURING A FIRE or FIRE ALARM
Bethesda Healthcare System 14
Electricity
bull In the event of a power outage an emergency power system will
activate within 10 seconds The emergency system will only
power emergency outlets (red outlets) switches and certain
emergency lighting (on all the time with no onoff switches)
bull Use the red outlets (emergency outlets) for ALL life sustaining
equipment
Bethesda Healthcare System 15
Electrical Hazards
bull Electricity is such a common part of our everyday lives that we
sometimes forget the hazards of using this form of energy Signs of
potential electrical hazard are
ndash frayed or damaged cords
ndash loose connections
ndash cords or connections in or near liquids
ndash electrical tools that spark shock or smoke due to damage or defect
ndash loss or lack of grounding electrical equipment
bull Extension cords are to be used only on a temporary basis and must
be approved by Engineering
bull Any appliances brought from home MUST by approved by Biomedical
Maintenance
Bethesda Healthcare System 16
Electrical Hazards
Make it common practice
bull When unplugging electrical cords from the wall outlet
bull DO NOT TO PULL or YANK on the cord when
removing ELECTRICAL CORDS FROM OUTLETS This may result in damage to the wiring and has been known to
cause a spark or a shock to the user
bull Bend (at the knees)
bull Grab the electrical cord by the plug ONLY
bull Carefully pull and ease it out from the outlet
Bethesda Healthcare System 17
Lock outTag Out
bull If you discover a problem with an electrical devise contact Biomedical Maintenance and remove the item from service Always submit a work order Try to be as detailed and specific as possible about how the equipment is malfunctioning You will find the form on the Intranet page under Links called EngBio Work orders
bull When an appliance or devise has been taken out of service (lock out or tag out) you may not use it again until it has been approved by Biomedical Maintenance
bull These rules were made for your safety Do not endanger yourself or your patient by using faulty equipment
Bethesda Healthcare System 18
Downtime Status Codes for eCOS amp SCM Systems
The following codes pertain to eCOS and SCM and will be
utilized when these systems are down These codes are
announced overhead
ldquoStatus 1rdquo = System will be unavailable for up to 1 hour
ldquoStatus 2rdquo = System will be unavailable for up to 2 hours
ldquoStatus 3rdquo = System will be unavailable for more than 2 hours
ldquoSystem is now availablerdquo = System is back up and running
Bethesda Healthcare System 19
Your Environment
bull As with any home or office place occasionally there will be a
broken or poorly functioning plumbing appliance damage to
walls floors or ceiling broken furniture or other damage to the
hospital
bull Report any damage you find to the Engineering Department In
a real crisis situation call Engineering to initially report the
problem In all situations submit an engineering work order
You will find the form on the Intranet page under Links called
EngBio Work orders Fill out the form and submit it
bull Any broken furniture should be labeled with the problem
ldquoBrokenrdquo is not especially helpful for the people trying to fix the
problem
Bethesda Healthcare System 20
Utility Failure OR 1600 Appendix G
The Utility Management Plan applies to all employees and
departments of the hospital and to the following systems
bull electrical power amp emergency power
bull natural gas medical gases vacuum
bull steam and condensation systems
bull heating and ventilation heating ventilation and air
conditioning systems
bull water (including domestic and fire protection) sewage
plumbing
bull horizontal and vertical transport systems alarm systems
(including fire) diesel fuel and
bull communicationsdata systems
Bethesda Healthcare System 21
Emergency Power
bull BHE currently have two 10000-gallon fuel tanks They are
underground with the tops about 24 feet above sea level
Therefore flooding is not likely to be the cause of a fuel tank
failure
bull A fifth generator was added with the addition of the Bethesda
Heart Hospital doubled our generating capability The new
generator is located in a separate hurricane enclosure at least 8
feet higher than the existing generators The new generator is
dedicated to air conditioning and ventilation loads but still has
the capability to carry critical loads if the need arises
bull BHW has two generators with 2 above ground 10000 gallon
fuel tanks
Bethesda Healthcare System 22
Internal Power Failure
INTERNAL POWER FAILURE
bull In the event of a power outage the red outlets would be switched to
emergency generator power
bull Life Safety lighting will be provided which will provide marginal
lighting throughout Flashlights and other portable lights are
maintained in individual departments
bull At the time of an outage persons in charge should check all red
outlets in their areas to make sure only items critical to patient care
are connected Toasters coffee pots etc should never be plugged
into red outlets
Bethesda Healthcare System 23
Red Outlets
bull To ensure life safety equipment is maintained in the event of a
power failure the only equipment that should be plugged into
ldquored emergency outletsrdquo is that equipment which is necessary to
provide appropriate care of the patient ie life safety
equipment communications equipment diagnostic information
physiological monitoring lighting etc
bull Computers are the only other acceptable pieces of equipment
that may be used in the red emergency outlets because of their
relatively low power consumption
bull Radios televisions fans etc should only be plugged into the
white normal power outlets
Bethesda Healthcare System 24
Water and Sewer
bull Water and sewer are supplied by the Local Municipal Water
Company Water comes into the building from different points
They can be isolated from one another and all are not needed
at the same time There are booster pumps to increase city
water pressure when needed If the City cannot provide water
the Engineering Department has a written procedure to connect
the irrigation well to the Hospital water supply if needed
bull Water samples are collected for testing of Legionella bacterium
annually
Bethesda Healthcare System 25
HVAC ndash Air Quality
bull Air quality throughout the building is monitored by
computer Filter changes on air handlers and isolation fans are
performed by maintenance schedules Critical care air handlers
controls pumps and fans are connected to the emergency
power system
bull Ultraviolet lighting is also used for more thorough filtration in
areas where invasive procedures are done
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 10
4 Extinguish (If safe to do so)
We have many types of fire extinguishers
ABC ndash Marked with an ABC and can be used on all types of fires
Carbon Dioxide ndash used mainly for electrical fires around large pieces of
equipment
Halon Suppression Systems used on sensitive electronic equipment
K Extinguishers ndash Used on grease fires
Water Mist Extinguisher ndash Found in ORLampD best choice for protection
of hospital environments books documents and clean room facilities
To use a fire Extinguisher
P ndash pull the safety pin
A ndash aim the fire extinguisher
S ndash squeeze the handle
S ndash sweep the base of the fire with the spray
Bethesda Healthcare System 11
5 Evacuate
bull Evacuate all persons you are responsible for plus yourself to the next adjacent smoke compartment on the same floor (horizontal evacuation)
bull The charge nurse or designee will prioritize each patientrsquos evacuationcategory
bull Charge nurse or designee ensures that bag valve mask is at bedside of all ventilator dependent patients and oxygen for oxygen dependent patients
bull Staff will be assigned to conduct a methodical room-by-room search accounting for all visitors and leading all patients and visitors to safety A rubber glove will be placed on the doorknobs of all vacated rooms
bull All Emergency equipment is to be plugged into red outlets
bull Station someone at the elevator to prohibit elevator use
bull In some cases relocating patients to another floor may become necessary This is called Vertical Evacuation
Bethesda Healthcare System 12
Fire Drills
bull All staff members will actively participate in hospital-wide fire
drills The Fire Response Team is made up of specific people
throughout the hospital They have additional duties during
each fire drill and fire event
bull Each department has a fire plan Each staff member is
responsible to know that plan
bull Staff will stay alert to the fire situation until the end of the drill
when ldquoCode Red All Clearrdquo is announced three times
Bethesda Healthcare System 13
Oxygen
bull Oxygen is one of the primary ingredients of fire Special care
must be taken during a fire concerning oxygen being delivered
to patients
ndash ZONE OXYGEN valves shall only be turned off by
engineering after consultation with nursing or the nursing
supervisor (new policy 2013)
ndash Bedside oxygen may be turned off by trained employees
bull The hospital is divided into smoke compartments When the fire
alarm sounds the doors of the smoke compartments will
automatically close Do not block these doors which are the
heavy doors in the hallways Patient room doors are not smoke
compartment doors
bull Another source of free air flow in a fire is the elevator shaft
DO NOT USE ELEVATORS DURING A FIRE or FIRE ALARM
Bethesda Healthcare System 14
Electricity
bull In the event of a power outage an emergency power system will
activate within 10 seconds The emergency system will only
power emergency outlets (red outlets) switches and certain
emergency lighting (on all the time with no onoff switches)
bull Use the red outlets (emergency outlets) for ALL life sustaining
equipment
Bethesda Healthcare System 15
Electrical Hazards
bull Electricity is such a common part of our everyday lives that we
sometimes forget the hazards of using this form of energy Signs of
potential electrical hazard are
ndash frayed or damaged cords
ndash loose connections
ndash cords or connections in or near liquids
ndash electrical tools that spark shock or smoke due to damage or defect
ndash loss or lack of grounding electrical equipment
bull Extension cords are to be used only on a temporary basis and must
be approved by Engineering
bull Any appliances brought from home MUST by approved by Biomedical
Maintenance
Bethesda Healthcare System 16
Electrical Hazards
Make it common practice
bull When unplugging electrical cords from the wall outlet
bull DO NOT TO PULL or YANK on the cord when
removing ELECTRICAL CORDS FROM OUTLETS This may result in damage to the wiring and has been known to
cause a spark or a shock to the user
bull Bend (at the knees)
bull Grab the electrical cord by the plug ONLY
bull Carefully pull and ease it out from the outlet
Bethesda Healthcare System 17
Lock outTag Out
bull If you discover a problem with an electrical devise contact Biomedical Maintenance and remove the item from service Always submit a work order Try to be as detailed and specific as possible about how the equipment is malfunctioning You will find the form on the Intranet page under Links called EngBio Work orders
bull When an appliance or devise has been taken out of service (lock out or tag out) you may not use it again until it has been approved by Biomedical Maintenance
bull These rules were made for your safety Do not endanger yourself or your patient by using faulty equipment
Bethesda Healthcare System 18
Downtime Status Codes for eCOS amp SCM Systems
The following codes pertain to eCOS and SCM and will be
utilized when these systems are down These codes are
announced overhead
ldquoStatus 1rdquo = System will be unavailable for up to 1 hour
ldquoStatus 2rdquo = System will be unavailable for up to 2 hours
ldquoStatus 3rdquo = System will be unavailable for more than 2 hours
ldquoSystem is now availablerdquo = System is back up and running
Bethesda Healthcare System 19
Your Environment
bull As with any home or office place occasionally there will be a
broken or poorly functioning plumbing appliance damage to
walls floors or ceiling broken furniture or other damage to the
hospital
bull Report any damage you find to the Engineering Department In
a real crisis situation call Engineering to initially report the
problem In all situations submit an engineering work order
You will find the form on the Intranet page under Links called
EngBio Work orders Fill out the form and submit it
bull Any broken furniture should be labeled with the problem
ldquoBrokenrdquo is not especially helpful for the people trying to fix the
problem
Bethesda Healthcare System 20
Utility Failure OR 1600 Appendix G
The Utility Management Plan applies to all employees and
departments of the hospital and to the following systems
bull electrical power amp emergency power
bull natural gas medical gases vacuum
bull steam and condensation systems
bull heating and ventilation heating ventilation and air
conditioning systems
bull water (including domestic and fire protection) sewage
plumbing
bull horizontal and vertical transport systems alarm systems
(including fire) diesel fuel and
bull communicationsdata systems
Bethesda Healthcare System 21
Emergency Power
bull BHE currently have two 10000-gallon fuel tanks They are
underground with the tops about 24 feet above sea level
Therefore flooding is not likely to be the cause of a fuel tank
failure
bull A fifth generator was added with the addition of the Bethesda
Heart Hospital doubled our generating capability The new
generator is located in a separate hurricane enclosure at least 8
feet higher than the existing generators The new generator is
dedicated to air conditioning and ventilation loads but still has
the capability to carry critical loads if the need arises
bull BHW has two generators with 2 above ground 10000 gallon
fuel tanks
Bethesda Healthcare System 22
Internal Power Failure
INTERNAL POWER FAILURE
bull In the event of a power outage the red outlets would be switched to
emergency generator power
bull Life Safety lighting will be provided which will provide marginal
lighting throughout Flashlights and other portable lights are
maintained in individual departments
bull At the time of an outage persons in charge should check all red
outlets in their areas to make sure only items critical to patient care
are connected Toasters coffee pots etc should never be plugged
into red outlets
Bethesda Healthcare System 23
Red Outlets
bull To ensure life safety equipment is maintained in the event of a
power failure the only equipment that should be plugged into
ldquored emergency outletsrdquo is that equipment which is necessary to
provide appropriate care of the patient ie life safety
equipment communications equipment diagnostic information
physiological monitoring lighting etc
bull Computers are the only other acceptable pieces of equipment
that may be used in the red emergency outlets because of their
relatively low power consumption
bull Radios televisions fans etc should only be plugged into the
white normal power outlets
Bethesda Healthcare System 24
Water and Sewer
bull Water and sewer are supplied by the Local Municipal Water
Company Water comes into the building from different points
They can be isolated from one another and all are not needed
at the same time There are booster pumps to increase city
water pressure when needed If the City cannot provide water
the Engineering Department has a written procedure to connect
the irrigation well to the Hospital water supply if needed
