policy approval workflow

Policy Approval Workflow

*Clinical Workgroup broadly includes any medical staff committee, nursing

committee such as Patient Care Leadership Team, administrative committee,

and/or other ad hoc workgroups.

1

Executive Summary for Policies and Procedures

QSPC and BOT February 2019 Title of Policy Last

Approved Date

Next review date after

BOT approval

Policy Owner/Author/

Reviewer

Purpose Summary of Changes

History of Review Committee

Type

AHS SYSTEM ONLY

Controlled Substance (System)

NEW 1/2020 Medication Safety Officer

Controls to meet DEA and State Board Requirements for controlled substances

P&T approval 9/2017 PCLT 12/2018 CPC approval 10/2018 MEC AH 1/2019 MEC HGH/FH/JGPH 1/2019 MEC SLH 1/2019

Clinical

CRE Infection Control (System)

Revision 12/2020 Director of Infection Control

Plan surveillance of Carbapenem-resistant Enterobacteriaceae (CRE) and guidance for precautionary measures

Minor Revisions Infection Control approval 4/2018 PCLT 12/2018 CPC approval 1/2019 MEC AH 1/2019 MEC HGH/FH/JGPH

Clinical

2

Title of Policy Last Approved

Date


BOT approval


Reviewer



Type

01/2019 MEC SLH 1/2019

HIPAA Violations Sanctions Policy (System)

Revision VP of Internal Audit and Compliance

Guidelines for enforcing the confidentiality of individually identifiable patient health information

Minor Revisions CPC approval 12/2018 PCLT 12/2018 MEC AH 1/2019 MEC HGH/FH/JGPH 01/2019 MEC SLH 1/2019

Administrative

Workplace Violence Prevention (System)

NEW Director of Environmental Health and Safety

The purpose of this policy is to protect the safety and security of all personnel, patient and visitors at Alameda Health System. Alameda Health System will represent all properties owned or leased by Alameda Health System including operations off the system/hospital grounds

NEW Environment of Care approval 4/2018 PCLT 12/2018 CPC approval 12/2018 MEC AH 1/2019 MEC HGH/FH/JGPH 01/2019 MEC SLH 1/2019

Administrative

ALAMEDA HOSPITAL ONLY

Stroke Program Administration (Alameda Hospital)

05/2015 05/2021 VP of Nursing To provide acute stroke care and enhance stroke recognition to the community.

Minor Revisions Alameda Hosp. stroke committee approval 4/2018 PCLT 12/2018 CPC approval 12/2018

Administrative

3

Title of Policy Last Approved

Date


BOT approval


Reviewer



Type

MEC AH 1/2019

Stroke Management Nursing (Alameda Hospital)

05/2015 05/2021 VP of Nursing Rapidly identify and manage patients identified with acute ischemic stroke or acute hemorrhagic stroke.

Minor Revisions Alameda Hosp. stroke committee approval 4/2018 PCLT 12/2018 CPC approval 12/2018 MEC AH 1/2019

Clinical

Medical Staff Focused Professional Practice Review (FPPE) Proctoring ( Alameda Hospital)

01/2019 Chief Medical Officer To define the process for satisfying the focused processional practice evaluation (FPPE) / proctoring requirements of the Alameda Hospital Medical Staff (AH).

MEC AH 1/2019 Administrative

HIGHLAND HOSPITAL ONLY

Addendum to Code Blue/Code White Crash Cart Medication Trays and Transport boxes (Highland Hospital )

NA NA Director of Pharmacy Additional Instructions for Code Cart Inventory and Process

New Process System P&T 10/2018 PCLT 10/2018 CPC 12/2018 MEC HGH/ FH/JGPH 1/2019

Clinical

SAN LEANDRO HOSPITAL ONLY Surgical Residency (San Leandro Hospital)

NEW Director of Perioperative Services

To define parameters of graduate education program provided through UCSF

N/A PCLT 12/2018 CPC 1/2019 MEC SLH 1/2019

Clinical

Alameda Health System Page 1 of 7

Controlled Substance Management Policy Department Pharmacy, Nursing, Medical Staff,

HIM Effective Date 1/2017

Campus All Date Revised Unit All Next Scheduled Review 1/2020 Manual Author Priya Patel Pharm.D. Replaces the following Policies: 1. AH Pyxis Medstation 4000 Controlled Substance

Accountability 2. AH Controlled Substances 3. SLH Medication Controlled Substance Theft or Loss

Responsible Person System Director of Pharmacy CAO, CNE

Purpose The organization shall have controls in place that meet all DEA and State Board Requirements for controlled substances and for other medications deemed to have high potential for diversion.

Definitions: • Controlled Substances (CS): Any medication defined by the DEA as a Scheduled Medication in Class I,

II, III, IV, or V. • Narcotics: All a subset of controlled substances that produce sedation or drowsiness effect.

Policy: A. Security

a. Storage i. Any area containing CS shall remain secure at all times. CS should never be left unattended.

ii. All CS for inpatient use shall be secured in a designated automating dispensing machine (ADM) or in a locked, irremovable cart/cabinet.

iii. CS will not be stocked in any ancillary unlocked areas. iv. Each pharmacy will remain securely locked. Only designated pharmacy staff shall have

access to the securely locked area. v. The pharmacy, including medication preparation, dispensing, and storage areas will be

designated as a “Restricted Area.” Access shall be granted only to pharmacy staff and those authorized by a staff pharmacist. No access by non-pharmacy personnel will be permitted unless a licensed pharmacist is in the pharmacy, (a pharmacist must remain in the pharmacy during the presence of non-pharmacy personnel).

vi. In the Pharmacy, controlled substances must be securely locked within the designated controlled substance pharmacy storage area at all times. Only a pharmacist or pharmacy technician shall have access to controlled substances in the pharmacy.

vii. All controlled substances (Schedules II-V) will be secured in a designated Automated Dispensing Machine (ADM). The DOP/PIC will maintain a list of all prescribers (as authorized by state regulations) and personnel authorized to handle controlled substances, inclusive of pharmacists, pharmacy technicians, nurses, nurse anesthetists/practitioners, physician assistants, and physicians. Records shall be maintained for a minimum period of 2 years following cessation of employment.

b. Access


Controlled Substance Management Policy

i. Access to CS storage areas will only be accessible to authorized staff. ii. Automated dispensing machine ADM access shall only through BIO-ID

iii. If BIO-ID is unavailable, and ADM passwords must be used, the passwords will be set to expire every 90 days

iv. For all sites and units with automated dispensing machine ADM’s the blind count process will be used when CS are stocked and removed. The blind count process is when the automated dispensing machine ADM user is required to manually count the remaining product and enter this information as part of the transaction. The user is not provided the tallied count of remaining medication.

v. Automated dispensing machine ADM and non- automated dispensing machine ADM access is removed promptly for terminated employees.

vi. Patient specific CS infusions (e.g. PCA’s, epidurals, large volume continuous infusions) are enclosed in a locked box.

vii. CS brought in by a patient that cannot be returned home are considered Patient Own Medication will be stored in a locked area of the pharmacy.

B. Pharmacy Ordering and Receiving of Controlled Substances

a. General requirements i. Ordering and receiving of CS scheduled II may be completed by either of the two processes

outlined in Section B (CSOS -preferred) or Section C (use of DEA 222 forms) or a combination of both processes.

ii. The registrant of the DEA renewal is the person of record for the Power of attorney for the site.

iii. Pharmacist in Charge will determine maximum number of staff/managers who that person will grant the Power of Attorney authority to execute orders for CS Scheduled II drugs.

iv. The registrant will complete DEA paperwork to give these staff/managers power of attorney authority. If a pharmacist in charge changes and/or the DEA renewal registrant changes, all new power of attorney paperwork for staff/managers must be completed prior to execution of CII order forms. Power of Attorney authority and paperwork are maintained on site at the pharmacy.

v. Monthly Record of Controlled Substance Purchases. The Pharmacy Director or Administrator must maintain the purchasing summary available from drug wholesalers, or a written history of all controlled substance purchases made by the facility for the month, sorted by date.

vi. Use of the Controlled Substance Ordering System to Purchase Controlled Substances, Schedule

b. Campuses are encouraged to adopt the electronic CSOS process for ordering control substances. c. Control of DEA 222 Forms and Registration Certificate

i. DEA 222 forms used to order Schedule II if CSOS not available ii. Authority: Upon receipt of the DEA 222 form from the Drug Enforcement Agency (DEA), the

PIC or designee must record each DEA form 222 into a control log to document all forms received into the pharmacy.



iii. Security: Unused DEA 222 forms will be stored in a secured area (e.g. vault, locked drawer) and only accessible by those individuals authorized to order controlled substances for schedules II.

iv. NO PRE-SIGNING of DEA 222 Forms allowed. DEA 222 forms should only be signed by the authorized agent only as orders are placed. Blank forms should never be pre-signed.

v. Execution: Care should be taken when filling out a DEA 222 form so that no erasures or alterations are made anywhere on the form. If a mistake is made, void all copies of the form and maintain the voided copy in your records. The Suppliers Copy 1 and DEA Copy 2 are sent to the drug wholesaler/supplier and Purchasers Copy 3 retained in the pharmacy.

vi. Ordering and Receiving of Controlled Substances: should be performed by different individuals whenever possible, including at least one pharmacist. Two employees will sign out DEA 222 forms or forms are kept in CII safe.

vii. Reconciliation: The receiving process must include reconciliation of controlled substances against the packing slip or invoice accompanying the order as well as the DEA 222 ordering form.

1. When Schedule II drugs are delivered/received, a pharmacist must verify the order immediately against the invoice, prior to signing the delivery receipt and releasing the courier. Pharmacy personnel must be in attendance for receipt of any delivery or delivery cannot be accepted.

2. Reconciliation of the DEA 222 form will be completed within 24 hours 3. The quantity received and date will be filled in on all DEA 222 forms 4. The quantity received and date and signatures will be filled in on the invoice. 5. The filled out DEA 222 form will be attached to the original corresponding invoice

and filed separately for 7 years. 6. The medications are then logged into the automated dispensing machine ADM for

secure storage. viii. Discrepancies: In case of any order discrepancy, shortage or breakage, the wholesaler must

be notified and the incident documented on the packing slip/invoice. 1. Incomplete or Partial Schedule II Orders and Filing DEA Form 222

a. If the DEA Form 222 is not complete (i.e. part of the order has not been received), the form and the invoice(s) shall be filed in a pending file until the balance of the order is received.

b. At the time of the receipt of the additional order, the accompanying invoice(s) must be attached to the DEA Form 222 and invoice(s) from the pending file must also be attached to complete the documentation as outlined above.

c. Upon the completion of the DEA Form 222, updates to the DEA Form 222 Log and Controlled Substance Perpetual Inventory Record, the DEA Form 222 shall be attached to the applicable invoice(s) and filed numerically in a secure retrievable file, as prescribed by state and/or federal statute/law. OR

d. If the vendor is unable to fill an order in its entirety, do not backorder. If unavailable the pharmacist will note “0 (zero)” quantity, date and sign the DEA Form 222. The Schedule-II controlled substances will then be reordered on a new DEA Form 222.



e. Pharmacist receives medications, match amount against ordered quantity, Form 222 and invoice.

f. Reconciliation of inventory is done and receipt is signed by receiving pharmacist. The medications are then logged into automated dispensing machine ADM for secure storage.

g. Any unfilled narcotic orders will not be signed off as being received. The outstanding, unfilled order will then be matched up with a later invoice when that item is subsequently delivered.

h. All of the above records are then stapled together and stored in the CII medication file.