bull Water samples are collected for testing of Legionella bacterium
annually
Bethesda Healthcare System 25
HVAC ndash Air Quality
bull Air quality throughout the building is monitored by
computer Filter changes on air handlers and isolation fans are
performed by maintenance schedules Critical care air handlers
controls pumps and fans are connected to the emergency
power system
bull Ultraviolet lighting is also used for more thorough filtration in
areas where invasive procedures are done
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 11
5 Evacuate
bull Evacuate all persons you are responsible for plus yourself to the next adjacent smoke compartment on the same floor (horizontal evacuation)
bull The charge nurse or designee will prioritize each patientrsquos evacuationcategory
bull Charge nurse or designee ensures that bag valve mask is at bedside of all ventilator dependent patients and oxygen for oxygen dependent patients
bull Staff will be assigned to conduct a methodical room-by-room search accounting for all visitors and leading all patients and visitors to safety A rubber glove will be placed on the doorknobs of all vacated rooms
bull All Emergency equipment is to be plugged into red outlets
bull Station someone at the elevator to prohibit elevator use
bull In some cases relocating patients to another floor may become necessary This is called Vertical Evacuation
Bethesda Healthcare System 12
Fire Drills
bull All staff members will actively participate in hospital-wide fire
drills The Fire Response Team is made up of specific people
throughout the hospital They have additional duties during
each fire drill and fire event
bull Each department has a fire plan Each staff member is
responsible to know that plan
bull Staff will stay alert to the fire situation until the end of the drill
when ldquoCode Red All Clearrdquo is announced three times
Bethesda Healthcare System 13
Oxygen
bull Oxygen is one of the primary ingredients of fire Special care
must be taken during a fire concerning oxygen being delivered
to patients
ndash ZONE OXYGEN valves shall only be turned off by
engineering after consultation with nursing or the nursing
supervisor (new policy 2013)
ndash Bedside oxygen may be turned off by trained employees
bull The hospital is divided into smoke compartments When the fire
alarm sounds the doors of the smoke compartments will
automatically close Do not block these doors which are the
heavy doors in the hallways Patient room doors are not smoke
compartment doors
bull Another source of free air flow in a fire is the elevator shaft
DO NOT USE ELEVATORS DURING A FIRE or FIRE ALARM
Bethesda Healthcare System 14
Electricity
bull In the event of a power outage an emergency power system will
activate within 10 seconds The emergency system will only
power emergency outlets (red outlets) switches and certain
emergency lighting (on all the time with no onoff switches)
bull Use the red outlets (emergency outlets) for ALL life sustaining
equipment
Bethesda Healthcare System 15
Electrical Hazards
bull Electricity is such a common part of our everyday lives that we
sometimes forget the hazards of using this form of energy Signs of
potential electrical hazard are
ndash frayed or damaged cords
ndash loose connections
ndash cords or connections in or near liquids
ndash electrical tools that spark shock or smoke due to damage or defect
ndash loss or lack of grounding electrical equipment
bull Extension cords are to be used only on a temporary basis and must
be approved by Engineering
bull Any appliances brought from home MUST by approved by Biomedical
Maintenance
Bethesda Healthcare System 16
Electrical Hazards
Make it common practice
bull When unplugging electrical cords from the wall outlet
bull DO NOT TO PULL or YANK on the cord when
removing ELECTRICAL CORDS FROM OUTLETS This may result in damage to the wiring and has been known to
cause a spark or a shock to the user
bull Bend (at the knees)
bull Grab the electrical cord by the plug ONLY
bull Carefully pull and ease it out from the outlet
Bethesda Healthcare System 17
Lock outTag Out
bull If you discover a problem with an electrical devise contact Biomedical Maintenance and remove the item from service Always submit a work order Try to be as detailed and specific as possible about how the equipment is malfunctioning You will find the form on the Intranet page under Links called EngBio Work orders
bull When an appliance or devise has been taken out of service (lock out or tag out) you may not use it again until it has been approved by Biomedical Maintenance
bull These rules were made for your safety Do not endanger yourself or your patient by using faulty equipment
Bethesda Healthcare System 18
Downtime Status Codes for eCOS amp SCM Systems
The following codes pertain to eCOS and SCM and will be
utilized when these systems are down These codes are
announced overhead
ldquoStatus 1rdquo = System will be unavailable for up to 1 hour
ldquoStatus 2rdquo = System will be unavailable for up to 2 hours
ldquoStatus 3rdquo = System will be unavailable for more than 2 hours
ldquoSystem is now availablerdquo = System is back up and running
Bethesda Healthcare System 19
Your Environment
bull As with any home or office place occasionally there will be a
broken or poorly functioning plumbing appliance damage to
walls floors or ceiling broken furniture or other damage to the
hospital
bull Report any damage you find to the Engineering Department In
a real crisis situation call Engineering to initially report the
problem In all situations submit an engineering work order
You will find the form on the Intranet page under Links called
EngBio Work orders Fill out the form and submit it
bull Any broken furniture should be labeled with the problem
ldquoBrokenrdquo is not especially helpful for the people trying to fix the
problem
Bethesda Healthcare System 20
Utility Failure OR 1600 Appendix G
The Utility Management Plan applies to all employees and
departments of the hospital and to the following systems
bull electrical power amp emergency power
bull natural gas medical gases vacuum
bull steam and condensation systems
bull heating and ventilation heating ventilation and air
conditioning systems
bull water (including domestic and fire protection) sewage
plumbing
bull horizontal and vertical transport systems alarm systems
(including fire) diesel fuel and
bull communicationsdata systems
Bethesda Healthcare System 21
Emergency Power
bull BHE currently have two 10000-gallon fuel tanks They are
underground with the tops about 24 feet above sea level
Therefore flooding is not likely to be the cause of a fuel tank
failure
bull A fifth generator was added with the addition of the Bethesda
Heart Hospital doubled our generating capability The new
generator is located in a separate hurricane enclosure at least 8
feet higher than the existing generators The new generator is
dedicated to air conditioning and ventilation loads but still has
the capability to carry critical loads if the need arises
bull BHW has two generators with 2 above ground 10000 gallon
fuel tanks
Bethesda Healthcare System 22
Internal Power Failure
INTERNAL POWER FAILURE
bull In the event of a power outage the red outlets would be switched to
emergency generator power
bull Life Safety lighting will be provided which will provide marginal
lighting throughout Flashlights and other portable lights are
maintained in individual departments
bull At the time of an outage persons in charge should check all red
outlets in their areas to make sure only items critical to patient care
are connected Toasters coffee pots etc should never be plugged
into red outlets
Bethesda Healthcare System 23
Red Outlets
bull To ensure life safety equipment is maintained in the event of a
power failure the only equipment that should be plugged into
ldquored emergency outletsrdquo is that equipment which is necessary to
provide appropriate care of the patient ie life safety
equipment communications equipment diagnostic information
physiological monitoring lighting etc
bull Computers are the only other acceptable pieces of equipment
that may be used in the red emergency outlets because of their
relatively low power consumption
bull Radios televisions fans etc should only be plugged into the
white normal power outlets
Bethesda Healthcare System 24
Water and Sewer
bull Water and sewer are supplied by the Local Municipal Water
Company Water comes into the building from different points
They can be isolated from one another and all are not needed
at the same time There are booster pumps to increase city
water pressure when needed If the City cannot provide water
the Engineering Department has a written procedure to connect
the irrigation well to the Hospital water supply if needed
bull Water samples are collected for testing of Legionella bacterium
annually
Bethesda Healthcare System 25
HVAC ndash Air Quality
bull Air quality throughout the building is monitored by
computer Filter changes on air handlers and isolation fans are
performed by maintenance schedules Critical care air handlers
controls pumps and fans are connected to the emergency
power system
bull Ultraviolet lighting is also used for more thorough filtration in
areas where invasive procedures are done
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 12
Fire Drills
bull All staff members will actively participate in hospital-wide fire
drills The Fire Response Team is made up of specific people
throughout the hospital They have additional duties during
each fire drill and fire event
bull Each department has a fire plan Each staff member is
responsible to know that plan
bull Staff will stay alert to the fire situation until the end of the drill
when ldquoCode Red All Clearrdquo is announced three times
Bethesda Healthcare System 13
Oxygen
bull Oxygen is one of the primary ingredients of fire Special care
must be taken during a fire concerning oxygen being delivered
to patients
ndash ZONE OXYGEN valves shall only be turned off by
engineering after consultation with nursing or the nursing
supervisor (new policy 2013)
ndash Bedside oxygen may be turned off by trained employees
bull The hospital is divided into smoke compartments When the fire
alarm sounds the doors of the smoke compartments will
automatically close Do not block these doors which are the
heavy doors in the hallways Patient room doors are not smoke
compartment doors
bull Another source of free air flow in a fire is the elevator shaft
DO NOT USE ELEVATORS DURING A FIRE or FIRE ALARM
Bethesda Healthcare System 14
Electricity
bull In the event of a power outage an emergency power system will
activate within 10 seconds The emergency system will only
power emergency outlets (red outlets) switches and certain
emergency lighting (on all the time with no onoff switches)
bull Use the red outlets (emergency outlets) for ALL life sustaining
equipment
Bethesda Healthcare System 15
Electrical Hazards
bull Electricity is such a common part of our everyday lives that we
sometimes forget the hazards of using this form of energy Signs of
potential electrical hazard are
ndash frayed or damaged cords
ndash loose connections
ndash cords or connections in or near liquids
ndash electrical tools that spark shock or smoke due to damage or defect
ndash loss or lack of grounding electrical equipment
bull Extension cords are to be used only on a temporary basis and must
be approved by Engineering
bull Any appliances brought from home MUST by approved by Biomedical
Maintenance
Bethesda Healthcare System 16
Electrical Hazards
Make it common practice
bull When unplugging electrical cords from the wall outlet
bull DO NOT TO PULL or YANK on the cord when
removing ELECTRICAL CORDS FROM OUTLETS This may result in damage to the wiring and has been known to
cause a spark or a shock to the user
bull Bend (at the knees)
bull Grab the electrical cord by the plug ONLY
bull Carefully pull and ease it out from the outlet
Bethesda Healthcare System 17
Lock outTag Out
bull If you discover a problem with an electrical devise contact Biomedical Maintenance and remove the item from service Always submit a work order Try to be as detailed and specific as possible about how the equipment is malfunctioning You will find the form on the Intranet page under Links called EngBio Work orders
bull When an appliance or devise has been taken out of service (lock out or tag out) you may not use it again until it has been approved by Biomedical Maintenance
bull These rules were made for your safety Do not endanger yourself or your patient by using faulty equipment
Bethesda Healthcare System 18
Downtime Status Codes for eCOS amp SCM Systems
The following codes pertain to eCOS and SCM and will be
utilized when these systems are down These codes are
announced overhead
ldquoStatus 1rdquo = System will be unavailable for up to 1 hour
ldquoStatus 2rdquo = System will be unavailable for up to 2 hours
ldquoStatus 3rdquo = System will be unavailable for more than 2 hours
ldquoSystem is now availablerdquo = System is back up and running
Bethesda Healthcare System 19
Your Environment
bull As with any home or office place occasionally there will be a
broken or poorly functioning plumbing appliance damage to
walls floors or ceiling broken furniture or other damage to the
hospital
bull Report any damage you find to the Engineering Department In
a real crisis situation call Engineering to initially report the
problem In all situations submit an engineering work order
You will find the form on the Intranet page under Links called
EngBio Work orders Fill out the form and submit it
bull Any broken furniture should be labeled with the problem
ldquoBrokenrdquo is not especially helpful for the people trying to fix the
problem
Bethesda Healthcare System 20
Utility Failure OR 1600 Appendix G
The Utility Management Plan applies to all employees and
departments of the hospital and to the following systems
bull electrical power amp emergency power
bull natural gas medical gases vacuum
bull steam and condensation systems
bull heating and ventilation heating ventilation and air
conditioning systems
bull water (including domestic and fire protection) sewage
plumbing
bull horizontal and vertical transport systems alarm systems
(including fire) diesel fuel and
bull communicationsdata systems
Bethesda Healthcare System 21
Emergency Power
bull BHE currently have two 10000-gallon fuel tanks They are
underground with the tops about 24 feet above sea level
Therefore flooding is not likely to be the cause of a fuel tank
failure
bull A fifth generator was added with the addition of the Bethesda
Heart Hospital doubled our generating capability The new
generator is located in a separate hurricane enclosure at least 8
feet higher than the existing generators The new generator is
dedicated to air conditioning and ventilation loads but still has
the capability to carry critical loads if the need arises
bull BHW has two generators with 2 above ground 10000 gallon
fuel tanks
Bethesda Healthcare System 22
Internal Power Failure
INTERNAL POWER FAILURE
bull In the event of a power outage the red outlets would be switched to
emergency generator power
bull Life Safety lighting will be provided which will provide marginal
lighting throughout Flashlights and other portable lights are
maintained in individual departments
bull At the time of an outage persons in charge should check all red
outlets in their areas to make sure only items critical to patient care
are connected Toasters coffee pots etc should never be plugged
into red outlets
Bethesda Healthcare System 23
Red Outlets
bull To ensure life safety equipment is maintained in the event of a
power failure the only equipment that should be plugged into
ldquored emergency outletsrdquo is that equipment which is necessary to
provide appropriate care of the patient ie life safety
equipment communications equipment diagnostic information
physiological monitoring lighting etc
bull Computers are the only other acceptable pieces of equipment
that may be used in the red emergency outlets because of their
relatively low power consumption
bull Radios televisions fans etc should only be plugged into the
white normal power outlets
Bethesda Healthcare System 24
Water and Sewer
bull Water and sewer are supplied by the Local Municipal Water
Company Water comes into the building from different points
They can be isolated from one another and all are not needed
at the same time There are booster pumps to increase city
water pressure when needed If the City cannot provide water
the Engineering Department has a written procedure to connect
the irrigation well to the Hospital water supply if needed
bull Water samples are collected for testing of Legionella bacterium
annually
Bethesda Healthcare System 25
HVAC ndash Air Quality
bull Air quality throughout the building is monitored by
computer Filter changes on air handlers and isolation fans are
performed by maintenance schedules Critical care air handlers
controls pumps and fans are connected to the emergency
power system
bull Ultraviolet lighting is also used for more thorough filtration in
areas where invasive procedures are done
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 13
Oxygen
bull Oxygen is one of the primary ingredients of fire Special care
must be taken during a fire concerning oxygen being delivered
to patients
ndash ZONE OXYGEN valves shall only be turned off by
engineering after consultation with nursing or the nursing
supervisor (new policy 2013)
ndash Bedside oxygen may be turned off by trained employees
bull The hospital is divided into smoke compartments When the fire
alarm sounds the doors of the smoke compartments will
automatically close Do not block these doors which are the
heavy doors in the hallways Patient room doors are not smoke
compartment doors
bull Another source of free air flow in a fire is the elevator shaft
DO NOT USE ELEVATORS DURING A FIRE or FIRE ALARM
Bethesda Healthcare System 14
Electricity
bull In the event of a power outage an emergency power system will
activate within 10 seconds The emergency system will only
power emergency outlets (red outlets) switches and certain
emergency lighting (on all the time with no onoff switches)
bull Use the red outlets (emergency outlets) for ALL life sustaining
equipment
Bethesda Healthcare System 15
Electrical Hazards
bull Electricity is such a common part of our everyday lives that we
sometimes forget the hazards of using this form of energy Signs of
potential electrical hazard are
ndash frayed or damaged cords
ndash loose connections
ndash cords or connections in or near liquids
ndash electrical tools that spark shock or smoke due to damage or defect
ndash loss or lack of grounding electrical equipment
bull Extension cords are to be used only on a temporary basis and must
be approved by Engineering
bull Any appliances brought from home MUST by approved by Biomedical
Maintenance
Bethesda Healthcare System 16
Electrical Hazards
Make it common practice
bull When unplugging electrical cords from the wall outlet
bull DO NOT TO PULL or YANK on the cord when
removing ELECTRICAL CORDS FROM OUTLETS This may result in damage to the wiring and has been known to
cause a spark or a shock to the user
bull Bend (at the knees)
bull Grab the electrical cord by the plug ONLY
bull Carefully pull and ease it out from the outlet
Bethesda Healthcare System 17
Lock outTag Out
bull If you discover a problem with an electrical devise contact Biomedical Maintenance and remove the item from service Always submit a work order Try to be as detailed and specific as possible about how the equipment is malfunctioning You will find the form on the Intranet page under Links called EngBio Work orders
bull When an appliance or devise has been taken out of service (lock out or tag out) you may not use it again until it has been approved by Biomedical Maintenance
bull These rules were made for your safety Do not endanger yourself or your patient by using faulty equipment
Bethesda Healthcare System 18
Downtime Status Codes for eCOS amp SCM Systems
The following codes pertain to eCOS and SCM and will be
utilized when these systems are down These codes are
announced overhead
ldquoStatus 1rdquo = System will be unavailable for up to 1 hour
ldquoStatus 2rdquo = System will be unavailable for up to 2 hours
ldquoStatus 3rdquo = System will be unavailable for more than 2 hours
ldquoSystem is now availablerdquo = System is back up and running
Bethesda Healthcare System 19
Your Environment
bull As with any home or office place occasionally there will be a
broken or poorly functioning plumbing appliance damage to
walls floors or ceiling broken furniture or other damage to the
hospital
bull Report any damage you find to the Engineering Department In
a real crisis situation call Engineering to initially report the
problem In all situations submit an engineering work order
You will find the form on the Intranet page under Links called
EngBio Work orders Fill out the form and submit it
bull Any broken furniture should be labeled with the problem
ldquoBrokenrdquo is not especially helpful for the people trying to fix the
problem
Bethesda Healthcare System 20
Utility Failure OR 1600 Appendix G
The Utility Management Plan applies to all employees and
departments of the hospital and to the following systems
bull electrical power amp emergency power
bull natural gas medical gases vacuum
bull steam and condensation systems
bull heating and ventilation heating ventilation and air
conditioning systems
bull water (including domestic and fire protection) sewage
plumbing
bull horizontal and vertical transport systems alarm systems
(including fire) diesel fuel and
bull communicationsdata systems
Bethesda Healthcare System 21
Emergency Power
bull BHE currently have two 10000-gallon fuel tanks They are
underground with the tops about 24 feet above sea level
Therefore flooding is not likely to be the cause of a fuel tank
failure
bull A fifth generator was added with the addition of the Bethesda
Heart Hospital doubled our generating capability The new
generator is located in a separate hurricane enclosure at least 8
feet higher than the existing generators The new generator is
dedicated to air conditioning and ventilation loads but still has
the capability to carry critical loads if the need arises
bull BHW has two generators with 2 above ground 10000 gallon
fuel tanks
Bethesda Healthcare System 22
Internal Power Failure
INTERNAL POWER FAILURE
bull In the event of a power outage the red outlets would be switched to
emergency generator power
bull Life Safety lighting will be provided which will provide marginal
lighting throughout Flashlights and other portable lights are
maintained in individual departments
bull At the time of an outage persons in charge should check all red
outlets in their areas to make sure only items critical to patient care
are connected Toasters coffee pots etc should never be plugged
into red outlets
Bethesda Healthcare System 23
Red Outlets
bull To ensure life safety equipment is maintained in the event of a
power failure the only equipment that should be plugged into
ldquored emergency outletsrdquo is that equipment which is necessary to
provide appropriate care of the patient ie life safety
equipment communications equipment diagnostic information
physiological monitoring lighting etc
bull Computers are the only other acceptable pieces of equipment
that may be used in the red emergency outlets because of their
relatively low power consumption
bull Radios televisions fans etc should only be plugged into the
white normal power outlets
Bethesda Healthcare System 24
Water and Sewer
bull Water and sewer are supplied by the Local Municipal Water
Company Water comes into the building from different points
They can be isolated from one another and all are not needed
at the same time There are booster pumps to increase city
water pressure when needed If the City cannot provide water
the Engineering Department has a written procedure to connect
the irrigation well to the Hospital water supply if needed
bull Water samples are collected for testing of Legionella bacterium
annually
Bethesda Healthcare System 25
HVAC ndash Air Quality
bull Air quality throughout the building is monitored by
computer Filter changes on air handlers and isolation fans are
performed by maintenance schedules Critical care air handlers
controls pumps and fans are connected to the emergency
power system
bull Ultraviolet lighting is also used for more thorough filtration in
areas where invasive procedures are done
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 14
Electricity
bull In the event of a power outage an emergency power system will
activate within 10 seconds The emergency system will only
power emergency outlets (red outlets) switches and certain
emergency lighting (on all the time with no onoff switches)
bull Use the red outlets (emergency outlets) for ALL life sustaining
equipment
Bethesda Healthcare System 15
Electrical Hazards
bull Electricity is such a common part of our everyday lives that we
sometimes forget the hazards of using this form of energy Signs of
potential electrical hazard are
ndash frayed or damaged cords
ndash loose connections
ndash cords or connections in or near liquids
ndash electrical tools that spark shock or smoke due to damage or defect
ndash loss or lack of grounding electrical equipment
bull Extension cords are to be used only on a temporary basis and must
be approved by Engineering
bull Any appliances brought from home MUST by approved by Biomedical
Maintenance
Bethesda Healthcare System 16
Electrical Hazards
Make it common practice
bull When unplugging electrical cords from the wall outlet
bull DO NOT TO PULL or YANK on the cord when
removing ELECTRICAL CORDS FROM OUTLETS This may result in damage to the wiring and has been known to
cause a spark or a shock to the user
bull Bend (at the knees)
bull Grab the electrical cord by the plug ONLY
bull Carefully pull and ease it out from the outlet
Bethesda Healthcare System 17
Lock outTag Out
bull If you discover a problem with an electrical devise contact Biomedical Maintenance and remove the item from service Always submit a work order Try to be as detailed and specific as possible about how the equipment is malfunctioning You will find the form on the Intranet page under Links called EngBio Work orders
bull When an appliance or devise has been taken out of service (lock out or tag out) you may not use it again until it has been approved by Biomedical Maintenance
bull These rules were made for your safety Do not endanger yourself or your patient by using faulty equipment
Bethesda Healthcare System 18
Downtime Status Codes for eCOS amp SCM Systems
The following codes pertain to eCOS and SCM and will be
utilized when these systems are down These codes are
announced overhead
ldquoStatus 1rdquo = System will be unavailable for up to 1 hour
ldquoStatus 2rdquo = System will be unavailable for up to 2 hours
ldquoStatus 3rdquo = System will be unavailable for more than 2 hours
ldquoSystem is now availablerdquo = System is back up and running
Bethesda Healthcare System 19
Your Environment
bull As with any home or office place occasionally there will be a
broken or poorly functioning plumbing appliance damage to
walls floors or ceiling broken furniture or other damage to the
hospital
bull Report any damage you find to the Engineering Department In
a real crisis situation call Engineering to initially report the
problem In all situations submit an engineering work order
You will find the form on the Intranet page under Links called
EngBio Work orders Fill out the form and submit it
bull Any broken furniture should be labeled with the problem
ldquoBrokenrdquo is not especially helpful for the people trying to fix the
problem
Bethesda Healthcare System 20
Utility Failure OR 1600 Appendix G
The Utility Management Plan applies to all employees and
departments of the hospital and to the following systems
bull electrical power amp emergency power
bull natural gas medical gases vacuum
bull steam and condensation systems
bull heating and ventilation heating ventilation and air
conditioning systems
bull water (including domestic and fire protection) sewage
plumbing
bull horizontal and vertical transport systems alarm systems
(including fire) diesel fuel and
bull communicationsdata systems
Bethesda Healthcare System 21
Emergency Power
bull BHE currently have two 10000-gallon fuel tanks They are
underground with the tops about 24 feet above sea level
Therefore flooding is not likely to be the cause of a fuel tank
failure
bull A fifth generator was added with the addition of the Bethesda
Heart Hospital doubled our generating capability The new
generator is located in a separate hurricane enclosure at least 8
feet higher than the existing generators The new generator is
dedicated to air conditioning and ventilation loads but still has
the capability to carry critical loads if the need arises
bull BHW has two generators with 2 above ground 10000 gallon
fuel tanks
Bethesda Healthcare System 22
Internal Power Failure
INTERNAL POWER FAILURE
bull In the event of a power outage the red outlets would be switched to
emergency generator power
bull Life Safety lighting will be provided which will provide marginal
lighting throughout Flashlights and other portable lights are
maintained in individual departments
bull At the time of an outage persons in charge should check all red
outlets in their areas to make sure only items critical to patient care
are connected Toasters coffee pots etc should never be plugged
into red outlets
Bethesda Healthcare System 23
Red Outlets
bull To ensure life safety equipment is maintained in the event of a
power failure the only equipment that should be plugged into
ldquored emergency outletsrdquo is that equipment which is necessary to
provide appropriate care of the patient ie life safety
equipment communications equipment diagnostic information
physiological monitoring lighting etc
bull Computers are the only other acceptable pieces of equipment
that may be used in the red emergency outlets because of their
relatively low power consumption
bull Radios televisions fans etc should only be plugged into the
white normal power outlets
Bethesda Healthcare System 24
Water and Sewer
bull Water and sewer are supplied by the Local Municipal Water
Company Water comes into the building from different points
They can be isolated from one another and all are not needed
at the same time There are booster pumps to increase city
water pressure when needed If the City cannot provide water
the Engineering Department has a written procedure to connect
the irrigation well to the Hospital water supply if needed
bull Water samples are collected for testing of Legionella bacterium
annually
Bethesda Healthcare System 25
HVAC ndash Air Quality
bull Air quality throughout the building is monitored by
computer Filter changes on air handlers and isolation fans are
performed by maintenance schedules Critical care air handlers
controls pumps and fans are connected to the emergency
power system
bull Ultraviolet lighting is also used for more thorough filtration in