C. Preparation and Distribution of Controlled Substances within the Hospital

a. Tamper evident packaging is utilized for CS prepared by pharmacy b. Automated dispensing machine ADM’s are utilized in patient care areas for the distribution of CS

and are interfaced with the electronic patient profile in those units that profiled machines will be used to limit access only to medications ordered for a specific patient.

c. Bar code scanning is utilized when replenishing automated dispensing machines ADM’s whenever possible.

d. The number of CS on override status in profiled automated dispensing machines ADM’s are minimized (e.g. one time injectables for emergencies)

e. For CS delivered to patient care areas, two staff members must be involved (e.g., pharmacist orders the drug, technician sends the drug).

f. Manual deliveries to non- automated dispensing machine ADM’s must be co-signed by the receiving RN and documentation is kept in the pharmacy.

g. Only a pharmacist and pharmacy technician will distribute controlled substances from the pharmacy stock to the nursing unit/OR suite.

h. Controlled substances stock will be replenished daily during pharmacy operating hours, or as needed.

i. Routinely used controlled substances will be stocked on each unit per established par levels based on regular usage evaluation or collaboration with nursing personnel.

D. Ordering and Prescribing a. Prescribing of CS is limited to only those who have a DEA which may include physicians, Licensed

Independent Practitioner (LIP) or APP (Advanced Practice Professional) with controlled substance prescribing privileges that have been granted only if the practitioner has a verified and current DEA registration.

b. The hospital shall have medical staff bylaws or a policy that shall specify the requirements for an LIP or APP with control substance prescribing privileges to have a verified and current DEA registration.

E. Administration

a. Only healthcare providers operating within the scope of their practice may administer CS. b. The individual retrieving CS from an automated dispensing machine ADM/locked storage area is

also the person that administers the medication. Exception may include emergencies.



c. Scheduled medication removal and administration should occur within 60 minutes of order d. Unscheduled/PRN medication administration should occur within 30 min of removal e. PCA syringe administration should have two licensed personnel verifying order and verification of

amount F. Waste and Destruction of CS

a. Waste i. Waste should occur at time of removal or within 30 minutes of removal and

documented in the automated dispensing machine ADM when possible ii. A witness is required for all waste

iii. Waste should occur in limited access pharmaceutical waste bins iv. For waste of CS Patches, staff is to wear gloves, fold with sticky sides together and cut

patch. Dispose of the cut patch into the appropriate limited access pharmaceutical waste bin.

b. Destruction: i. Any CS approaching expiration will be removed from stock documented in the CS

Destruction Log and kept segregated from other stock. ii. Expired meds will be destroyed using the “Reverse Distributor” process.

G. Inventory of CS c. Pharmacy

i. Two pharmacy staff, (at least one being a pharmacist), will be involved with the quarterly controlled substance inventory reconciliation

1. Full physical count of all CII quantities 2. Reconciliation

a. Perform a physical count, not an estimate, of all quantities of federal C-II controlled substances.

b. Review all acquisitions and dispositions of federal C-II controlled substances since the last inventory reconciliation report;

c. Compare (a) and (b) to determine if there are any variances; d. All records used to compile each inventory reconciliation report shall be

maintained in the pharmacy or clinic for at least 3 years in a readily retrievable form;

e. Possible causes of overages shall be identified in writing and incorporated into the inventory reconciliation report.

3. Inventory Reconciliation reports must be dated and signed by the person performing the inventory and countersigned by the Consultant Pharmacist, PIC or clinic professional director.

ii. Annual Perpetual Inventory Count includes inventory of all controlled substances in the

facility performed once a year. The inventory of the controlled substances must include the following:

1. Name and location of the hospital 2. DEA # 3. Time/date of inventory 4. Opening/close of business

Comment [Priya1]: New Law CCR 1715.65



5. Beginning date of stocking of the control drug inventory iii. Controlled substances waiting to be destroyed will be sequestered and segregated while

waiting for reverse distribution.

d. Nursing i. Unit automated dispensing machines ADM’s

1. Depending on the campus and the automated dispensing machine functionality, either of the two will occur:

a. Two licensed nursing staff members will be involved with both the end of shift accessed only CS inventory count and the weekly inventory count of all CS

b. Two licensed nursing staff members will be involved with end of shift count inventory.

H. Record Keeping of CS

e. Most controlled substance records need to be maintained on site for the prescribed DEA storage timelines (e.g., inventory records) of 3 years.

f. Record keeping of inventories and invoices for controlled substances will be kept separate for CI & CII, CIII-CV and non-controlled drugs.

g. Pharmacy must keep a record of all records from the Reverse Distribution Company for a minimum of 2 years.

I. Monitoring h. A “Compare Report” to identify stock removal and delivery will be reviewed, validated and

signed off by the pharmacist for reconciliation as the delivery of the CS occurs. i. Non-profiled automated dispensing machine ADM’s will require monthly random auditing to

reconcile physician order with Controlled substance automated dispensing machine ADM removal and administration.

j. Undocumented controlled substance waste reports will be generated and reconciled k. All automated dispensing machine ADM CS Discrepancies shall be resolved by the involved

nurse(s) and nurse manager before change of shift. No licensed staff is to be dismissed until the discrepancy is resolved. Discrepancies that cannot be resolved are jointly reviewed by pharmacy and nursing leadership.

l. Metrics will be tracked and trended to MERT m. Any discrepancies shall be submitted into the AHS Safety Alert.

J. Reporting CS losses a. A pharmacy or clinic shall report in writing identified losses and known causes to the following

regulatory bodies: i. State Board of Pharmacy within 30 days of discovery unless the cause of the loss is theft,

diversion, or self-use in which case the report shall be made within 14 days of discovery. ii. DEA for any theft or significant loss of any controlled substance within one business day of

discovery of such loss or theft.

Comment [Priya2]: Meets law CCR 1715.65 Section C which requires records be kept for 3 years.

Comment [Priya 3]: Directly from State Board of Pharmacy requirements

Comment [Priya 4]: Directly from DEA requirements



b. If the pharmacy or clinic is unable to identify the cause of the loss, further investigation shall be undertaken to identify the cause and actions necessary to prevent additional losses of controlled substances.

References 1. Title 16 State Board of Pharmacy CCR 1715.65 Inventory Reconciliation Report of Controlled Substances 2. Drug Enforcement Administration: 1-800-882-9539 and www.deadiversion.usdoj.gov. 3. US Dept of Justice: DEA Division. Pharmacist Manual: An Informational Outline of the Control Substance Act.

(http://www.deadiversion.usdoj.gov/pubs/manuals/pharm2/pharm_manual.pdf) 4. California State Board of Pharmacy. Current Year Lawbook for Pharmacy.

(http://www.pharmacy.ca.gov/laws_regs/lawbook.pdf) 5. Reducing Controlled Substances Diversion in Hospitals

(http://www.chpso.org/sites/main/files/file-attachments/controlled_substance_diversion.pdf) Approvals:

AHS Core Alameda

Hospital San Leandro

Hospital System Pharmacy Leadership Date: 9/2017 Pharmacy and Therapeutics Date: Clinical Practice Committee Medical Executive Committee Date Board of Trustees Date:

System Alameda AHS Core San Leandro Departmental - Pharmacy Date: 9/2017 Patient Care Leadership Team Date: 10/2018 Clinical Practice Council Date: 1/2019 Medical Executive Committee Date: Board of Trustees Date:

http://www.deadiversion.usdoj.gov/

http://www.deadiversion.usdoj.gov/pubs/manuals/pharm2/pharm_manual.pdf

http://www.pharmacy.ca.gov/laws_regs/lawbook.pdf

http://www.chpso.org/sites/main/files/file-attachments/controlled_substance_diversion.pdf

Medical Staff Committee: P&T Committee (if medication is involved) Critical Care Resuscitation Committee Health Information Management Infection Control Committee Quality and Patient Safety Emergency Management Environment of Care Unit Council(s) Advanced Practice Providers Committee Other

ALAMEDA HEALTH SYSTEM POLICY, PROCEDURE, GUIDELINE, STANDARDIZED PROCEDURE APPROVAL ROUTING SHEET

POLICIES WITH INCOMPLETE FORMS WILL NOT BE PROCESSED; ALL SECTIONS MUST BE COMPLETED

A Policy Owner’s Role and Campus: Document Type: Plan Title of Document: CRE Infection Control Management Plan Key Word(s) for Document search:

A hor Name: Author’s Title: Deborah Ellis System Director Infection Prevention a

Control

Dept. and Campus: Quality

Date:

B . Identify STAKEHOLDERS impacted by policy and form a reviewer work group: Nursing Allied Health EMR Med Staff Other: C. Policy Owner will identify all other stakeholders and obtain

relevant committee approval and indicate Campus and meeting date in chart below. Indicate names of people involved if possible.

Campus(s)

Meeting / Approval

Date

P&T Committee (If medication is involved): Select Medical Staff Committee: Select Critical Care: Select Resuscitation Committee: Select Health Information Management: Select Quality and Patient Safety: Select Emergency Management: Select Environment of Care: Select Advanced Practice Providers Committee: Select Infection Control Committee Highland General Hospital April, 2018

Unit Council Select Select Select D m

. VERIFY Are there any currently existing documents in A ake this document System Wide?