areas where invasive procedures are done
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 15
Electrical Hazards
bull Electricity is such a common part of our everyday lives that we
sometimes forget the hazards of using this form of energy Signs of
potential electrical hazard are
ndash frayed or damaged cords
ndash loose connections
ndash cords or connections in or near liquids
ndash electrical tools that spark shock or smoke due to damage or defect
ndash loss or lack of grounding electrical equipment
bull Extension cords are to be used only on a temporary basis and must
be approved by Engineering
bull Any appliances brought from home MUST by approved by Biomedical
Maintenance
Bethesda Healthcare System 16
Electrical Hazards
Make it common practice
bull When unplugging electrical cords from the wall outlet
bull DO NOT TO PULL or YANK on the cord when
removing ELECTRICAL CORDS FROM OUTLETS This may result in damage to the wiring and has been known to
cause a spark or a shock to the user
bull Bend (at the knees)
bull Grab the electrical cord by the plug ONLY
bull Carefully pull and ease it out from the outlet
Bethesda Healthcare System 17
Lock outTag Out
bull If you discover a problem with an electrical devise contact Biomedical Maintenance and remove the item from service Always submit a work order Try to be as detailed and specific as possible about how the equipment is malfunctioning You will find the form on the Intranet page under Links called EngBio Work orders
bull When an appliance or devise has been taken out of service (lock out or tag out) you may not use it again until it has been approved by Biomedical Maintenance
bull These rules were made for your safety Do not endanger yourself or your patient by using faulty equipment
Bethesda Healthcare System 18
Downtime Status Codes for eCOS amp SCM Systems
The following codes pertain to eCOS and SCM and will be
utilized when these systems are down These codes are
announced overhead
ldquoStatus 1rdquo = System will be unavailable for up to 1 hour
ldquoStatus 2rdquo = System will be unavailable for up to 2 hours
ldquoStatus 3rdquo = System will be unavailable for more than 2 hours
ldquoSystem is now availablerdquo = System is back up and running
Bethesda Healthcare System 19
Your Environment
bull As with any home or office place occasionally there will be a
broken or poorly functioning plumbing appliance damage to
walls floors or ceiling broken furniture or other damage to the
hospital
bull Report any damage you find to the Engineering Department In
a real crisis situation call Engineering to initially report the
problem In all situations submit an engineering work order
You will find the form on the Intranet page under Links called
EngBio Work orders Fill out the form and submit it
bull Any broken furniture should be labeled with the problem
ldquoBrokenrdquo is not especially helpful for the people trying to fix the
problem
Bethesda Healthcare System 20
Utility Failure OR 1600 Appendix G
The Utility Management Plan applies to all employees and
departments of the hospital and to the following systems
bull electrical power amp emergency power
bull natural gas medical gases vacuum
bull steam and condensation systems
bull heating and ventilation heating ventilation and air
conditioning systems
bull water (including domestic and fire protection) sewage
plumbing
bull horizontal and vertical transport systems alarm systems
(including fire) diesel fuel and
bull communicationsdata systems
Bethesda Healthcare System 21
Emergency Power
bull BHE currently have two 10000-gallon fuel tanks They are
underground with the tops about 24 feet above sea level
Therefore flooding is not likely to be the cause of a fuel tank
failure
bull A fifth generator was added with the addition of the Bethesda
Heart Hospital doubled our generating capability The new
generator is located in a separate hurricane enclosure at least 8
feet higher than the existing generators The new generator is
dedicated to air conditioning and ventilation loads but still has
the capability to carry critical loads if the need arises
bull BHW has two generators with 2 above ground 10000 gallon
fuel tanks
Bethesda Healthcare System 22
Internal Power Failure
INTERNAL POWER FAILURE
bull In the event of a power outage the red outlets would be switched to
emergency generator power
bull Life Safety lighting will be provided which will provide marginal
lighting throughout Flashlights and other portable lights are
maintained in individual departments
bull At the time of an outage persons in charge should check all red
outlets in their areas to make sure only items critical to patient care
are connected Toasters coffee pots etc should never be plugged
into red outlets
Bethesda Healthcare System 23
Red Outlets
bull To ensure life safety equipment is maintained in the event of a
power failure the only equipment that should be plugged into
ldquored emergency outletsrdquo is that equipment which is necessary to
provide appropriate care of the patient ie life safety
equipment communications equipment diagnostic information
physiological monitoring lighting etc
bull Computers are the only other acceptable pieces of equipment
that may be used in the red emergency outlets because of their
relatively low power consumption
bull Radios televisions fans etc should only be plugged into the
white normal power outlets
Bethesda Healthcare System 24
Water and Sewer
bull Water and sewer are supplied by the Local Municipal Water
Company Water comes into the building from different points
They can be isolated from one another and all are not needed
at the same time There are booster pumps to increase city
water pressure when needed If the City cannot provide water
the Engineering Department has a written procedure to connect
the irrigation well to the Hospital water supply if needed
bull Water samples are collected for testing of Legionella bacterium
annually
Bethesda Healthcare System 25
HVAC ndash Air Quality
bull Air quality throughout the building is monitored by
computer Filter changes on air handlers and isolation fans are
performed by maintenance schedules Critical care air handlers
controls pumps and fans are connected to the emergency
power system
bull Ultraviolet lighting is also used for more thorough filtration in
areas where invasive procedures are done
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 16
Electrical Hazards
Make it common practice
bull When unplugging electrical cords from the wall outlet
bull DO NOT TO PULL or YANK on the cord when
removing ELECTRICAL CORDS FROM OUTLETS This may result in damage to the wiring and has been known to
cause a spark or a shock to the user
bull Bend (at the knees)
bull Grab the electrical cord by the plug ONLY
bull Carefully pull and ease it out from the outlet
Bethesda Healthcare System 17
Lock outTag Out
bull If you discover a problem with an electrical devise contact Biomedical Maintenance and remove the item from service Always submit a work order Try to be as detailed and specific as possible about how the equipment is malfunctioning You will find the form on the Intranet page under Links called EngBio Work orders
bull When an appliance or devise has been taken out of service (lock out or tag out) you may not use it again until it has been approved by Biomedical Maintenance
bull These rules were made for your safety Do not endanger yourself or your patient by using faulty equipment
Bethesda Healthcare System 18
Downtime Status Codes for eCOS amp SCM Systems
The following codes pertain to eCOS and SCM and will be
utilized when these systems are down These codes are
announced overhead
ldquoStatus 1rdquo = System will be unavailable for up to 1 hour
ldquoStatus 2rdquo = System will be unavailable for up to 2 hours
ldquoStatus 3rdquo = System will be unavailable for more than 2 hours
ldquoSystem is now availablerdquo = System is back up and running
Bethesda Healthcare System 19
Your Environment
bull As with any home or office place occasionally there will be a
broken or poorly functioning plumbing appliance damage to
walls floors or ceiling broken furniture or other damage to the
hospital
bull Report any damage you find to the Engineering Department In
a real crisis situation call Engineering to initially report the
problem In all situations submit an engineering work order
You will find the form on the Intranet page under Links called
EngBio Work orders Fill out the form and submit it
bull Any broken furniture should be labeled with the problem
ldquoBrokenrdquo is not especially helpful for the people trying to fix the
problem
Bethesda Healthcare System 20
Utility Failure OR 1600 Appendix G
The Utility Management Plan applies to all employees and
departments of the hospital and to the following systems
bull electrical power amp emergency power
bull natural gas medical gases vacuum
bull steam and condensation systems
bull heating and ventilation heating ventilation and air
conditioning systems
bull water (including domestic and fire protection) sewage
plumbing
bull horizontal and vertical transport systems alarm systems
(including fire) diesel fuel and
bull communicationsdata systems
Bethesda Healthcare System 21
Emergency Power
bull BHE currently have two 10000-gallon fuel tanks They are
underground with the tops about 24 feet above sea level
Therefore flooding is not likely to be the cause of a fuel tank
failure
bull A fifth generator was added with the addition of the Bethesda
Heart Hospital doubled our generating capability The new
generator is located in a separate hurricane enclosure at least 8
feet higher than the existing generators The new generator is
dedicated to air conditioning and ventilation loads but still has
the capability to carry critical loads if the need arises
bull BHW has two generators with 2 above ground 10000 gallon
fuel tanks
Bethesda Healthcare System 22
Internal Power Failure
INTERNAL POWER FAILURE
bull In the event of a power outage the red outlets would be switched to
emergency generator power
bull Life Safety lighting will be provided which will provide marginal
lighting throughout Flashlights and other portable lights are
maintained in individual departments
bull At the time of an outage persons in charge should check all red
outlets in their areas to make sure only items critical to patient care
are connected Toasters coffee pots etc should never be plugged
into red outlets
Bethesda Healthcare System 23
Red Outlets
bull To ensure life safety equipment is maintained in the event of a
power failure the only equipment that should be plugged into
ldquored emergency outletsrdquo is that equipment which is necessary to
provide appropriate care of the patient ie life safety
equipment communications equipment diagnostic information
physiological monitoring lighting etc
bull Computers are the only other acceptable pieces of equipment
that may be used in the red emergency outlets because of their
relatively low power consumption
bull Radios televisions fans etc should only be plugged into the
white normal power outlets
Bethesda Healthcare System 24
Water and Sewer
bull Water and sewer are supplied by the Local Municipal Water
Company Water comes into the building from different points
They can be isolated from one another and all are not needed
at the same time There are booster pumps to increase city
water pressure when needed If the City cannot provide water
the Engineering Department has a written procedure to connect
the irrigation well to the Hospital water supply if needed
bull Water samples are collected for testing of Legionella bacterium
annually
Bethesda Healthcare System 25
HVAC ndash Air Quality
bull Air quality throughout the building is monitored by
computer Filter changes on air handlers and isolation fans are
performed by maintenance schedules Critical care air handlers
controls pumps and fans are connected to the emergency
power system
bull Ultraviolet lighting is also used for more thorough filtration in
areas where invasive procedures are done
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 17
Lock outTag Out
bull If you discover a problem with an electrical devise contact Biomedical Maintenance and remove the item from service Always submit a work order Try to be as detailed and specific as possible about how the equipment is malfunctioning You will find the form on the Intranet page under Links called EngBio Work orders
bull When an appliance or devise has been taken out of service (lock out or tag out) you may not use it again until it has been approved by Biomedical Maintenance
bull These rules were made for your safety Do not endanger yourself or your patient by using faulty equipment
Bethesda Healthcare System 18
Downtime Status Codes for eCOS amp SCM Systems
The following codes pertain to eCOS and SCM and will be
utilized when these systems are down These codes are
announced overhead
ldquoStatus 1rdquo = System will be unavailable for up to 1 hour
ldquoStatus 2rdquo = System will be unavailable for up to 2 hours
ldquoStatus 3rdquo = System will be unavailable for more than 2 hours
ldquoSystem is now availablerdquo = System is back up and running
Bethesda Healthcare System 19
Your Environment
bull As with any home or office place occasionally there will be a
broken or poorly functioning plumbing appliance damage to
walls floors or ceiling broken furniture or other damage to the
hospital
bull Report any damage you find to the Engineering Department In
a real crisis situation call Engineering to initially report the
problem In all situations submit an engineering work order
You will find the form on the Intranet page under Links called
EngBio Work orders Fill out the form and submit it
bull Any broken furniture should be labeled with the problem
ldquoBrokenrdquo is not especially helpful for the people trying to fix the
problem
Bethesda Healthcare System 20
Utility Failure OR 1600 Appendix G
The Utility Management Plan applies to all employees and
departments of the hospital and to the following systems
bull electrical power amp emergency power
bull natural gas medical gases vacuum
bull steam and condensation systems
bull heating and ventilation heating ventilation and air
conditioning systems
bull water (including domestic and fire protection) sewage
plumbing
bull horizontal and vertical transport systems alarm systems
(including fire) diesel fuel and
bull communicationsdata systems
Bethesda Healthcare System 21
Emergency Power
bull BHE currently have two 10000-gallon fuel tanks They are
underground with the tops about 24 feet above sea level
Therefore flooding is not likely to be the cause of a fuel tank
failure
bull A fifth generator was added with the addition of the Bethesda
Heart Hospital doubled our generating capability The new
generator is located in a separate hurricane enclosure at least 8
feet higher than the existing generators The new generator is
dedicated to air conditioning and ventilation loads but still has
the capability to carry critical loads if the need arises
bull BHW has two generators with 2 above ground 10000 gallon
fuel tanks
Bethesda Healthcare System 22
Internal Power Failure
INTERNAL POWER FAILURE
bull In the event of a power outage the red outlets would be switched to
emergency generator power
bull Life Safety lighting will be provided which will provide marginal
lighting throughout Flashlights and other portable lights are
maintained in individual departments
bull At the time of an outage persons in charge should check all red
outlets in their areas to make sure only items critical to patient care