No other similar documents exists at any AHS location (New)

HS PolicyTech which we can be included in this? Can we

Yes: this document will be in addition to: Yes, this document

w f

ill replace the ollowing: Previous versions

R ASON for submission: Change in practice New Re g ulation Document Integration Other:

D cument Type: ALL documents must be system wide unless not applicable to all campuses. New policy Reviewed (No changes) Major revisions made Minor revisions made System Wide

I f not System Wide please explain why this is not below Campus specific: Department specific:

R urn the Routing Sheet and the Completed document to Co o rdinat or at [email protected] Effective Date: N/A change in practice already occuring

For Coordinator Us e Only

APPROVALS System Alameda AHS Core San Leandro VP of Patient Care Services Date: Pharmacy and Therapeutics (P & T) Date: 4/2018 Patient Care Leadership Team Date: 12/2018 Clinical Practice Council Date: 1/2019 Medical Executive Committee Date: Board of Trustees Date:

P&P approval form 09/2016 revised 10/16/2018

mailto:[email protected]

1

Alameda Health System

CARBAPENEM-RESISTANT ENTEROBACTERIACEAE (CRE) INFECTION PREVENTION AND CONTROL PLAN

uality

Contents Background: ............................................................................................................................ 1 Purpose .................................................................................................................................... 1 Definitions ............................................................................................................................... 2 Policy: ..................................................................................................................................... 2 CRE Infection Control Transfer Form: (included) .................................................................. 4 References: .............................................................................................................................. 4 Approvals: ............................................................................................................................... 4

Background: Control of resistant organisms is a national problem and requires that facilities who share patients work together to prevent transmission.1 This includes acute care facilities, long-term acute care hospitals, and nursing homes providing skilled nursing or rehabilitation services, but generally excludes assisted living facilities and nursing homes that do not provide more than long-term custodial care.

Purpose: To provide a plan for active surveillance of Carbapenem-resistant Enterobacteriaceae (CRE) and guidance for precautionary measures to prevent healthcare-associated transmission of CRE infection to patients, staff, and the community. This plan aligns with recommendations from the Centers for Disease Control (CDC) CRE Toolkit1 and recommendations from the California Department of Public Health (CDPH).2

Department Infection Prevention and Control Effective D ate July 13 , 2016 Campus All Date Revi sed April 1 , 2018 Unit All Next Sche duled Review Manual Infection Prevention and Control Author Infection Prevention and Control Replaces the following Policies: Responsible Person VP of

2

Definitions: CRE1: Enterobacteriaceae that are:

• Resistant to any carbapenem antimicrobial (i.e., minimum inhibitory concentrations of ≥4 mcg/ml for doripenem, meropenem, or imipenem OR ≥2 mcg/ml for ertapenem) OR

• Documented to produce carbapenemase

Additionally, for bacteria that have intrinsic imipenem nonsusceptibility (i.e., Morganella morganii, Proteus spp., Providencia spp.), resistance to carbapenems other than imipenem is required.

CP CRE vs NON-CP CRE

• CP CRE: A CRE organism that produces carbapenemase (CP). Carbapenemases are genetic elements that facilitate transfer of resistance among Enterobacteriaceae and can directly break down carbapenems. Some common carbapenemases are Klebsiella pneumoniae Carbapenemase (KPC), and the New Delhi Metallo-β-lactamase (NDM).

• Non-CP CRE: A CRE organism that does not produce carbapenemase. Policy: Patients admitted directly or through the emergency department to a critical care unit (i.e. ICU or SDU) from a long-term care facility will be placed on pre-emptive Contact Precautions and screened for CRE. If the CRE screen result is negative, Contact Precautions shall be discontinued unless required for another condition. Patients from long-term care facilities who are admitted to non-critical care units will be managed with Standard Precautions and do not require admission CRE screening.

Placement of Patients with Lab-Confirmed CRE Infection or Colonization Patients with laboratory confirmed CRE colonization or infection will be placed on Contact Precautions and may be geographically cohorted for patient care depending on the facility’s layout. Patient Care Services has the authority to designate a location for cohorting CRE patients depending on the patients’ level of care and staffing capabilities.

Infection Control has the authority to downgrade enhanced Contact Precaution measures for patients with lab confirmed non-CP CRE. This type of CRE is not typically associated with outbreaks and the patient may be managed with Contact Precautions on a general med-surg unit same as MDRO or ESBL patients. Cohorting geographically or dedicated staff is not required.

Staffing Assignment for Care of CRE Patients CP-CRE colonization or infection

• 1:1 assignment for nurses and respiratory (if respiratory services required) • Use of a CNA hall monitor may be considered on a case by case basis at the Unit

Manager or House supervisor’s discretion. For example: if there are multiple CP-CRE patients with same organism and carbapenemase in a cohorted area.

• Sitters log (included) will be implemented to track staff entering the patient’s room

3

Non-CP CRE • Patient will be managed on Contact Precautions just as a patient with confirmed MDRO

or ESBL and may be placed on a med-surg Unit.

A dedicated respiratory therapist will not be used unless there is an outbreak and multiple vented CRE patients on a unit.

Periodic Active Surveillance CRE Screening of patients in critical care units Unit-wide screening of patients and staff cohorting will be reserved only for critical care units with a CP-CRE patient as follows:

• Every other week for as long as at least one CP-CRE patient is on the unit. Move to once per month for three months if patient(s) has been discharged or left the unit.

• Infection Control has the authority to request periodic active surveillance on a different unit when a CP-CRE positive patient is identified

Infection Prevention Measures for ALL patient care units facility-wide

• Hand Hygiene compliance monitoring and reporting monthly on all patient care units • Stress importance of patients performing hand hygiene as well as healthcare workers • PPE and Contact Precautions monitoring and intervention by IC nurse during rounds

Department Specific CRE Prevention and Control Measures

Department CRE Plan Prevention Activities Emergency • Identify patients who come from long-term care facilities and if the patient will be

admitted to a critical care unit, notify the critical care unit Critical Care Units (i.e. ICU or SDU)

• Perform CRE screen on patients admitted from ED identified as having come from a long-term care facility or directly from a long-term care facility

• Pre-emptive Contact Precautions for admissions being screened for CRE • Periodic CRE screening of all patients in the critical care unit if a CP-CRE patient is on

the unit • Daily CHG bath for all ICU patients • Daily CHG bath for all CRE patients on any other critical care units • Daily device necessity review by MD – remove central lines and foleys ASAP • Assure communication of CRE status to other AHS units and other receiving facilities • Notify Infection Prevention prior to patient discharge or transfer • Complete Infection Control Transfer Form prior to patient transfer (form attached)

Respiratory Therapy

• Daily cleaning/disinfection of RT equipment/vent (high touch areas) in the occupied CP- CRE room

• Dedicated RT for cohorted CP-CRE patients will be determined on an as needed basis Infection Control • Daily consultation and rounding as needed on units with CRE patients

• Consult on the need for dedicated RT staff as needed • Enter positive CRE MDRO in patient’s Medical Record Alerts • Infection Control staff and Unit Managers will provide ongoing education regarding CRE • Ensure HH, PPE use, and proper don/doff techniques are in Infection Control Education

– new hire orientation, physician education at hire and when new residents are starting. • Provide HH compliance reports to all patient care units monthly • Support the unit based HH Champions • Report all new cases of CRE to Alameda County Public Health Department Conduct a

intensive epidemiologic review of all new CRE patients:

4

• Assess for risk of transmission within our facility • Track commonalities of the CRE patients and their prior locations

Laboratory • The microbiology laboratory will notify the IC department in addition to the patient’s nurse of positive CRE cases and whether the organism is a carbapenemase-producer

EVS - Cleaning and disinfection

• Daily cleaning of any occupied CRE room which includes high touch surfaces (e.g. bedrails, door knobs, light switches, bedside tables, call lights, phone), and all equipment (e.g. monitors, wires, IV pump, etc) to be wiped down with the hospital-approved Quat disinfectant. (Bleach-based disinfectant is not indicated for CRE)

• Terminal cleaning of room following discharge • Utilize Xenex machines (if available) on all terminal isolation rooms • Change curtains at terminal clean • ATP testing after terminal cleaning and unannounced ATP testing of high touch surfaces

in critical care and med-surg units • Reinforce disinfectant product wet contact times for EVS workers • Annual re-education/competencies on cleaning and disinfection of high touch surfaces

with return demonstration • Regular cleaning and disinfection of mop handles and EVS carts; use a clean microfiber

mop head for every room Physicians • Review necessity of vascular and foley catheters every day – order removal ASAP

• Assess admission for high risk group and order pre-emptive contact precautions and CRE screen

CRE Infection Control Transfer Form: (included) The transfer form is used to foster communication each time a patient is moved or transferred to/from another facility. This is a mandatory form required by Alameda County Public Health and must be filled out by the sending facility and provided prior to the patient’s transfer to the accepting facility. A phone handoff between facilities is also required. Notify Infection Prevention prior to patient transfer. Please attach copies of latest culture reports with susceptibilities if available.

References: 1. Centers for Disease Control and Prevention. Facility Guidance for Control of Carbapenem-

resistant Enterobacteriaceae (CRE), November 2015 Update – CRE Toolkit. National Center for Emerging and Zoonotic Infectious Diseases. Division of Healthcare Quality Promotion. Atlanta, GA. November 2015.

2. California Department of Public Health, Healthcare-Associated Infections Program. CRE Prevention Consultation. CRE Prevention Consultation. Richmond, CA. February 23, 2016.

Approvals:

System Alameda AHS Core San Leandro Departmental Date: 4/2018 Patient Care Leadership Team Date: 12/2018 Clinical Practice Council Date: 1/2019 Medical Executive Committee Date: Board of Trustees Date:

CRE High Alert Isolation Compliance Tracking Tool

Date

Time

Name (print)

Sevices (RN,

MD,RT, EVS, OT/PT)

Observe

Gel In

Observe Gown Glove

Donning

Observe Gown Glove Doffing

Observe Gel Out

Observers

Initials

Patient Sticker: Roo m number:

*Return completed forms to Infection control or the unit ma ager

Observer Printed Name Initials Observer Printed Name Initials

INFECTION CONTROL TRANSFER FORM This form should be sent with the patient/resident upon transfer. It is NOT meant to be used as criteria for admission, only to foster the continuum of care once admission has been accepted.

Demographics Patient/Resident (Last Name, First Name): Date of Birth: MRN: Transfer Date: Sending Facility Name: Contact Name: Contact Phone: Receiving Facility Name:

Precautions and PPE

Currently in Isolation Precautions? Yes If Yes, check: Contact Droplet

Airborne Other:

PERSONAL PROTECTIVE EQUIPMENT CONSIDERATIONS

CHECK ALL PPE TO BE CONSIDERED AT RECEIVING FACILITY

No isolation precautions (currently)

Organisms If the patient currently or in the past had a culture positive for a multi-drug resistant (MDR) organism

or other organism of significance to infection control/prevention, indicate organism details below and send culture report with susceptibilities to receiving facility.

Methicillin-resistant Staphylococcus aureus (MRSA)‡ No known MDR

organism or communicable

diseases

Vancomycin-resistant Enterococcus (VRE)‡

MDR Acinetobacter species, resistant to carbapenem antibiotic(s) ‡

MDR resistant to carbapenem antibiotic(s) without (organism name) carbapenemase production (non-CP-CRE)‡

Carbapenemase-producing resistant to carbapenem antibiotic(s) (CP-CRE)# (organism name)

Enterobacteriaceae† resistant to expanded-spectrum beta-lactam antibiotics (ESBL)‡

Clostridium difficile (C. diff)

Other (identify) ^: (current or ruling out*) *Additional information if known:

Symptoms/Risk Factors for Transmission Check yes to any that currently apply**: Concerning rash (e.g., vesicular) Cough/uncontrolled respiratory secretions Acute diarrhea or incontinent of stool Incontinent of urine Draining wounds Vomiting Other uncontained bodily fluid/drainage **NOTE: Appropriate PPE required if incontinent/drainage/rash NOT contained.