are connected Toasters coffee pots etc should never be plugged
into red outlets
Bethesda Healthcare System 23
Red Outlets
bull To ensure life safety equipment is maintained in the event of a
power failure the only equipment that should be plugged into
ldquored emergency outletsrdquo is that equipment which is necessary to
provide appropriate care of the patient ie life safety
equipment communications equipment diagnostic information
physiological monitoring lighting etc
bull Computers are the only other acceptable pieces of equipment
that may be used in the red emergency outlets because of their
relatively low power consumption
bull Radios televisions fans etc should only be plugged into the
white normal power outlets
Bethesda Healthcare System 24
Water and Sewer
bull Water and sewer are supplied by the Local Municipal Water
Company Water comes into the building from different points
They can be isolated from one another and all are not needed
at the same time There are booster pumps to increase city
water pressure when needed If the City cannot provide water
the Engineering Department has a written procedure to connect
the irrigation well to the Hospital water supply if needed
bull Water samples are collected for testing of Legionella bacterium
annually
Bethesda Healthcare System 25
HVAC ndash Air Quality
bull Air quality throughout the building is monitored by
computer Filter changes on air handlers and isolation fans are
performed by maintenance schedules Critical care air handlers
controls pumps and fans are connected to the emergency
power system
bull Ultraviolet lighting is also used for more thorough filtration in
areas where invasive procedures are done
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 18
Downtime Status Codes for eCOS amp SCM Systems
The following codes pertain to eCOS and SCM and will be
utilized when these systems are down These codes are
announced overhead
ldquoStatus 1rdquo = System will be unavailable for up to 1 hour
ldquoStatus 2rdquo = System will be unavailable for up to 2 hours
ldquoStatus 3rdquo = System will be unavailable for more than 2 hours
ldquoSystem is now availablerdquo = System is back up and running
Bethesda Healthcare System 19
Your Environment
bull As with any home or office place occasionally there will be a
broken or poorly functioning plumbing appliance damage to
walls floors or ceiling broken furniture or other damage to the
hospital
bull Report any damage you find to the Engineering Department In
a real crisis situation call Engineering to initially report the
problem In all situations submit an engineering work order
You will find the form on the Intranet page under Links called
EngBio Work orders Fill out the form and submit it
bull Any broken furniture should be labeled with the problem
ldquoBrokenrdquo is not especially helpful for the people trying to fix the
problem
Bethesda Healthcare System 20
Utility Failure OR 1600 Appendix G
The Utility Management Plan applies to all employees and
departments of the hospital and to the following systems
bull electrical power amp emergency power
bull natural gas medical gases vacuum
bull steam and condensation systems
bull heating and ventilation heating ventilation and air
conditioning systems
bull water (including domestic and fire protection) sewage
plumbing
bull horizontal and vertical transport systems alarm systems
(including fire) diesel fuel and
bull communicationsdata systems
Bethesda Healthcare System 21
Emergency Power
bull BHE currently have two 10000-gallon fuel tanks They are
underground with the tops about 24 feet above sea level
Therefore flooding is not likely to be the cause of a fuel tank
failure
bull A fifth generator was added with the addition of the Bethesda
Heart Hospital doubled our generating capability The new
generator is located in a separate hurricane enclosure at least 8
feet higher than the existing generators The new generator is
dedicated to air conditioning and ventilation loads but still has
the capability to carry critical loads if the need arises
bull BHW has two generators with 2 above ground 10000 gallon
fuel tanks
Bethesda Healthcare System 22
Internal Power Failure
INTERNAL POWER FAILURE
bull In the event of a power outage the red outlets would be switched to
emergency generator power
bull Life Safety lighting will be provided which will provide marginal
lighting throughout Flashlights and other portable lights are
maintained in individual departments
bull At the time of an outage persons in charge should check all red
outlets in their areas to make sure only items critical to patient care
are connected Toasters coffee pots etc should never be plugged
into red outlets
Bethesda Healthcare System 23
Red Outlets
bull To ensure life safety equipment is maintained in the event of a
power failure the only equipment that should be plugged into
ldquored emergency outletsrdquo is that equipment which is necessary to
provide appropriate care of the patient ie life safety
equipment communications equipment diagnostic information
physiological monitoring lighting etc
bull Computers are the only other acceptable pieces of equipment
that may be used in the red emergency outlets because of their
relatively low power consumption
bull Radios televisions fans etc should only be plugged into the
white normal power outlets
Bethesda Healthcare System 24
Water and Sewer
bull Water and sewer are supplied by the Local Municipal Water
Company Water comes into the building from different points
They can be isolated from one another and all are not needed
at the same time There are booster pumps to increase city
water pressure when needed If the City cannot provide water
the Engineering Department has a written procedure to connect
the irrigation well to the Hospital water supply if needed
bull Water samples are collected for testing of Legionella bacterium
annually
Bethesda Healthcare System 25
HVAC ndash Air Quality
bull Air quality throughout the building is monitored by
computer Filter changes on air handlers and isolation fans are
performed by maintenance schedules Critical care air handlers
controls pumps and fans are connected to the emergency
power system
bull Ultraviolet lighting is also used for more thorough filtration in
areas where invasive procedures are done
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 19
Your Environment
bull As with any home or office place occasionally there will be a
broken or poorly functioning plumbing appliance damage to
walls floors or ceiling broken furniture or other damage to the
hospital
bull Report any damage you find to the Engineering Department In
a real crisis situation call Engineering to initially report the
problem In all situations submit an engineering work order
You will find the form on the Intranet page under Links called
EngBio Work orders Fill out the form and submit it
bull Any broken furniture should be labeled with the problem
ldquoBrokenrdquo is not especially helpful for the people trying to fix the
problem
Bethesda Healthcare System 20
Utility Failure OR 1600 Appendix G
The Utility Management Plan applies to all employees and
departments of the hospital and to the following systems
bull electrical power amp emergency power
bull natural gas medical gases vacuum
bull steam and condensation systems
bull heating and ventilation heating ventilation and air
conditioning systems
bull water (including domestic and fire protection) sewage
plumbing
bull horizontal and vertical transport systems alarm systems
(including fire) diesel fuel and
bull communicationsdata systems
Bethesda Healthcare System 21
Emergency Power
bull BHE currently have two 10000-gallon fuel tanks They are
underground with the tops about 24 feet above sea level
Therefore flooding is not likely to be the cause of a fuel tank
failure
bull A fifth generator was added with the addition of the Bethesda
Heart Hospital doubled our generating capability The new
generator is located in a separate hurricane enclosure at least 8
feet higher than the existing generators The new generator is
dedicated to air conditioning and ventilation loads but still has
the capability to carry critical loads if the need arises
bull BHW has two generators with 2 above ground 10000 gallon
fuel tanks
Bethesda Healthcare System 22
Internal Power Failure
INTERNAL POWER FAILURE
bull In the event of a power outage the red outlets would be switched to
emergency generator power
bull Life Safety lighting will be provided which will provide marginal
lighting throughout Flashlights and other portable lights are
maintained in individual departments
bull At the time of an outage persons in charge should check all red
outlets in their areas to make sure only items critical to patient care
are connected Toasters coffee pots etc should never be plugged
into red outlets
Bethesda Healthcare System 23
Red Outlets
bull To ensure life safety equipment is maintained in the event of a
power failure the only equipment that should be plugged into
ldquored emergency outletsrdquo is that equipment which is necessary to
provide appropriate care of the patient ie life safety
equipment communications equipment diagnostic information
physiological monitoring lighting etc
bull Computers are the only other acceptable pieces of equipment
that may be used in the red emergency outlets because of their
relatively low power consumption
bull Radios televisions fans etc should only be plugged into the
white normal power outlets
Bethesda Healthcare System 24
Water and Sewer
bull Water and sewer are supplied by the Local Municipal Water
Company Water comes into the building from different points
They can be isolated from one another and all are not needed
at the same time There are booster pumps to increase city
water pressure when needed If the City cannot provide water
the Engineering Department has a written procedure to connect
the irrigation well to the Hospital water supply if needed
bull Water samples are collected for testing of Legionella bacterium
annually
Bethesda Healthcare System 25
HVAC ndash Air Quality
bull Air quality throughout the building is monitored by
computer Filter changes on air handlers and isolation fans are
performed by maintenance schedules Critical care air handlers
controls pumps and fans are connected to the emergency
power system
bull Ultraviolet lighting is also used for more thorough filtration in
areas where invasive procedures are done
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 20
Utility Failure OR 1600 Appendix G
The Utility Management Plan applies to all employees and
departments of the hospital and to the following systems
bull electrical power amp emergency power
bull natural gas medical gases vacuum
bull steam and condensation systems
bull heating and ventilation heating ventilation and air
conditioning systems
bull water (including domestic and fire protection) sewage
plumbing
bull horizontal and vertical transport systems alarm systems
(including fire) diesel fuel and
bull communicationsdata systems
Bethesda Healthcare System 21
Emergency Power
bull BHE currently have two 10000-gallon fuel tanks They are
underground with the tops about 24 feet above sea level
Therefore flooding is not likely to be the cause of a fuel tank
failure
bull A fifth generator was added with the addition of the Bethesda
Heart Hospital doubled our generating capability The new
generator is located in a separate hurricane enclosure at least 8
feet higher than the existing generators The new generator is
dedicated to air conditioning and ventilation loads but still has
the capability to carry critical loads if the need arises
bull BHW has two generators with 2 above ground 10000 gallon
fuel tanks
Bethesda Healthcare System 22
Internal Power Failure
INTERNAL POWER FAILURE
bull In the event of a power outage the red outlets would be switched to
emergency generator power
bull Life Safety lighting will be provided which will provide marginal
lighting throughout Flashlights and other portable lights are
maintained in individual departments
bull At the time of an outage persons in charge should check all red
outlets in their areas to make sure only items critical to patient care
are connected Toasters coffee pots etc should never be plugged
into red outlets
Bethesda Healthcare System 23
Red Outlets
bull To ensure life safety equipment is maintained in the event of a
power failure the only equipment that should be plugged into
ldquored emergency outletsrdquo is that equipment which is necessary to
provide appropriate care of the patient ie life safety
equipment communications equipment diagnostic information
physiological monitoring lighting etc
bull Computers are the only other acceptable pieces of equipment
that may be used in the red emergency outlets because of their
relatively low power consumption
bull Radios televisions fans etc should only be plugged into the
white normal power outlets
Bethesda Healthcare System 24
Water and Sewer
bull Water and sewer are supplied by the Local Municipal Water
Company Water comes into the building from different points
They can be isolated from one another and all are not needed
at the same time There are booster pumps to increase city
water pressure when needed If the City cannot provide water
the Engineering Department has a written procedure to connect
the irrigation well to the Hospital water supply if needed
bull Water samples are collected for testing of Legionella bacterium
annually
Bethesda Healthcare System 25
HVAC ndash Air Quality
bull Air quality throughout the building is monitored by
computer Filter changes on air handlers and isolation fans are
performed by maintenance schedules Critical care air handlers
controls pumps and fans are connected to the emergency
power system
bull Ultraviolet lighting is also used for more thorough filtration in
areas where invasive procedures are done
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 21
Emergency Power
bull BHE currently have two 10000-gallon fuel tanks They are
underground with the tops about 24 feet above sea level
Therefore flooding is not likely to be the cause of a fuel tank
failure
bull A fifth generator was added with the addition of the Bethesda
Heart Hospital doubled our generating capability The new
generator is located in a separate hurricane enclosure at least 8
feet higher than the existing generators The new generator is
dedicated to air conditioning and ventilation loads but still has
the capability to carry critical loads if the need arises
bull BHW has two generators with 2 above ground 10000 gallon
fuel tanks
Bethesda Healthcare System 22
Internal Power Failure
INTERNAL POWER FAILURE
bull In the event of a power outage the red outlets would be switched to
emergency generator power
bull Life Safety lighting will be provided which will provide marginal
lighting throughout Flashlights and other portable lights are
maintained in individual departments
bull At the time of an outage persons in charge should check all red
outlets in their areas to make sure only items critical to patient care
are connected Toasters coffee pots etc should never be plugged
into red outlets
Bethesda Healthcare System 23
Red Outlets
bull To ensure life safety equipment is maintained in the event of a
power failure the only equipment that should be plugged into
ldquored emergency outletsrdquo is that equipment which is necessary to
provide appropriate care of the patient ie life safety
equipment communications equipment diagnostic information
physiological monitoring lighting etc
bull Computers are the only other acceptable pieces of equipment
that may be used in the red emergency outlets because of their
relatively low power consumption
bull Radios televisions fans etc should only be plugged into the
white normal power outlets
Bethesda Healthcare System 24
Water and Sewer
bull Water and sewer are supplied by the Local Municipal Water
Company Water comes into the building from different points
They can be isolated from one another and all are not needed
at the same time There are booster pumps to increase city
water pressure when needed If the City cannot provide water
the Engineering Department has a written procedure to connect
the irrigation well to the Hospital water supply if needed
bull Water samples are collected for testing of Legionella bacterium
annually
Bethesda Healthcare System 25
HVAC ndash Air Quality
bull Air quality throughout the building is monitored by
computer Filter changes on air handlers and isolation fans are
performed by maintenance schedules Critical care air handlers
controls pumps and fans are connected to the emergency
power system
bull Ultraviolet lighting is also used for more thorough filtration in
areas where invasive procedures are done
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 22
Internal Power Failure
INTERNAL POWER FAILURE
bull In the event of a power outage the red outlets would be switched to
emergency generator power
bull Life Safety lighting will be provided which will provide marginal
lighting throughout Flashlights and other portable lights are
maintained in individual departments
bull At the time of an outage persons in charge should check all red
outlets in their areas to make sure only items critical to patient care
are connected Toasters coffee pots etc should never be plugged
into red outlets
Bethesda Healthcare System 23
Red Outlets
bull To ensure life safety equipment is maintained in the event of a
power failure the only equipment that should be plugged into
ldquored emergency outletsrdquo is that equipment which is necessary to
provide appropriate care of the patient ie life safety
equipment communications equipment diagnostic information
physiological monitoring lighting etc
bull Computers are the only other acceptable pieces of equipment
that may be used in the red emergency outlets because of their
relatively low power consumption
bull Radios televisions fans etc should only be plugged into the
white normal power outlets
Bethesda Healthcare System 24
Water and Sewer
bull Water and sewer are supplied by the Local Municipal Water
Company Water comes into the building from different points
They can be isolated from one another and all are not needed
at the same time There are booster pumps to increase city
water pressure when needed If the City cannot provide water
the Engineering Department has a written procedure to connect
the irrigation well to the Hospital water supply if needed
bull Water samples are collected for testing of Legionella bacterium
annually
Bethesda Healthcare System 25
HVAC ndash Air Quality
bull Air quality throughout the building is monitored by
computer Filter changes on air handlers and isolation fans are
performed by maintenance schedules Critical care air handlers
controls pumps and fans are connected to the emergency
power system
bull Ultraviolet lighting is also used for more thorough filtration in
areas where invasive procedures are done
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 23
Red Outlets
bull To ensure life safety equipment is maintained in the event of a
power failure the only equipment that should be plugged into
ldquored emergency outletsrdquo is that equipment which is necessary to
provide appropriate care of the patient ie life safety
equipment communications equipment diagnostic information
physiological monitoring lighting etc
bull Computers are the only other acceptable pieces of equipment
that may be used in the red emergency outlets because of their
relatively low power consumption
bull Radios televisions fans etc should only be plugged into the
white normal power outlets
Bethesda Healthcare System 24
Water and Sewer
bull Water and sewer are supplied by the Local Municipal Water
Company Water comes into the building from different points
They can be isolated from one another and all are not needed
at the same time There are booster pumps to increase city
water pressure when needed If the City cannot provide water
the Engineering Department has a written procedure to connect
the irrigation well to the Hospital water supply if needed
bull Water samples are collected for testing of Legionella bacterium
annually
Bethesda Healthcare System 25
HVAC ndash Air Quality
bull Air quality throughout the building is monitored by
computer Filter changes on air handlers and isolation fans are
performed by maintenance schedules Critical care air handlers
controls pumps and fans are connected to the emergency
power system
bull Ultraviolet lighting is also used for more thorough filtration in
areas where invasive procedures are done
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 24
Water and Sewer
bull Water and sewer are supplied by the Local Municipal Water
Company Water comes into the building from different points
They can be isolated from one another and all are not needed
at the same time There are booster pumps to increase city
water pressure when needed If the City cannot provide water
the Engineering Department has a written procedure to connect
the irrigation well to the Hospital water supply if needed
bull Water samples are collected for testing of Legionella bacterium
annually
Bethesda Healthcare System 25
HVAC ndash Air Quality
bull Air quality throughout the building is monitored by
computer Filter changes on air handlers and isolation fans are
performed by maintenance schedules Critical care air handlers
controls pumps and fans are connected to the emergency
power system
bull Ultraviolet lighting is also used for more thorough filtration in
areas where invasive procedures are done
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 25
HVAC ndash Air Quality
bull Air quality throughout the building is monitored by
computer Filter changes on air handlers and isolation fans are
performed by maintenance schedules Critical care air handlers
controls pumps and fans are connected to the emergency
power system
bull Ultraviolet lighting is also used for more thorough filtration in
areas where invasive procedures are done
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 26
Medical Gasses
bull Medical Gases are supplied by several methods The
purchased gases are stored in the tank farm
bull The Hospitalrsquos main distribution for oxygen and nitrous oxide
resides there
bull The supply of oxygen is 3500 gallons with a reserve of 500 gallons
Nitrous oxide back-up is kept in the tank farm and a procedure for
connecting tanks to the manifold is an Engineering Departmental
procedure Procedures for changing other tanks are also covered
bull Medical vacuum and air are produced on site and the pumps are
connected to the emergency power system with engineering
procedures to bypass or tie together separate systems for
redundancy
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 27
Communications
bull Communication systems are connected to the emergency power
system with battery back-up capable of holding the system up
for 30 minutes without the generators
bull If the phone system is out of service the Hospital has portable
walkie-talkies for distribution to critical areas
bull In the event of a hurricane employees are encouraged to bring
their cell phones to work
bull Battery back-up systems are maintained semi-annually
They include the Laboratory Telephone system Information
systems and battery operated light packs
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 28
OR 1600- Plan Delta And OR 1600 Environment of Care Plans
bull OR 1600 - The framework of the Emergency Operations Plan is designed as an ldquoAll Hazardsrdquo guide to mitigate prepare respond and recover from a variety of emergency eventshazards
bull OR 1600 identifies the roles and responsibilities in the command structure in the event of an emergency or disaster
bull OR 1600 can be reviewed on the intranet under administrative policies
bull OR 1600 ndash Environment of Care Plans - The environment of care plans cover the 6 areas of the environment of care and can be found on the intranet under administrative policies
bull Safety Management
bull Security Management
bull Hazardous Materials and Waste Plan
bull Fire Safety Management Plan
bull Utilities Management
bull Medical Equipment Management Plan
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 29
Code Pink
Code Pink is used to alert the hospital to an infant or child abduction with a registered patient
Code Amber is used for an unregistered child
bull In the unit where the abduction occurred call the Operator by dialing 855 at the East or 755 at the West hospital and give the age and sex of the infant or child Notify the Charge Nurse immediately
bull Seal off the unit from which the child was taken Get names addresses and telephone numbers of anyone leaving the area Do not allow anyone to enter or touch the room where the child was taken Account for all patients on the unit
bull Upon hearing the announcement indicating a male child age 5 ldquoCode Pink Male 5 yearsrdquo for example do the following
bull In your department conduct a room-by-room search
bull In the rest of the hospital when Code Pink is announced secure the building by taking a position at all exits Look for persons carrying an infant or parcel large enough to hold an infant or a child
bull Security will contain the hospital grounds contact authorities and direct any press inquiries to Public Relations or Administration
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 30
Code Yellow
bull Code Yellow is used to refer to a bomb threat This code is not
used over the loudspeakers
bull The two basic methods of discovering the threat of a bomb is to
ndash notice a suspicious looking package
ndash receive a threatening call on the telephone
bull If you notice something you suspect is a bomb ndash do not touch it
Immediately notify security and quietly evacuate the area
bull If you receive a threatening call ndash keep the caller on the line as long as
possible while sending another employee to notify security and the
Safety Officer USE THE BOMB THREAT CHECKLIST While talking
note as much information as you can about the caller and any
background noises you may hear Do not challenge the person in
any way
bull During a Code Yellow do not use cell phones or pagers as these are
possible detonation devises
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 31
Code Strong
bull Code Strong is called in any situation involving a disorderly or violent visitor patient or employee when additional personnel are needed on a short-term emergency basis
bull Procedure
ndash The first person to come upon this situation should dial ldquo855rdquo for BHE or ldquo755rdquo for BHW and call a Code Strong
ndash The code strong team will respond immediately to the call to give assistance
ndash While waiting for the team to arrive individuals should
bull not escalate the situation
bull clear the area if indicated
ndash The Administrative Supervisor is responsible for directing the Code Strong If necessary the Administrative Supervisor or Security will call 911 for police assistance
ndash The Charge Nurse Department Supervisor or designee must fill out a ldquoCode Strong Reportrdquo (Ops Reg 2608 Appendix A)
ndash When the situation is concluded the Operator announces overhead ldquoALL Clear Code Strongrdquo three times
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 32
Code Orange
bull Code Orange refers to a hostage situation
bull Upon announcement you should
ndash remain calm
ndash return to your department IF SAFELY ABLE TO DO SO
ndash do not discuss the threat in public
ndash close all doors
ndash use telephones for emergency only
bull If you are in the vicinity of the Hostage area do the following
ndash cordon off the area and restrict traffic
ndash notify Security
ndash remain calm
ndash keep other patients visitors and staff out of immediate area of danger
ndash consider whether it is prudent to move patients from nearby rooms
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 33
Code Orange
bull If you become the hostage the following behavior is recommended
bullAccept your situation
bullDo as you are told (no more no
less)
bullTry to retain your composure
bullWhen police arrive ndash follow their
instructions
bullBe observant
bullDo not make quick movements
bullDo not make suggestions
bullDo not argue
bullDo not lose hope
bullRequest medication if needed
bullOnly attempt to escape if you
are 100 positive you can get away
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 34
Code Gamma
bull This indicates a radiation accident has occurred
bull This code is part of the Plan Delta similar to chemical and biological
bull Radiation accidents can happen in many ways The accident may be
ndash Internal An I-131 Therapy patient on the Oncology Unit (who is in Radiation Isolation) that has had cardiac or respiratory arrest
ndash External A community event like a nuclear plant meltdown Cyclotron accident or a ldquoDirty Bombrdquo
bull If Code Gamma is called all departments will respond the same (as outlined in the Plan Delta Document) for all Plan Deltarsquos whether it is chemical biological or radioactive
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 35
Code Gamma ndash Policy References
bull The Code Gamma Policy can be found under
the Disaster Plan in Ops Reg 1603
bull In addition there is also an amendment to the
Code Blue Policy to help aide in event an I-
131 in-house patient suffers a cardiac or
respiratory arrest Ops Reg 2105
Attachment C
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 36
Radiation Accident during a Code Blue
bull To help aide personnel in the response to a radiation incident a radiation cart has been created It is kept and stocked by the Nuclear Medicine Department It contains items such as a GM survey meter pocket dosimeters gowns gloves signs absorbent barrier pads (chucks) hazard tape etc
bull If there is an I-131 Therapy inpatient on the Oncology floor (only 6 ndash 8 of these a year) the radiation cart will be kept in the patientrsquos room during hisher hospital stay (Since this is the most likely scenario to cause a Code Gamma) Otherwise it will be kept in Nuclear Medicine
bull The most important thing to keep in mind is to try not to spread radioactive contamination around the facility Check your shoes stretcher or any other possibly contaminated equipment with a GM survey meter
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 37
Radiation Accident during a Code Blue
bull If you are a nurse on Oncology and caring for an I-131 patient
and you find them unresponsive or in cardiacrespiratory arrest
call a Code Blue and a Code Gamma by dialing 855 at the East
hospital or 755 at the West hospital and announcing the both
codes and the location
bull Access the Radiation Cart in the patientrsquos room for handy
protection supplies during the Code Blue process
bull Check anything leaving the room for contamination This
includes BP cuffs defibrillator or stretcher even you own
shoes A trained staff member can do this with a GM survey
meter
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 38
MRI Safety
MRI Safety
There are potential risks
in the MR environment
that can affect the
patient accompanying
family members health
care personnel and
anyone finding
themselves within the