No Symptoms requiring

additional PPE

Other MDRO Risk Factors Is the patient currently on antibiotics? Yes No Antibiotic: Dose, Frequency: Treatment for: Start date: Stop date:

Does the patient currently have any of the following devices? Yes No Tracheostomy/Endotracheal tube Suprapubic catheter Colostomy Central line/PICC, Date inserted: Percutaneous gastrostomy tube Rectal tube Urinary catheter, Date inserted: Hemodialysis catheter †includes E.coli, Enterobacter, Klebsiella, Proteus, Serratia, Citrobacter and others ‡MDRO infection prevention precautions: https://www.cdc.gov/infectioncontrol/guidelines/mdro/index.html #Intensified MDRO Control Efforts: https://www.cdc.gov/infectioncontrol/guidelines/mdro/table3-2-intensified-control.html ^e.g. lice, scabies, disseminated shingles, norovirus, influenza, TB

Affix patient label here

https://www.cdc.gov/infectioncontrol/guidelines/mdro/index.html

https://www.cdc.gov/infectioncontrol/guidelines/mdro/table3-2-intensified-control.html

2

For patients coming from a SNF and admitted directly or through ED to ICU or SDU: 1) ORDER CRE Screen, 2) START pre-emptive Contact Precautions

No screening necessary for patients transferred to ICU/SDU from another unit OR patients admitted to non-ICU/SDU unit

Positive: “CRE + Organism”

Negative: “No CRE recovered”

RAPIDEC Positive: “Carbapenemase

producer”

RAPIDEC Negative: “No carbapenemase

detected”

No Precautions Note: patient may still be on

precautions for other conditions

Enhanced Contact Precautions • 1:1 nursing • 1:1 respiratory (if applicable) • Implement sitters log • Ensure hand hygiene, PPE use, and proper

don/doff technique of staff/visitor by sitter • Further testing by AC Public Health Lab

3 will determine type of carbapenemase (i.e. KPC, NDM, etc.). ~2wks from SpecColl

Staff Cohorting Patients must have the same CRE organism and carbapenemase for 1:1 staff cohorting

Contact Precautions ➢ Contact IC as soon as patient with CRE or

CP-CRE plans to be discharged home or to another facility

➢ Complete and fax transfer form to IC if patient discharged home or to another facility

➢ See PolicyTech for the comprehensive AHS CRE Policy

Sep 2018

Carbapenem-resistant Enterobacteriaceae (CRE) Nursing Tool

Infection Prevention & Control Department Phone: (510) 437-4131 | Fax: (510) 535-7675

CRE Screen or Culture

Keep Contact Precautions until RAPIDEC carbapenemase (CP)

test results are known

1

1Positive:

“CRE + Organism”

2

CRE Screen or Culture

Keep Contact Precautionsuntil RAPIDEC carbapenemase (CP)

test results are known

Enhanced Contact Precautions• 1:1 nursing• 1:1 respiratory (if applicable)• Implement sitters log• Ensure hand hygiene, PPE use, and proper

don/doff technique of staff/visitor by sitter

• Further testing by AC Public Health Lab will determine type of carbapenemase(i.e. KPC, NDM, etc.). ~2wks from SpecColl

Staff CohortingPatients must have the same CRE organism and carbapenemase for 1:1 staff cohorting

Carbapenem-resistant Enterobacteriaceae(CRE) Nursing Tool

Negative:“No CRE recovered”

No PrecautionsNote: patient may still be on

precautions for other conditions

Sep 2018

RAPIDEC Positive: “Carbapenemase

producer”

Contact Precautions

RAPIDEC Negative:“No carbapenemase

detected”

Infection Prevention & Control DepartmentPhone: (510) 437-4131 | Fax: (510) 535-7675

3

➢ Contact IC as soon as patient with CRE or CP-CRE plans to be discharged home or to another facility

➢ Complete and fax transfer form to IC if patient discharged home or to another facility

➢ See PolicyTech for the comprehensive AHS CRE Policy

For patients coming from a SNF and admitted directly or through ED to ICU or SDU: 1) ORDER CRE Screen, 2) START pre-emptive Contact Precautions

No screening necessary for patients transferred to ICU/SDU from another unit OR patients admitted to non-ICU/SDU unit

ALAMEDA HEALTH SYSTEM POLICY AND PROCEDURE APPROVAL ROUTING SHEET


P&P approval form 09/2016

A Document Owner (Person Responsible for policy) Rick Kibler, VP Compliance & Internal Audit Name / Title: HIPAA Violations Sanctions Policy____________ Dept: _Internal Audit & Compliance Date: ___10/16/18___________ Key Word(s):__ HIPAA Violations Sanctions _________________________________________________________________________ VERIFY Are there any currently existing policies in AHS PolicyTech: No dept should have separate policies outside of PolicyTech

No other similar policy exists at any AHS location Yes: this policy will be in addition to the following:_____________________________________________________________________ Yes, this policy will replace the following:_ HIPAA Violations Sanctions Policy dated 5/2013_____________________________

VERIFY Are there any current existing procedures on AHS Intranet (Clinical Skills / Mosby): No other procedure exists on AHS Intranet (Clinical Skills / Mosby) Yes procedure exists however it does not match our practice Explain: _____________________________________________________

REASON for submission: Change in practice New Regulation Policy Integration Other

TYPE of policy / procedure: ALL policies must be system wide unless service is not offered at all campuses Changes to existing policies must be made using track changes

System Wide: explain if Campus specific ______________________ Department specific______________________ New policy Reviewed (No changes) Major revisions made Minor revisions made Submit rationale for new policy and/or summary of changes made via email to P&P Coordinator upon completion of section A.

SHAREHOLDERS impacted by policy: Nursing IDT EMR Staffing Other__All AHS workforce members______________________ References on policy are current and evidence based best practice Leadership approval received at EACH campus prior to submitting to P&P Coordinator. Identify Leader(s) and Campus(s)

Tony Redmond, Mike Moye, Dr. Jamaleddine, David English, Richard Espinoza, Compliance Steering Committee

Submitted to P&P Coordinator by: __Rick Kibler_______________________________ Date: __10/16/18______________________ B P&P Coordinator will identify needed committee approval; after policy owner receives the identified approvals, re-submit to P&P Coordinator

Campus(s) Meeting / Approval Date

Medical Staff Committee P&T Committee Critical Care Resuscitation Committee Health Information Management Infection Control Committee Quality and Patient Safety Emergency Management Environment of Care Unit Council(s) Advanced Practice Providers Committee Other__________________________

C Once all above approvals received, return to P&P Coordinator for below approvals. Date received: __________________ Pre-Clinical Practice Council Clinical Practice Council Nursing Advisory Council Patient Care Leadership Team

CPC 12/2018

Medical Staff Service Committee(s) AH/SL only Medical Executive Committee QPSC Board of Trustees

P&P coordinator: Keywords added Archive any previous P&P(s) Document owner notified of outcome Published

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HIPAA VIOLATIONS SANCTIONS POLICY

t and Compliance Printed copies are for reference only. Please refer to electronic copy for the latest version.

Purpose This policy sets forth guidelines for enforcing the confidentiality of individually identifiable patient health information, also known as “Protected Health Information” (“PHI”).

Background Alameda Health System (AHS) follows HIPAA, HITECH and California law requirements in determining whether a breach of PHI occurred. These laws apply to the organization, as well as to all AHS workforce members.

There are consequences to the individual and the organization when we are not in compliance with Privacy laws. Federal and State Privacy laws impose civil fines up to $25,000 per violation to be paid by the employer, and criminal fines up to $250,000 to be paid by the employer and/or the individual employee. HITECH provides a tiered system for assessing the level of each HIPAA violation with penalties ranging from $100 to $50,000, not exceeding $1,500,000 in a calendar year. Some cases can also result in imprisonment of the offending employee up to one year for a standard violation. The criminal penalties increase to $100,000 and up to five years imprisonment of the offending employee if the wrongful conduct involves false pretenses, and to $250,000 and up to 10 years imprisonment of the offending employee if the wrongful conduct involves the intent to sell, transfer, or use identifiable health information for commercial advantage, personal gain or malicious harm. Additionally, violating AHS’ policies can lead to disciplinary actions, up to and including termination.

Policy AHS is committed to complying with State and Federal laws regarding the use and disclosure of protected health information. Alameda Health System’s workforce member may not access, use, or disclose any protected health information except for the purpose of Treatment, Payment, or Health Care Operations, also known as “TPO” or unless expressly authorized by the patient or otherwise permitted or required by law.

Unauthorized individuals who attempt to access, use, disclose, and/or assist others to access PHI when it is not authorized, will be sanctioned appropriately. It is the policy of AHS to take appropriate disciplinary action against any AHS workforce member that violates AHS’ privacy policies, in addition to state and federal confidentiality laws or regulations.

AHS will provide a confidential and non-retaliatory process for AHS workforce members to report potential violations to the laws and policies governing the privacy and confidentiality of

Department Compliance/Privacy Effective D te 5/2013 Campus AHS System Date Revised 2/2013, 7/2016, 8 /2018 Unit All Next Sche duled Review Manual Administrative Author Privacy and Regu latory Counsel Replaces the following Policies: Responsible Person VP, Internal Audi

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health information. All AHS workforce members should only access, use and disclose PHI as necessary for their job duties.

Definition AHS Workforce Member – consists of employees, contractors, medical staff, volunteers or any other individual who is working at AHS.

Authorized Access or Disclosure – access or disclosure of Protected Health Information that is necessary to support treatment, payment or business operations when authorized by the patient or as otherwise permitted by law.

Confidentiality of Medical Information Act (CMIA) – A state law that adds to the federal protection of personal medical records under the Health Information Portability and Accountability Act (HIPAA). CMIA protects the confidentiality of individually identifiable medical information.

Health Insurance Portability and Accountability Act (HIPAA) – A federal law that sets standards to protect the privacy and security for use and disclosure of patient health information.

Health Information Technology for Economic and Clinical Health Act (HITECH Act) - enacted to promote the adoption and meaningful use of health information technology. Subtitle D of the HITECH Act addresses and enhances the privacy and security protections associated with the electronic transmission of health information, in part, through several provisions that strengthen the civil and criminal enforcement of the HIPAA rules.

Protected Health Information (PHI) – is any element of personal information sufficient to allow identification of the individual, such as the patient's name, address, electronic mail address, telephone number, social security number, patient billing, health insurance information, or other information that alone or in combination with other publicly available information, reveals the individual's identity. Additionally, it is any individually identifiable health information that applies to a patient's past, present or future physical, mental health or condition.