very powerful magnetic
field of an MR scanner
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 39
How safe is an MRI
The powerful magnetic field of the MR scanner IS ALWAYS ON Even when a scan is not being performed the magnet is still on
bull This powerful magnetic field can cause ferromagnetic objects to become airborne projectiles (similar to fired missiles) potentially injuring anyone within its path
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 40
Missile effect of magnetic field
bull Anything ferromagnetic being brought within the MRI scan room can become a projectile from anywhere within the room and without warning Ferromagnetic objects are drawn rapidly into the scanner and with extreme force
bull For this reason it is imperative that all people and objects be properly screened prior to coming into contact with the magnetic field
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 41
Non safe objects within the bodyhellip
bull DO NOT ENTER THE MRI SCAN ROOM WITH THE FOLLOWING
ndash cardiac pacemakers defibrillators aneurysm clips metallic foreign bodies (especially within the eye) cochlear implants and neuro or bone stimulators implanted drug infusion devices
bull Below is an image of an implanted cardiac pacemaker
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 42
Other non safe objects
Other non safe objects
bull Stethoscopes
bull Hemostats
bull Pagers
bull Cell phones
bull Watches
bull Jewelry
bull Ferromagnetic needles
bull Metallic clothing
bull Tattoos with ink containing iron oxide
bull Money clips
bull Cameras
bull Calculators
bull Hearing aids
bull Anything ferromagnetic
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 43
Pay attention to the MRI Zones
bull Zone I Open to general public The surrounding hallways leading to MRI
bull Zone II The interface between the publicly accessible uncontrolled Zone I and the strictly controlled Zones III and IV (Front desk including inpatient and outpatient waiting rooms)
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 44
Pay attention to the MRI Zones
bull Zone III this area is where free access by unscreened personnel patients or visitors could result in serious injury or death as a result of the interactions with the MRI environment This region is restricted from the general public access by a badge swipe door opening
bull Zone IV The MR scanner magnet room Zone IV is clearly marked and has a red-lighted sign stating ldquoMAGNET ALWAYS ONrdquo This zone is restricted to screened MR patients under constant supervision of trained MR personnel
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 45
Medical Codes
Life-saving instruction is a part of the days program at Camp Timpoochee
where everybody goes swimming in Choctawhatchee Bay August 1 1935
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 46
Code Blue
bull Dial 855 at the East hospital and 755 at the West hospital and request the Operator announce ldquoCode Blue and the Location (including room and bed number if applicable)
bull The person identifying the arrest will establish unresponsiveness and using standard precautions initiate Cardiopulmonary Resuscitation (CPR) if qualified UNTIL THE CODE TEAM ARRIVES
bull The next person responding is responsible for bringing the Crash Cart and setting up the equipment
bull All members of the Code Blue Team will receive notice of the Code BlueLocation via Alpha pager and respond accordingly
bull Be sure to relieve the person performing compressions every 2 minutes or 5 cycles of CPR
bull If there is an equipment malfunction during a Code Blue the equipment must be isolated bagged properly and sent to Risk Management immediately
bull All persons not needed for the emergency will stay clear of the area
Cardiac Respiratory Arrest or Medical Emergency
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 47
BEE Team- TO BEEhellipOR NOT TO BLUE
bull The Bethesda Emergency Evaluation (BEE) Team consists of the on-duty Critical Care Charge Nurse or designee and the on-duty Charge Respiratory Therapists or designee
bull The purpose of the BEE Team is to provide prompt and timely assessment and intervention for patients who demonstrate acute changes in their physical well-being
bull In the event of an unstable or rapidly deteriorating patient the floor RN Charge RN or any ancillary department staff will request the BEE Team by dialing Ext 855 at the East hospital and 755 at the West hospital and saying ldquoBEE Team to Room XXXXrdquo
bull Stay with the patient and assist the BEE Team when they arrive It will be a learning experience for you and you in turn will provide needed information for the Team
bull Donrsquot forget to complete a BEE Team feedback form available on your unit or under Clinical OR 2106 (Attachment B)
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 48
BEE Team (Cont)
Why should you take advantage of the BEE Team
bull It has been shown to increase survivability of our
patients
bull Our goal to reduce or eliminate Code Blue calls
outside of the Critical Care Units since it has been
shown that the survivability from Code Blue is better
in the Critical Care Units
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 49
BEE Team-Family Initiated
Can family membersvisitors initiate BEE team response Yes
bull Familyvisitors may activate the team by dialing ext 83111 from any hospital phone
bull The operator will use the following guidelines to determine if the rapid response team should be activated for example patient is bleeding difficulty breathingshortness of breath chest pain ldquosomething just isnrsquot rightrdquo states ldquothis is an emergencyrdquo says they are in pain or difficulty speaking
bull if the operator is in doubt the team should be activated
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 50
BEE Team-Family Initiated
bull Do not activate BEE Team for customer service issues such as
ndash Diet concerns
ndash Television problems etc
bull When the team is not activated the operator notifies the charge nurse and the RN Patient Advocate so they know and respond to the customer service issue The Patient Advocates may be reached at either extension 85013 or 85105
bull If the Patient Advocates are not available such as during the evening or weekend leave a message stating the customer service issue and also notify the Administrative Supervisor
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 51
Special Code Response Situations
bull Code Grey ndash Stroke - Operations Regulation 2134 with
Appendix A establishes a protocol for the management of
ischemic stroke before the occurrence of irreversible brain
damage occurs
bull Code HIT (Hemorrhagic Intravascular Team) ndash Operations
Regulation 2140 outlines the procedure for notification of the
appropriate personnel for the treatment and care of a
hemorrhagic condition ruptured or dissecting aortic aneurysm
or trauma to the vascular system
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 52
Signs of Abuse
bull In watching out for safety the hospital employee should be
aware that there are times when patients family members or co-
workers show signs of ill treatment This treatment can be
broken down into two broad categories
ndash Neglect ndash where basic needs such as housing clothing
nutrition or supervision are not provided and medical care is
needed
ndash Abuse ndash where a person is treated in a way that results in
damage to that person
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 53
Neglect
bull Neglect can be self inflicted or inflicted by a caregiver upon a dependent adult or child Neglect can be done on purpose but can also be unintentional
bull Signs of Neglect may include
Physical Indicators
-malnourishment
-dehydration
-poor hygiene
-overunder medication
-lack of medical care
Behavioral Indicators
-beggingstealing food
-extended stay at school
-alcohol or drug abuse
-delinquency
-consistent fatigue
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 54
Abuse
bull Abuse can be self inflicted or inflicted by a caregiver upon a dependent
adult or child Abuse can take several forms
ndash Emotional ndash aggressive or unreasonable behavior that lowers the
self esteem of the dependent person
ndash Physical -- causing non-accidental injury to the dependent
ndash Sexual ndash unethical use of a person for personal pleasure
bull All hospital personnel with direct patient contact will be alert for
signs of childadultabuseneglectdomestic violence and will report
potential abuse as required by Florida Statute
bull If you notice a situation in the hospital that you think is a sign of neglect
or abuse discuss the situation with your supervisor This is always a
highly charged emotional situation that is often best handled with
careful consideration
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 55
Incident Reporting
bull An incident is an unexpected happening
bull It could be
ndash an accident to a person
ndash faulty equipment
ndash violation of a policy or regulation
ndash medication error
bull An incident is something that needs to be
fixed The hospital cannot fix it if they donrsquot
know about it
bull If an incident occurs immediately complete
an incident report and tell your supervisor
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 56
bull An incident report is completed via the online form found on Bethesdas Intranet under Forms Tab em2-Incident reporting Detailed instructions including examples and a training program can be found on the Intranet under HELP Tab em2-Incident reporting
bull Your managerDirector or Clinical Educator can assist you with completing an incident report
bull For questionsproblems call the Quality Improvement office at extension 83653 between 8 AM and 430 PM or Risk Management at extension 84017 between 9 AM to 5 PM
How to complete an Incident Report
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 57
Sentinel Event
bull A Sentinel Event is an unanticipated death or major permanent loss
of function or one of the following
ndash infant abduction
ndash infant discharged to the wrong family
ndash rape
ndash hemolytic transfusion reaction involving major blood group
incompatibilities
ndash surgery on the wrong site or wrong patient
ndash an infection caught in the hospital that was not related to the patientrsquos
illness or condition and resulted in death or major injury
bull A Sentinel Event must be reported within 24 hours Complete an
incident report and notify your supervisor
bull The hospital cannot fix a dangerous process or lack of process they donrsquot
know about it Never hide an incident or sentinel event report
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 58
Near Miss
bull A near miss is an incident or sentinel event that was narrowly
avoided
bull A near miss is an event that signals a weakness that if not remedied
could lead to significant consequences in the near future
bull Again a dangerous process or lack of process cannot be fixed if it is not
recognized
bull Near misses are to be reported in an incident report and the supervisor
notified
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 59
Hazardous Materials
bull In our efforts to increase the health of our patients ndash we are
exposed to the presence of hazards ourselves both chemical
and biological hazards are present in the hospital
bullA copy of our Hazard Communication Program can be found in
the Operations Manual and the Human Resource Manual
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 60
Definition of Biomedical Waste (BMW) from Florida
Administrative Code Chapter 64E-16
ndashAny solid or liquid waste which may present a threat of
infection to human
ndashAbsorbent materials saturated with blood or body fluids
Body excretions such as vomit urine feces and
sputum etc are NOT considered biomedical waste
unless visibly contaminated with blood
ndashDisposable devices contaminated with blood or body
fluids
Biomedical Waste Definition
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 61
bull International biological hazard symbol on the container that
transports the waste
bull Red bags are inscribed with the biological symbol and phrases
such as ldquoBiohazard Infectious Wasterdquo
Biomedical Waste Identification
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 62
bull Biomedical waste will be identified and segregated from non-regulated
waste into two separate bins at point of origin (dirty utility room)
bull Biomedical waste red bags will be labeled with the hospital name and
address
bull Red bags must be securely tied by one of two methods
ndash Twist tightly tie in single knot
ndash Twist tightly fold over tie with cable lock
bull Biomedical waste must be transferred in a covered leak resistant
container labeled with the international biological hazard symbol
Handling Biomedical Waste
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 63
bull BMW transported off hospital property will be hauled away by a
licensed biomedical trash hauler per chapter 64E-16 Biomedical Waste
bull All BMW will be stored in a designated area that is maintained in a
sanitary condition and secured from vermin insects or unauthorized
entry and clearly labeled with the international biological hazard
symbol
bull All BMW will be incinerated on site unless there is an incinerator failure
and the contingency plan Clinical Operations Regulation 2609 is
implemented
ndash Red Bags are for Biomedical Waste (BMW) only
ndash Never reopen a Red Bag
Handling Biomedical Waste continued
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 64
bull Wear your Personal Protective Equipment
bull Use absorbent material to clean up spill
bull Discard BMW spill into into an appropriate biomedical waste container
bull Disinfect area
bull If you encounter broken glass
ndash Donrsquot pick up glass with your hands
ndash Use a dust pan amp broom tongs etc
ndash Place glass into a sharps container
Handling Biomedical Waste Spills
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 65
Chemical Hazards
bull A chemical is considered hazardous if it is flammable explosive toxic
andor corrosive Accidental exposure to hazardous chemicals can have
serious health effects for health care workers and clients
bull To be considered a hazardous chemical a substance must be
characterized by at least one of the following traits
ndash Flammable can burn or catch fire easily
ndash Explosive can explode under certain conditions
ndash Toxic has been found to be potentially poisonous
ndash Corrosive can react and damage a personrsquos skin or a container
made of certain metals or other materials
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 66
Chemical Hazards continued
bull You have the ldquoRight to Knowrdquo what hazardous materials are involved in your job and how to protect yourself
ndash The employer has the responsibility to provide the information and make it available
ndash The employee has the responsibility to ask questions read labels following instructions and adhere to all warnings
bull Safety Data Sheets (SDS) Hazardous Material Tracking Forms and Hazardous Material Inventory for your department are in a manual that is readily available Be sure to know where it is
bull SDS provide information on health amp physical hazards safety procedures spill clean up methods of disposal recommended personal protective equipment and other relevant information about each hazardous material
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 67
Procedure for Hazardous Spill
These rules apply to spills of known or unknown substances
1 Immediately secure the area (close doors windows and move