Unauthorized Access or Disclosure – The inappropriate review or viewing of patient medical information without a direct need for diagnosis, treatment or other lawful use.

Violation – A violation is an act that is contrary to the meaning of HIPAA and AHS guidelines to guarantee the confidentiality of protected health information.

Procedure A. Reporting a potential privacy-related violation

AHS workforce members must immediately report all alleged, apparent, or potential violations of confidentiality to his/her supervisor, the Compliance Department, or via the Compliance Hotline.

Compliance Department Email: Compliance AHS (Global Address List) Phone: (510) 535-7788

AHS Confidential Compliance Hotline

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Compliance uses a third party vendor called Lighthouse Services for our hotline, which is available 24 hours a day, 7 days a week.

•Telephone:

◦English speaking: 844-310-0005

◦Spanish speaking: 800-216-1288

•Website: lighthouse-services.com/alamedahealthsystem

•E-mail: [email protected] (must include AHS name with report)

•Fax: (215) 689-3885 (must include AHS name with report)

All AHS workforce members are responsible for reporting suspected violations of privacy laws or policies immediately, but no later than 24 hours after discovery. No employee will be subject to retaliation, retribution or harassment for reporting a potential violation of the law, regulation, or policies; whether anonymously or not. Should an employee not require anonymity, it is suggested they contact their immediate supervisor, and follow the chain-of- command for all reports or issues. Failure to report privacy violations will result in disciplinary action.

Upon receiving a report, the Compliance Department will immediately conduct a thorough investigation and coordinate corrective measures, as necessary. All reports will be handled confidentially.

B. Breach Notification – see Breach Notification Process Policy

C. Violations The unauthorized access, use or disclosure of PHI is a privacy violation. State and Federal laws impose civil and/or criminal liability, including fines, on the organization and the workforce member who inappropriately accesses PHI. In addition, the workforce member may be subject to disciplinary action, up to and including termination.

There are two levels of privacy violations. The following list provides an outline of some, but not all, types of violations under each level.

Level 1 –unintentional violations include, but are not limited to: a. Misdirecting faxes or emails that contain PHI b. Discussing PHI in public areas where the public could overhear conversation c. Leaving computer and/or documents with PHI unattended or in a non-secure area d. Accidentally accessing the wrong patient medical record e. Accidentally providing a patient’s PHI to another patient

Level 2 –intentional violations include, but are not limited to:

a. Committing multiple (2 or more using a one year look back) Level 1 violations b. Obtaining PHI under false pretenses c. Access, use or disclosure of PHI without a job-related reason d. Discussing PHI with any unauthorized individual e. Requesting or assisting an individual in gaining unauthorized access to PHI


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f. Sharing computer information, such as passwords, that allows others to access PHI g. Using PHI for commercial or personal purposes h. Falsifying information or failing to cooperate during a privacy investigation

D. Sanctions and Enforcement

Failure to comply with AHS’ policies and procedures will result in disciplinary action. A Level 1 violation will result in a Final Reminder and a Level 2 violation will result in immediate termination. Compliance Department will collaborate with the Human Resources Department regarding appropriate disciplinary action. Results of the investigation and decision will be documented in writing and records will be retained in the employee’s HR file.

Contractors/Vendors: Failure of a contractor/vendor to follow any provisions of this policy or mitigate any unauthorized access, use or disclosure of PHI upon mutually agreeable terms may result in termination of the contract and/or vendor agreement.

References 45 CFR § 160.103 45 CFR § 164.308(1)(i) 45 CFR § 164.506(a) 45 CFR § 164.530 (e)(1) Breach Notification Process Policy California Health & Safety Code 1280.15 Compliance Non-Retaliation and Non-Retribution Policy U.S. Department of Health & Human Services

Approvals

System Alameda AHS Core San Leandro Departmental Date: Patient Care Leadership Team Date: 12/2018 Clinical Practice Council Date: 12/2018 Medical Executive Committee Date: Board of Trustees Date:




A Policy Owner’s Role and Campus: Stroke Coordinator Alameda Hospital Document Type: Administrative Policy Title of Document: Stroke Center Program, Administrative Policy Key Word(s) for Document search: Stroke, Stroke Center

A hor Name: Author’s Title: Michaele Baxter RN, MSN Stroke Coordinator

Dept. and Campus: Nursing Administration, Alamed

Date: a Hospital 12/4/2018



Campus(s)

Meeting / Approval

Date

P&T Committee (If medication is involved): Select Medical Executive Committee Alameda Hospital 6/15/2018

Critical Care: Select Resuscitation Committee: Select Health Information Management: Select Quality and Patient Safety: Select Emergency Management: Select Environment of Care: Select Advanced Practice Providers Committee: Select ER/CCU Committee Alameda Hospital 6/12/2018

Medicine Committee Alameda Hospital 6/8/2018

Stroke Team Committee Alameda Hospital 4/18/2018

D m





w f

ill replace the ollowing:

R ASON for submission: Change in practice New Re g ulation Document Integration Other: Revised


I f not System Wide please explain why this is not below Campus specific: Alameda Hospital Certified Primary Stroke Center Department specific:

R urn the Routing Sheet and the Completed document to Co o rdinat or at [email protected] Effective Date: June 2018


APPROVALS System Alameda AHS Core San Leandro Pharmacy and Therapeutics (P & T) Date: Patient Care Leadership Team Date: Clinical Practice Council Date: 12/20/2018 Medical Executive Committee Date: Board of Trustees Date:



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WORKPLACE VIOLENCE PREVENTION AND RESPONSE PLAN IN THE WORKPLACE

Support Services Printed copies are for reference only. Please refer to electronic copy for the latest version.

Purpose

The purpose of this policy is to protect the safety and security of all personnel, patient and visitors at Alameda Health System. Alameda Health System will represent all properties owned or leased by Alameda Health System including operations off the system/hospital grounds.

Annual Plan/Policy Content

Acts or threats of physical violence, including intimidation, harassment, coercion, or stalking which involve and/or affect Alameda Health System, its employees, patients or visitors or which occur on Alameda Health System property will not be tolerated. This prohibition against threats and acts of violence applies to all persons involved in the operation of Alameda Health System, including, but not limited to, Alameda Health System personnel, contract and temporary employees, patients, vendors and visitors.

Workplace Violence Definition (CAL OSHA 3342)

“Workplace violence” means any act of violence or threat of violence that occurs at the work site. The term workplace violence shall not include lawful acts of self-defense or defense of others. Workplace violence includes the following:

1. The threat or use of physical force against an employee that results in, or has a high

likelihood of resulting in, injury, psychological trauma, or stress, regardless of whether the employee sustains an injury;

2. An incident involving the threat or use of a firearm or other dangerous weapon, including the

use of common objects as weapons, regardless of whether the employee sustains an injury;

3. Four workplace violence types: a. “Type 1 violence” means workplace violence committed by a person who has no

legitimate business at the work site, and includes violent acts by anyone who enters the workplace with the intent to commit a crime.

b. “Type 2 violence” means workplace violence directed at employees by customers, clients, patients, students, inmates, or visitors or other individuals accompanying a patient.

Department Environmental Health and Safety Effective D ate New Policy Campus AHS System Date Revi sed 4/2018 Unit Security Next Sche duled Review 4/2021 Manual Environmental Health and Safety Author Director, Enviro nmental Health and Safety Replaces the following Policies: Responsible Person Vice President,

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c. “Type 3 violence” means workplace violence against an employee by a present or former employee, supervisor, or manager.

d. “Type 4 violence” means workplace violence committed in the workplace by someone who does not work there, but has or is known to have had a personal relationship with an employee.

Annual Plan Review or When Changes Occur

The plan will be reviewed annual during the 1st quarter of the year at the Environment of Care Committee.

Address Corrective Actions

Corrective actions will be initiated by the Site Leaders and communicated to the Site CAOs.

Reporting WPV Incidents

All Alameda Health System employees are required to immediately report any urgent or potentially dangerous acts of violence to Security by contacting the operator to request security to come to the immediate area. Staff is expected to immediately contact their immediate supervisor and notify them of the incident

The supervisor will ensure an online incident report is filed in the MIDAS System. All acts or threats of violence and early warning signs of violence will be investigated by Security, site leaders, Risk Management and/or Human Resources in a timely manner.

Alameda Health System employees will also report any non-urgent incidents, acts or threats of violence, or acts of intimidation occurring on Alameda Health System premises to their supervisor or their Human Resources Business Partner. Employees are required to file a report of such acts or incidents in the online MIDAS System under the "Workplace Violence" category for Risk Management to review and notify leaders of incidents.

Contacting Law Enforcement

No employee will be retaliated against for reporting threats or acts of violence to law enforcement. Should staff contact law enforcement, they must notify their immediate supervisor.

Identify Harm Risks

Alameda Health System uses site leaders and system leaders to comprise a Threat Assessment Team to assess situations that pose a WPV risk to staff. Members of the Threat Assessment Team include, but are not limited to representatives from the following Alameda Health System departments: the site CAO, DON, House Supervisor, Workers Compensation Manager, System Safety Officer, Director of Environmental Health and Safety and Security Director. When appropriate, other hospital personnel including but not limited to, the departmental representative

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(Director, Manager, Supervisor) of a particular employee may participate on the threat assessment to expedite the resolution of a particular situation.

Provide Counseling

1. The Threat Assessment Team duties include, but are not limited to: improving the Site’s

readiness to address workplace violence by: a. responding with reports of threats or acts of violence b. establishing and maintaining policies for dealing with issues of workplace violence

amongst all employees c. developing an expertise among team members and members of management

regarding issues of workplace violence. 2. Security, Human Resources, Workers Compensation, Labor Relations, Environmental Health

and Safety and Risk Management will ensure record keeping is carefully maintained to protect the employee as well as the system.

Every effort will be used to maintain an employee's right to privacy; however, in cases where other employees are considered to be in potential danger, the Threat Assessment team will convey a warning to the employee and provide appropriate support.

AHS Policies

1. Alameda Health System Injury and Illness Prevention Program 2. Alameda Health System Violence Prevention Policy 3. Alameda Health system Unlawful Harassment Policy 4. Alameda Health System Occurrence Reporting Policy 5. Alameda Health Expectations of Conduct Policy 6. Alameda Health System Zero Tolerance to Violence Policy 7. Alameda Health System Code Gray Policy 8. Alameda Health System Workers Compensation reporting flyer

Situational Awareness/Staff Response

Staff is expected to maintain a level of situational awareness regarding the patients they come in contact with, those accompanying the patients, and the environment and surroundings where they are being treated. Any indication of a patient or a person accompanying a patient that results in, or has a high likelihood of resulting in, injury, psychological trauma, or stress, regardless of whether the employee sustains an injury, must be escalated to the supervisor.