patients if they are in the area)
2 Request assistance by contacting the Infection ControlEnvironmental
Regulations Coordinator on beeper 456-2605
3 Follow the written instructions for that hazardous substance (check
MSDS or the Tracking Form ndash both in the Hazardous Material
manual)
4 Attempt to clean up the spill ONLY if you have been trained and have
proper safety equipment on You must contact the Hazardous
Material Coordinator for any large spill any mercury spill and any
chemotherapy spill
5 Ensure that the material is properly disposed before returning
patients to the area Complete an incident report through the eM2
System
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 68
Mercury Spill
bull If you come upon a mercury spill do
not clean it up Contact the
Environmental Services Supervisor
on duty They are responsible for
using mercury spill kits
bull You will find an MSDS and Tracking
Form in all departments where
mercury is used and stored
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 69
Radioactive Spill
bull Evacuate the room if possible (Shoes may be contaminated Do not track through the building)
bull Isolate the affected area by closing all doors and windows (only if to do so you do not risk further contamination)
bull Limit access to the contaminated area
bull Provide first aid to anyone who may have been injured
bull Contact the Radiation Safety Officer by paging 456-0819
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 70
Portable Oxygen Cylinders
bull Portable oxygen cylinders must be placed in a rack when not in
use
bull Empty and full oxygen cylinders need to be segregated within the
rack
ndash Full cylinders must be placed on one side of the rack
ndash Empty cylinders must be placed on the other side of the rack
bull The number of e size oxygen cylinders (empty or full) per smoke
compartment may not exceed 12
bull If you exceed the number of oxygen cylinders on your unit please
call Respiratory Therapy to return
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 71
Biological Hazards
bull Tuberculosis or TB is a disease that infects over 25000 people a
year in the US
bull TB is a disease that damages a personrsquos lungs and other parts of the
body
bull TB is spread when people who have active untreated TB germs in
their lungs (or throat) cough sneeze or speak and send their germs
into the air If you breath these germs into your lungs you can become
infected
bull TB infection means that the TB germs are in the body but in an
inactive state In most cases the body defenses control the germs by
building a wall around them The germs can stay alive inside these
walls for years in an inactive state The person is infected but not sick
bull TB disease is when the TB germs break through the walls The
germs multiply and damage the lungs or other organs
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 72
Signs amp Symptoms of TB
bull The signs of TB disease are
ndash A cough that hangs on
ndash fevers
ndash weight loss
ndash night sweats
ndash constant tiredness
ndash loss of appetite
ndash in some advanced cases coughing up blood streaked
sputum
bull People with active TB disease may have only mild symptoms
and not know that they have the disease
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 73
TB ndash Risks and Precautions
bull Some people who are infected with TB get TB disease shortly after the
germs enter the body if the defenses are weak
bull For some people the inactive TB germs become active when the body
defenses are weakened due to aging serious illness drug or alcohol
abuse or HIV infection
bull People with TB can be cured if they have proper medical treatment and
take their medication as prescribed
bull As an employee of Bethesda hospital you are required to have a TB
test every year and follow any recommendations given by the
employee nurse If you are in contact with patients with active disease
you must wear a properly fit-tested respirator to protect yourself from
infection
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 74
HIVAIDS
bull The AIDS Update and AIDS Primer CBLrsquos discuss what this
disease is and how to avoid contracting it
bull The Confirmation of Exposure Education CBL and the Infection
Control CBLs add important information on how to protect
yourself from being infected by this virus
bull If you have questions about HIVAIDS after going through the
required courses please contact the Employee Nurse for
answers
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 75
Flu Season
bull Flu season comes around every year So we want all hospital
employees to be aware of the impact of Influenza among Health
Care Workers and what you can do about it
bull Influenza is highly contagious viral disease Adults are
typically infectious 1 day before symptoms begin through
approximately 5 days after onset of illness Approximately
30-50 percent of infected person may remain asymptomatic
but they can still transmit the virus to others So the best
way to prevent this is through vaccination
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 76
Flu Season
bull When influenza affects patients disease can be severe An
increase in mortality generally accompanies influenza
epidemics this increased mortality results not only from
respiratory illness including pneumonia but also from
exacerbation of preexisting conditions such as heart lung and
kidney diseases
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 77
Flu Season
bull So every healthcare worker will want to receive the flu vaccine for their protection as well as for the protection of their patients
bull The flu vaccine is an inactivated virus so it cannot give you the flu You could develop redness or swelling at the injection site
bull Flu season peaks in January in Florida
bull After you receive the vaccine it will take 10-14 days for your body to develop antibodies to the vaccine
bull The flu vaccine will not prevent every cough or cold but it can prevent you from getting the type of influenza that can lead to serious complications like pneumonia
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 78
Flu Season Requirements
bull Bethesda is requiring the influenza vaccine for all employees
medical staff students Contractagency and volunteers by the
designated deadline They may receive the vaccine here or if
they receive it at another facility then they will need to provide
proof of receipt to Employee Health by the deadline
bull Failure to comply with this will result in disciplinary actions for
the employee Medical staff can provide documentation to
Medical staff office Volunteers can provide documentation to
Volunteer office students can provide documentation to
Education Resource Center and ContractAgency staff can
provide documentation to the Patient Services Staffing Office
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 79
Flu Season Requirements
bull We will allow declination of the vaccine for any reason but all
employees will need to sign a declination form and provide that
to Employee Health by the designate deadline If they decline to
receive the vaccine they will be required to wear a surgical mask
during all interaction with patients or within 6 feet of a patient
Failure to comply with returning the form and wearing the mask
will result in disciplinary actions for the employee
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 80
Flu Season Requirements
bull Employee Health will be providing a sticker to employees
medical staff and volunteers who receive the flu vaccine to
adhere to their badge so that they can be identified If they
receive the vaccine somewhere else they will need to bring their
proof of receipt to Employee Health to receive the sticker
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 81
Summary
Operation Reg 2106 Code Blue
Bethesda Emergency Evaluation (BEE) Team 2106
Operation Reg 2134 Code Grey
Operation Reg 2140 Code HIT
Operation Reg 2608 Code Strong
Operation Reg 2614 Code Pink
Operation Reg 1601 Code Red
Operation Reg 1606 Code Yellow
Operation Reg 1603 Disaster Plan
Operation Reg 1612 Hazardous Materials
Operation Reg 1600 Appendix F Medical Equipment Management Plans
Operation Reg 1605 Incident Reports
Operation Reg 2604 Sentinel Events
bull This course is itself a summary of some of the more common hazards that
can be found in the hospital setting It is the responsibility of every employee
to be aware of these hazards and to know what to do in the event the hazard
happens
If you need more information you can read the following policies andor
contact your supervisor
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 82
Suspicious package
bull title but no name in address
bull excessive postage
bull oil stains or discolorations
bull excessive weight
bull lopsided or uneven envelop
bull visual distractions
bull incorrect titles
bull excessive security material such
as tape or string
bull misspellings of common words
bull incorrect titles
bull no return address
bull rigid envelop
bull foreign mail air mail or special
delivery
bull restrictive markings such as
ldquoconfidentialrdquo or ldquopersonalrdquo
bull Hand written or poorly typed
address
bull protruding wires or tinfoil
Letter or parcel bomb recognition points include
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 83
Primary Ingredients for a Fire
There are three parts to every fire If you get rid of one ndash the fire
will stop They are
ndash Oxygen found in the air we breathe as well as in medical
gases used for patient treatment
ndash Heat the source of ignition for example a spark a cigarette
a heating element or static electricity
ndash Fuel Any material which contributes to the combustion of a
fire for example furniture clothing linens and flammable
materials such as light fluid and rubbing alcohol
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 84
Smoke Compartments
bull Not every door that is controlled with a magnet is a smoke door Therefore smoke
door signs have been placed above smoke compartment doors throughout the
hospital to assist you in locating smoke compartments
bull Whats a smoke compartment Hospitals are designed with smoke
compartments smoke safe areas of refuge in a firesmoke condition
bull As a rule hospitals do not require full building evacuation when there is a fire due
to their compartmentalized design In the event of a firesmoke condition we first
evacuate horizontally to the next smoke compartment on the same level (floor)
bull How do you know where the next smoke compartment is Look for the
smoke door sign above the door If the next smoke compartment is not safe
then evacuate vertically to a smoke compartment on the floor above or
below A full building evacuation is unlikely and would only be performed
under direction of the fire department
Return to Course
Smoke Doors
What are these signs
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 85
Mercury
bull The element MERCURY (Hg) is a metal which is liquid at room temperature Mercury is a bit like LEAD but its liquid You can hold it in your hand (Not recommended - its toxic) Heavy (density 136) in fact so heavy that objects such as bricks cannonballs and lumps of lead or iron will FLOAT in Mercury Gold doesnt float in mercury - it behaves more like sugar in tea Mercury does NOT stick to magnets so if it gets into your carpets or under your floorboards it will be a long-term problem Mercury vapor makes nice bright lights but is not for breathing
bull The highly reflective surface of the Mercury or Quicksilver as it is sometimes known makes it the stuff of mirrors Its also used for thermometers barometers electrical devices etc However the problem is the cumulative poisonous nature In the pure metal form its relatively inert so not so deadly but in compounds such as mercuric chloride its skull-and-crossbones stuff
(Continued on next page)
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 86
Mercury continued
bull Although mercury is a liquid it is NOT WET It has a negative
coefficient of surface tension which means it does not soak into
material but more runs off in the style of water off a ducks
back
bull Mad as a Hatter A great many hatters were mad in the old
days because mercury was used for part of the process of felt
hat-making
bull The above information comes from the website zyraorguk
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 87
Fire Response Team
bull Nursing DirectorAdmin Supervisor will go at once to the
location of the fire and determine the extent of the fire and
immediate danger to patients
bull Charge Nurse of the fire affected unit will determine the
number of patients using oxygen and insure their safety then
give orders to Engineering to shut off oxygen
bull Director of Engineering is the Hospital Fire Chief will direct
the fire response until the arrival of the Fire Department In his
absence the senior person from Engineering will act as Chief
bull Fire Response Team will go to the location of the fire bringing
fire extinguishers and remain on duty until released by Fire
Chief Team is made up of all Engineering employees and
designated Environmental Services employees
(continued on next page)
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 88
Fire Response Team (cont)
bull Director of Facilities or Engineer on Duty responsible for
turning off the air conditioning ventilating systems oxygen
systems and placing the elevators under manual control
bull Respiratory Therapy Personnel report to their department
and standby to deliver portable oxygen cylinders if needed for
patients
bull Security Guards report to the location of the fire to provide
radio communications with the telephone operator
bull Fire Personnel Pool directed by HR Mon-Fri 800A ndash 500P
and directed by Admitting on nights and weekends Pool will
assemble in the hospital lobby (or radiology lobby if necessary)
(continued on next page)
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 89
Fire Response Team (cont)
Fire Personnel Pool (cont)
bull The Pool will be made up of
bull 1 person from each Nursing Unit
bull As many as possible from Environmental Services
bull 5 people from Food and Nutrition
bull 2 people from admittingregistration
bull All Transporters
bull All other employees will remain in their departments noting
the location of the fire and immediately close all doors and
windows Evacuation of personnel only as directed by the Fire
Marshal Nursing Admin Supervisor or the Engineer on Duty
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 90
Code Strong Team Membership
bull Security Personnel (except those assigned as
Emergency Department Security Guards) will
respond)
bull A designated person from the Engineering staff
trained in Crisis Prevention Intervention (CPI) will
respond
bull The Administrative Supervisor will respond and direct
the Code Strong
bull Any staff trained in CPI will respond to the Code
Strong
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course
Bethesda Healthcare System 91
Fire Procedures for Health City Service Center or the Plaza
The person discovering a fire will carry out the following steps
in the order presented
ndash Remove any patients that might be in the immediate
vicinity of the fire
ndash Sound the nearest fire alarm
ndash Dial 911 Tell the operator your name and the exact
location of the fire
ndash Isolate the fire by closing doors to the area and insure
all fire doors are closed
ndash Notify the facility administrator and the Hospital Risk
Manager of the situation
Call Facility Administrator amp Risk
Manager
Close the
Door
Return to Course