The Department Leaders are expected to communicate to their staff by creating a written notice that can be shared with staff regarding patients or those accompanying them that has a high likelihood of injuring staff. The unit staff will be required to use de-escalation measures for managing patients and those accompanying them that display aggressive behavior. Once a patient or person accompanying a patient shows aggression during a shift, staff has the right to request from their supervisors that a Threat Management Plan be developed for those who may

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come in contact with the patient or those individuals who are accompanying the patient. This plan should be communicated during huddles and shift changes. A magnetic marker (e.g. circle or dot) will be placed on the door frame of the patient’s door.

Staff must activate a Code Gray /Harm Reduction Team (see policy) when verbal de-escalation measures are ineffective. Security will respond to assist with addressing the needs for staff’s security and safety. In situations where violence occurs or a weapon is used, staff should alert security and immediately notify local law enforcement.

WPV Response Team/Administrative Response

Staff will notify site leaders of an WPV Incident. Site Leaders will respond to ensure staff is protected from harm. Threat assessments will be initiated. Department Leaders and House Supervisors are able to request via the operator that a notification be sent to the Workplace Violence Prevention Assessment Group. This team will include the site CAO, DON, House Supervisor, Workers Compensation Manager, System Safety Officer, Director of Environmental Health and Safety and Security Director.

The CAO or designee will lead the Assessment Group in identifying the risks, mitigation strategies and language for the communications plan. The following should be addressed:

1. For threats or isolated cases where potential harm could occur, the CAO will develop a

Threat Assessment Plan. a. For situations where violence occurred, a WPVP Response and Communications

plan must be developed to further eliminate harm to staff. 2. The following information must be obtained immediately:

a. Identify all individuals involved in the incident or within close proximity of the incident e.g. staff, contractors, physicians

b. Document circumstances of each person’s involvement. c. Direct quotes of what was heard and seen. d. Description of behaviors and actions associated with the threat. e. Relationship between all individuals involved and any between the victim and

perpetrator. Communications/Incident Notice

The WPVP Response and Communications plan must be immediately shared with staff to prevent any harm or potential harm from occurring.

1. The Department Leader will share the final WPVP Response and Communications plan with

his/her staff. Where necessary, the Communications Plan will be shared at the time of “handoff” with other departments or AHS facilities (within the continuum of care) to protect individuals who may come in contact with the aggressive patient or those accompanying the patient.

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2. A safety message will be developed for AHS staff. This language must be referred to when

communicating with outside providers about the type of aggression displayed by the patient or those accompanying the patient.

3. Staff will be provided the number to contact the Employee Assistance Program. Also, staff

will be notified if a counselor is scheduled to come on campus to debrief with the department about the incident.

Post –Incident Response

When a workplace violence incident occurs, the immediate first steps are to provide emergency care for the injured worker(s) and to implement all necessary safety measures to prevent others from being injured. The Department Leader or designee will follow the policy on contacting the Workers’ Compensation Third party Administrator to report the incident. The Workers Compensation vendor will immediately complete the preliminary workplace violence report (State form 5120) and send an email via AHS’s designated WPVP Response Team’s group email address. The injured staff member and their manager must create a Safety Alert in Midas.

California Occupational Health and Safety Administration (CAL/OSHA) Notification

The CAO’s, Safety Officer, Director of Environmental Health and Safety, Workers Compensation Manager, and House Supervisors are the designated AHS representatives who can generate a report and send it to CAL OSHA on behalf of an AHS facility. All serious injuries to staff and any incident where a weapon is used must be reported within 24 hours to CAL/OSHA. All other injuries are reported within 72 hours.

Post Incident Debrief

The Post Incident Reporting process will be used to analyze the circumstances surrounding a violent episode resulting from employees being assaulted by patients and those accompanying the patient.

The process is intended to help the organization determine what can be done to prevent similar events from happening in the future. The Post Incident Debrief will review administrative controls, engineering controls and staff practices.

If no Post Incident Debrief is indicated, the CAO and Director of Environmental Health and Safety will need to agree.

Post Incident Debriefing

Post Incident Debriefings will be conducted by the local leaders after every incident.

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References

1. CALOSHA Workplace Violence 3342 2. Labor Agreements 3. OSHA Guidelines for Preventing Workplace Violence for Healthcare and Social Service

Workers 4. Health & Safety Code Sections 1257.7, 1257.8 5. Welfare and Institutions Code 1408.3 6. California Penal Code Section 243 (Sexual Battery) 7. California Penal Code Section 245 (Assault with a Deadly Weapon) 8. California Penal Code Section 417 (Brandishing a Weapon) 9. California Penal Code Section 422.75 (Hate Crimes) 10. California Penal Code Section 424 (Terrorists Threats) 11. California Penal Code Section 646.9 (Stalking) 12. California Penal Code Section 653 (Threatening or Annoying Phone Calls).

Approvals

System Alameda AHS Core San Leandro Departmental Date: 4/2018 6/2018 12/2018 6/2018 Patient Care Leadership Team Date: 12/2018 Clinical Practice Council Date: 12/2018 Medical Executive Committee Date: 01/2019 Board of Trustees Date:

Alameda Health System Workplace Violence Prevention & Response Plan in the Workplace

WPV Plan and Response Protocol page 8

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Alameda Hospital A Member of Alameda Health System Stroke Center Program Department Administration Effective Date 9/2015 Campus Alameda Hospital Date Revised 05/01/2015, 05/01/2018 Unit Stroke Center Next Scheduled Review 05/01/2018 05/2021 Manual Administrative Author Stroke Center Coordinator Replaces the following Policies: Responsible Person Chief Administrative

Officer - Acute Chief Medical Officer

Printed copies are for reference only. Please refer to electronic copy for the latest version.

Purpose To provide acute stroke care and enhance stroke recognition to the community. Recognizing that effective stroke treatment requires an integrated and coordinated approach, hospital leadership provides a hospital-wide Stroke Center Program that includes activities within the organization which contribute to the maintenance and improvement of acute stroke care and prevention. Mission Statement: Alameda Hospital is a health care district hospital dedicated to providing effective and efficient acute stroke care for the people of our community. This includes increasing public awareness about stroke recognition, stroke prevention and providing appropriate treatment quickly to enhance the quality of life for our patients.

Scope:

• Provide care for patients with ischemic strokes, hemorrhagic strokes and transient ischemic attacks (TIAs).

• Deliver patient care within a defined continuum of care.

• Provide education to our patients, families, health care providers, and the community on an ongoing basis.

• Collaborate with existing community agencies to align efforts and services toward primary and secondary stroke prevention.

Policy I. RECITALS

The Hospital recognizes that a patient with an acute stroke must be treated in a timely fashion for optimal results. The Hospital wishes to offer the best care possible to the citizens of Alameda. The Hospital will initiate actions to implement these protocols and plans with emphasis on processes and systems as outlined by the Brain Attack Coalition and American Heart Association/American Stroke Association statements. The Hospital also recognizes the need for community education in stroke prevention and awareness and commits the resources necessary to provide such education.

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The Hospital will communicate clearly with other facilities also providing stroke care, and will formulate formal written agreements with appropriate facilities for the emergent transfer of critical stroke patients requiring a higher level of care. The Hospital recognizes the importance of excellence in patient care upon arrival in the Emergency Department and commits the resources necessary for training of personnel to ensure all involved parties have the proper education needed to provide optimal stroke care for patients. The Hospital recognizes that maintenance of certification requires an ongoing effort directed at data collection, continuing education, and awareness of advances in stroke treatment, and commits the necessary resources to providing the above to maintain certification. The Hospital and its Medical Staff commit to providing current treatments available to the community and will maintain educational requirements as necessary. Patients who receive acute stroke treatment will be reviewed in the Medical Staff performance improvement process as is deemed necessary and appropriate to ensure quality care is given.

. STROKE PROGRAM OPERATION AND SERVICES Board of Trustees of Alameda Health System, through the approval of this document, authorizes the establishment of a planned and systematic approach to the stroke certification process, including the adequate allocation of resources. The Board delegates the oversight of the Stroke Center Program to the Medical Staff and Chief Administrative Officer. Medical Staff: The Medical Staff collaborates with hospital departments and other services or disciplines in an organization-wide approach to improving acute stroke care. Administration and Management Staff: The Chief Administrative Officer (CAO) along with the management staff actively fosters an effective approach to acute stroke care and program certification. They are authorized to assist with the implementation of the Stroke Program, and are responsible for the day-to-day implementation and evaluation of the processes and activities noted in this program, including allocation of adequate resources for employees to participate in stroke care improvement activities. A. Core Stroke Team

1. Stroke Medical Director

The Stroke Medical Director (SMD) is a board certified physician in Neurology, Internal Medicine, or Emergency Medicine. The SMD is responsible for overall organization and monitoring of the stroke program. SMD duties include oversight of the program, including response times and general management of the stroke patient, as well as evaluation and management of the stroke unit. The SMD is also responsible for clinical

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oversight of the stroke nurse coordinator and general administrative duties related to the Stroke program (See Stroke Medical Director Contract for specifics). The Stroke Director also provides education for physicians, the stroke team, leads clinical interdisciplinary rounds and has oversight for quality improvement.

2. Stroke Nurse Coordinator

The Stroke Nurse Coordinator is responsible for improving clinical care through the application of evidence-based practice. Provides for educational programs in conjunction with the nursing education department, leads quality improvement activities, develops, directs, and monitors, along with the SMD, clinical nursing practices related to stroke care.

The Stroke Nurse Coordinator will assist with or provide the following:

• Acute stroke response

• Monitor proper medical and nursing management of stroke patients

• Standards of care and practice guidelines for acute stroke patients

• Clinical activities related to stroke

• Education to families, patients, staff and to the community

• Data collection for Get With The Guidelines

• Performance improvement activities B. Stroke Team Members

1. Director of Emergency Department

The ED medical director serves on the Stroke Team. This role is vital to the team in serving as a resource to the ED physicians, members of the Core Stroke Team, providing clinical oversight for the emergency room care of stroke patients, and reviewing performance indicators for adherence to standards. The ED Medical Director also presents and reviews clinical cases identifying areas of strength and areas for improvement, as well as maintaining ongoing communication with the stroke nurse coordinator.

2. Emergency Department Nurse Manager

The ED Nurse Manager serves on the Stroke Team. The manager serves as a resource to the ED physicians and nurses, reviews performance indicators for adherence to standards and maintains ongoing communication with the stroke nurse coordinator.

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3. Nurse Manager of Critical Care and Telemetry Units

a. Serves on Stroke Team

b. Provides clinical direction and leadership for stroke patients.

c. Serves as a resource to other patient care managers and nursing staff

d. Serves as a resource for Nursing Administration

e. Provides back-up administrative support

4. Other Stroke Team members may include:

• Clinical Education Specialist

• Director of Community Relations

• Director of Laboratory Services

• Director of Radiology

• Director of Pharmacy

• Director of Respiratory • Director of Rehabilitation Services

C. Interdisciplinary Departments: The Stroke Program services are provided by a

number of departments and specialized personnel who function collaboratively as part of an interdisciplinary team to achieve positive patient outcomes. The departments who have direct contact with patients are outlined below. 1. Emergency Department Personnel

The Emergency Department personnel are fully integrated with the Emergency Medical System (EMS). Both local EMS and ED personnel are familiar with the diagnosis and treatment of patients with cerebrovascular disease. This includes the importance of rapid identification of patients with suspected stroke and initiation of therapy.

2. Critical Care/Telemetry

Stroke patients are routinely admitted to Critical Care and the Telemetry Unit for specialized monitoring and close neurological observation.

3. Radiology/Computerized Tomography (CT)/Diagnostic Imaging

• Radiologists are available to evaluate imaging studies 24 hours/day seven days a week.

• The CT scanner is available 24 hours/daily, seven days/week. Magnetic Resonance Imaging (MRI) and related techniques are available on a scheduled basis.

• General Radiology: available 24 hours, seven days a week.

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4. Laboratory Services

• Laboratory services: available 24 hours, seven days a week.

5. Cardiology Services

• EKGs are available 24 hours/day seven days a week.

• Transthoracic Echocardiography is available during normal business hours and as on-call basis on weekends.

• Transesophageal Echocardiography (TEE) is available on a scheduled basis.

6. Pharmacy Services

• Pharmacy services: available 24 hours/day seven days a week.

• All medications on the Stroke Order Sets are available 24 hours/day seven days a week.

7. Rehabilitation Services

Physical, occupational and speech therapy is available for patient assessment and therapy during hospitalization.

8. Case Management and Social Services

Case managers and social workers with experience dealing with stroke patients and their families are a part of our interdisciplinary stroke care. They have knowledge regarding inpatient rehabilitation facilities and community resources in the geographic regions represented by our patient population.

9. Patient and Family

The Hospital recognizes that patients are an integral part of healthcare and therefore will be educated about their role and responsibility in recognizing acute strokes, calling the EMS system and stroke prevention practices. In order to facilitate the best delivery of care, the patients or their designees are responsible to:

• Provide, to the best of their knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to their health. The onset of symptoms and the last time the patient was seen ‘normal’ are particularly important.

• To report perceived risks to their care and unexpected changes in their condition to the responsible practitioner.

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• Ask questions when they do not understand what they have been told about their care or what they are expected to do.

• Communicate any concerns they may have. III. STRATEGIES:

An effective approach to acute stroke care requires an environment in which patients, their families, and organization staff and leaders can identity an acute stroke event. This can be accomplished through:

• Recognition and acknowledgement of stroke signs and symptoms

• Initiation of community and patient education to reduce the risk of stroke

• Internal reporting of what has been found and the actions taken

• Focus on processes and systems

• Emphasizing cooperation and communication among health care providers to treat acute stroke care

• Staff education regarding medical care of acute strokes which supports the sharing of knowledge to effect behavioral changes.

As part of its process, the Hospital regularly reviews the scope and breadth of its services. Attendant to this review is an identification of care processes that, through the treatment of an acute stroke, would have a significant positive impact on the health and well-being of the patient. Areas of focus include:

• Processes identified through a review of the literature.

• Performance improvement program including Medical Staff Peer Review processes.

• Appropriate data collection of stroke patients and their care

• Processes identified as a result of findings by regulatory and/or accrediting agencies.

• Processes identified through benchmarking data IV. EDUCATION AND TRAINING:

Staff receives education and training during the initial orientation process and on an ongoing basis regarding job-related aspects of acute stroke management, including recognition of an acute stroke, thrombolytics treatment and time-sensitive treatment. Because the optimal provision of healthcare is provided in an interdisciplinary manner, staff members are educated and trained on the provision of an interdisciplinary and team approach to patient care.

1. Nursing Education

Nursing works collaboratively with the Stroke Team to provide ongoing stroke education. Education may be provided in one or more of the following ways:

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• Continuing education classes

• On unit in-service

• Unit specific skills day

• Standard of care, protocols, discharge home instruction

• Self-learning modules

• Computer education 2. Medical Education

The Stroke Team provides ongoing education to the medical staff in the form of

• Stroke lecture series

• CME classes

• Stroke clinical reviews

3. Ancillary Departments

Stroke education is available to ancillary departments through

• In-services

• CEU classes

• Stroke team committee meetings 4. Patient and Family

Hospital personnel provide education to the patients and families. A Stroke Education Packet containing information on stroke is also provided to all patients experiencing stroke. Upon discharge, individualized discharge stroke education materials, which include personal risk factor education, are provided.

5. Community

Periodic community education services, such as Stroke Risk Assessments and health fairs provide additional education to promote stroke prevention and awareness.

V. CODE STROKE NOTIFICATION SYSTEM

The Code Stroke notification system is activated to notify appropriate personnel for urgent treatment of stroke patients.

VI. STROKE PROTOCOLS AND ORDER SETS

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All order sets and protocols are developed from evidence based practices, and clinical practice guidelines as recommended by The Brain Attack Coalition and American Heart Association/American Stroke Association statements.

VII. STROKE REGISTRY

Stroke patient data is entered into the hospital-based program Get with the Guidelines (GWTG). The stroke module of GWTG focuses on the acute treatment and the secondary prevention regimen for stroke patients and is based on the American Stroke Association/American Heart Association guidelines and is consistent with the Brain Attack Coalition recommendations.

VIII. STROKE CORE TEAM

Oversight and coordination of Stroke program operations and performance improvement. Responsibilities

• Monitors coordination and integration of services in the identified continuum

• Identifies and resolves patient care or operational system issues

• Serves as a forum for discussion of new approaches to care

• Communicates programmatic initiatives and outcomes

• Monitors compliance with standards and clinical practice guidelines IX. MEETING TIMES The Stroke Team Committee meets at least 10 times a year.

Approval / Review Path

Stroke Team Committee, Emergency Medicine / Critical Care Committee, Surgery / GYN Committee, Medicine Committee, Medical Executive Committee, Board of Trustees of Alameda Health System

Approvals

System Alameda AHS Core San Leandro Departmental Date: 4/2018 Patient Care Leadership Team Date: 12/2018 Clinical Practice Council Date: 12/2018 Medical Executive Committee Date: 6/2018

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Board of Trustees Date:

Stroke Team Committee Date: 05/2015, 4/18/18 Medicine Committee ER/CCU Committee

Date: 6/8/2018,6/8/2018 Date: 6/2015,6/12/2018

Medical Executive Committee Date: 7/2015, 6/15/2018 Board of Trustees Date: 9/2015




A Policy Owner’s Role and Campus: Stroke Coordinator, Alamed a Hospita l Document Type: Policy and Procedure Title of Document: Stroke Management (nursing) Policy and Procedure Key Word(s) for Document search: Stroke

A hor Name: Author’s Title: Michaele Baxter RN, MSN Stroke Coordinator

Dept. and Campus: Date: Nursing Administration, Alameda 12/4/2018



Campus(s)

Meeting / Approval

Date

P&T Committee (If medication is involved): Select Medical Executive Committee Alameda Hospital 6/15/2018

Critical Care: Select Resuscitation Committee: Select Health Information Management: Select Quality and Patient Safety: Select Emergency Management: Select Environment of Care: Select Advanced Practice Providers Committee: Select ER/CCU Alameda Hospital 6/12/2018

Medicine Alameda Hospital 6/8/2018

Stroke Team Committee Alameda Hospital 4/18/2018

D m





w f

ill replace the ollowing:

R ASON for submission: Change in practice New Re g ulation Document Integration Other: Revised


I f not System Wide please explain why this is not below Campus specific: Alameda Hospital Department specific:

R urn the Routing Sheet and the Completed document to Co o rdinat or at [email protected] Effective Date:


APPROVALS System Alameda AHS Core San Leandro Pharmacy and Therapeutics (P & T) Date: Patient Care Leadership Team Date: Clinical Practice Council Date: 12/20/2018 Medical Executive Committee Date: Board of Trustees Date:



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Alameda Hospital A Member of Alameda Health System Stroke Center Program Department Administration, Nursing Effective Date Campus Alameda Hospital Date Revised Unit Stroke Center Next Scheduled Review Manual Administrative Author Stroke Center Coordinator Replaces the following Policies: Responsible Person Chief Administrative

Officer – Acute; Chief Medical Officer

Printed copies are for reference only. Please refer to electronic copy for the latest version. ALAMEDA HOSPITAL

NURSING DEPARTMENT POLICY & PROCEDURE

TITLE: Stroke Management Policy & Procedure

POLICY #: TBD EFFECTIVE DATE: 08/11 REVIEW DATE(S):

PERSONNEL

COVERED: Nursing Department Staff

And Stroke Response Team REVISED DATE(S): 09/11,07/14, 01/15

Policy is based on current evidence based guidelines and the Target Stroke Initiative by the American Stroke Association

PURPOSE

Rapidly identify and manage patients identified with acute ischemic stroke or acute hemorrhagic stroke. Outline the major care priorities instituted by the multidisciplinary team during the resuscitation period through the admission and/or transfer phase.

DEFINITIONS

Acute Ischemic Stroke occurs due to a disruption in arterial blood flow to a portion of the

brain. This disruption in flow leads to neuronal ischemia and cell death, resulting in loss of

neurologic function.

Alteplase (Activase) is a thrombolytic agent used in the treatment of ischemic stroke.

Intracranial Hemorrhage is a form of stroke which involves the rupture of a blood vessel within

the brain. It impedes blood flow to the brain, decreasing availability of oxygen and nutrients to brain tissue, causing dysfunction and possible brain cell death.

Transient Ischemic Attack (TIA) is a brief episode of neurologic dysfunction resulting from

temporary brain ischemia without infarction. These episodes can last from minutes to hours.

POLICY

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Patients presenting with stroke symptoms and signs must be rapidly identified in order to differentiate the cause of the stroke; ischemic vs. hemorrhagic. The stroke policy and procedure will expedite the identification, assessment, and optimal treatment of the patients sustaining acute ischemic or hemorrhagic stroke. See Attachment 1 (Acute Stroke Pathway).

CONTENT

A patient may exhibit stroke signs and symptoms presenting to the Emergency Department (ED) or while an in-patient. If the patient has new onset of ischemic stroke symptoms or has symptoms consistent with hemorrhagic stroke, then “Code Stroke” is called by dialing 5555 to activate the response team.

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1. ED Arrival:

a. EMS: The ED Physician and/or ED nurse will receive report from pre-hospital personnel and designate the patient as meeting inclusion criteria for Acute Stroke Management Protocol.

b. Private Auto: Patients with acute ischemic or hemorrhagic stroke symptoms who arrive by private auto to the ED and meet inclusion criteria for Acute Stroke Management Protocol

c. In-patient: The nurse recognizing the new onset of stroke signs and symptoms should initiate a code stroke by dialing 5555 and giving the PBX operator the room number or patient location to activate the stroke response team.

. .

2. Code Stroke may be called by MD or RN.

3. Code Stroke: The following individuals will respond to the ED or in-patient unit immediately. (See attachment for Stroke Pathway)

a. Physician (with stroke privileges) – obtains initial National Institute of Health Stroke Scale (NIHSS) score.

1) Emergency Department: ED physician or Neurologist directs Code Stroke.

2) In-Patient: Hospitalist, Primary Physician, ED Physician or Neurologist with Stroke Privileges directs Code Stroke.

b. RN, Clinical Supervisor, Stroke Coordinator or Nursing Supervisor assists, and directs Code Stroke process, such as; accompany patient to CT, mixing and administration of Alteplase, neurological assessment of patient.

ED

Nurse assigned to patient and Code Stroke Responders

1) Assesses patient’s ability to maintain patent airway

2) Attaches patient to cardiac monitor, non-invasive BP, and SpO2

3) Obtain FSBG

4 ) Obtains IV access

5 ) Assesses neurologic status Assessment.

6 ) Follow “Physician” order sets for stroke. Administers medications as ordered by protocol.

7 ) Monitors BP, Pulse and Respirations every 15 minutes or as condition warrants

c. Respiratory Therapy assists team with airway interventions

d. Laboratory Tech. obtains blood specimens for Stroke Panel

e. Radiology transporter assists with patient transport to Radiology for Head CT

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f. Chest x-ray may be done by portable

g. Cardiology: 12 Lead EKG

h. Nursing Services Technician (NST) assists where needed.

4. Interventions for Stroke

a. Initial Intervention

1) Assess time of onset

2) Evaluate patient

3) Assess airway and adequacy of ventilation. Attach Sp02 monitor. Maintain O2 saturation at 95%

4) Prevent Aspiration. All stroke patients to be NPO including medications until nursing bedside swallowing screening is completed and passed.

The Speech Language Pathologist (SLP) will assess the swallowing function as soon as possible.

5) Head of bed elevated 30 degrees or as ordered by physician

6) Maintain temperature 36-37 degrees C or 97-98.6 degrees F. or as ordered by physician

7) Monitor and treat abnormal blood glucose levels.

5. All patients presenting within 0 to 4.5 hours of symptom onset – IV Alteplase (Activase) option. (After physician review of inclusion/exclusion criteria and NIHSS assessment, lab and CT results)

a. Blood pressure considerations:

1) Maintain blood pressure (BP) as follows or as ordered by physician:

a) For patients receiving IV Alteplase (Activase) maintain BP less than 180/110.

b) For ischemic stroke or TIA patients not receiving IV Alteplase (Activase), BP may be as high as systolic 180 to 220 and diastolic BP less than 120.c) Hemorrhagic stroke or Subarachnoid Hemorrhage patients goal to maintain systolic blood pressure between110 – 140 and diastolic blood pressure 70 – 90.

6. IV Alteplase (Activase) Treatment

a. Place second secure peripheral IV line with Normal Saline. Do not delay infusion of IV Alteplase (Activase) for placement of secondary IV line.

b. Administer Alteplase (Activase) as ordered by physician.

7. Critical Care Phase Interventions:

a. First 24 hours Post Alteplase (Activase) see physician orders, monitor patient closely b. Ischemic Stroke or TIA Non Thrombolytic Patients: see physician orders

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c. Interventions for Hemorrhagic Stroke or Subarachnoid Hemorrhage: see physician orders

8. Other General Nursing Management:

a. Assess vital signs, neurological assessment, and blood pressure management as ordered.

b. Assess for signs of increased intracranial pressure (ICP)

• Headache

• Decreased level of consciousness

• Changes in motor function

• Visual disturbances

• Pupillary abnormalities

• Changes in respiratory patterns

• Changes in vital signs

c. Aspiration precautions

d. Continuous cardiac monitoring

e. Prevent DVT with the following:

1) Initiate sequential compression devices (SCDs)

2) Encourage mobilization and up in chair, especially for meals

3) Provide antithrombotics/anticoagulants as ordered

f. Prevent skin breakdown:

1) Turn every 2 hours while in bed

2) Monitor skin integrity especially at pressure points.

g. Prevent falls

1) Initiate Fall precautions

2) Keep bed in low position.

3) Keep call light in reach

9. Patient / Family Education:

a. Stroke Education Packet

1) Review with patient and family.

a) Individual risk factors for stroke

b) Methods to reduce risk factors for stroke

c) Signs and symptoms for stroke

d) What to do if symptoms occur (Call 911)

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e) New medications prescribed, uses, schedule, precautions, side effects

f) Smoking Cessation counseling (if appropriate)

g) Need for follow-up after discharge

h) Other lifestyle interventions as appropriate

• weight reduction

• activity recommendations

• antihypertensive diet

• healthy diet

• diabetes

• blood pressure

• cholesterol

• atrial fibrillation

10. Assess for Rehabilitation:

a. Case managers will continue to assess on an ongoing basis, and evaluate needs for interdisciplinary rehabilitation: physical therapy, occupational therapy, speech therapy and/or other rehabilitation needs, through collaboration with physicians, therapists, and nursing staff to determine appropriate rehabilitation disposition and discharge.

See Acute Stroke Pathway Appendix A

APPROVED BY COMMITTEE: DATE: STROKE TEAM 08/11, 07/14,4/9/18 ER/CCU 6/5/2018 MEDICINE 6/8/18 MEDICAL EXECUTIVE 6/15/2018

System Alameda AHS Core San Leandro Departmental Date: 4/2018 Patient Care Leadership Team Date: 12/2018 Clinical Practice Council Date: 12/2018 Medical Executive Committee Date: 6/2018 Board of Trustees Date:

Appendix A Acute Stroke Pathway

EMS Notification of Stroke Alert

● Patient with stroke symptoms to Emergency Department by private auto

● Inpatient with new stroke symptoms

CODE STROKE INITIATED

Response team notified including neurology

-Notifies physician

RN assesses patient Initial physician evaluation

-NIHSS/Neuro examination

-Labwork initiated

Code stroke triage orders initiated

-Obtains vital signs, pulse oximetry, ECG monitoring, and

finger stick blood glucose

-IV placement

-Patient history -CT scanner ready

-Patient in CT scan

-Head CT and labs interpreted

-Neurology consulted

-CTA as clinically indicated

Not an Alteplase (Activase) candidate NO

DECISION

YES IV Alteplase (Activase) candidate

Physician

-Inclusion/exclusion criteria met

-Orders Alteplase (Activase)

Ischemic Stroke Hemorrhagic Stroke

Alteplase (Activase)

administration in ED or

CCU

Assess for large vessel occlusion; consider

thrombectomy Admit Transfer as clinically

indicated

Assess for large vessel

occlusion; consider

thrombectomy

Admit Transfer as clinically

indicated Admit to CCU Transfer as clinically

indicated

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Alameda Hospital MEDICAL STAFF FOCUSED PROFESSIONAL PRACTICE REVIEW (FPPE) / PROCTORING

Department Medical Staff Effective Date 1/19 Campus Alameda Hospital Date Revised 12/18 Unit Alameda Hospital Next Scheduled Review 6/2021 Manual Medical Staff Author Director, Medical Staff Office Replaces the following Policies: Responsible Person Chief Medical Officer

Printed copies are for reference only. Please refer to electronic copy for the latest version. Purpose To define the process for satisfying the focused processional practice evaluation (FPPE) / proctoring requirements of the Alameda Hospital Medical Staff (AH). Policy 1. General proctoring issues

a. The core FPPE/proctoring requirements described in this policy, as well as advanced FPPE/proctoring requirements related to specific procedures as defined on the individual department privilege delineation forms or in Medical Staff policy, represent the minimum requirement for a successful completion of a FPPE/proctorship. A proctor or department chairperson may recommend to the Medical Executive Committee additional proctoring requirements.

b. Core FPPE/proctoring may include both concurrent and/or retrospective review of medical care and direct observation of any procedures performed.

c. Advanced procedural FPPE/proctoring requirements will involve direct observation of procedures unless otherwise determined by the Department Chair or Medical Executive Committee.

d. A proctor who is not providing direct clinical care at the hospital is not required to have a California medical license. The proctor must, however, have a valid medical license in at least one state. If the proctor is participating in direct clinical care, he or she must have a valid California license and appropriate clinical privileges at the hospital.

e. Focused Professional Practice Evaluation/Proctoring information is used as part of the Medical Staff’s Ongoing Professional Practice Evaluation program.

f. Proctoring as described in this policy is designed to meet the intent of Joint Commission Standards related to FPPE at the time of initial privileges or the granting of new privileges.

2. FPPE/Proctoring is required for:

a. All initial staff appointments. i. FPPE/Proctoring of AHS graduating residents who apply for membership and privileges at Alameda Hospital, the Department Chair (or designee) may,

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at their discretion, reduce (not waive) FPPE requirements for privileges for which the resident provides documentation of performance during the residency (e.g. logs of cases) and the Residency Program (via Program Director) verifies competency. Procedures and/or competency that cannot be verified must follow the FPPE requirements outlined in this or any other policy, the bylaws and/or rules and regulations.

b. Requests for new privileges from current Medical Staff members when proctoring requirements have been established relative to the privileges requested.

c. Temporary privileges granted in pendency of final action on an application for Medical Staff appointment and clinical privileges.

3. FPPE/Proctoring may be required at the discretion of the Medical Executive

Committee: a. As a condition for privilege renewal for privileges performed so infrequently

that assessment of current competence is not feasible. b. Whenever the Medical Executive Committee determines that additional

information is needed to assess a practitioner’s current competence. 4. FPPE/Proctoring may be required at the discretion of the Chief of Staff:

a. When recommending temporary privileges for reasons other than pendency of final action on an application for Medical Staff appointment and clinical privileges.

5. FPPE/Proctoring by physicians who are not currently members of the AH Medical

Staff: a. All practitioners who are not currently members of the AH Medical Staff must

be granted temporary privileges if the proctor will be providing patient care services.

i. Credentialing information for temporary privileges shall be in accordance with Section 5.6 of the Medical Staff Bylaws:

Core and Advanced Proctoring Requirements 1. Minimum proctoring requirements include both core and advanced FPPE/proctoring

requirements as described below. 2. Core FPPE/proctoring requirements include direct observation, concurrent review or

retrospective for the first cases performed. Each Department has specific core FPPE/proctoring requirements, as outlined on each Department -specific FPPE/proctoring form.

3. Advanced FPPE/proctoring requirements include proctoring for procedures which

have been identified as having advanced FPPE/proctoring requirements either on the Medical Staff privilege delineation form or in Medical Staff policy, or as otherwise recommended by the department chairperson.

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a. These advanced FPPE/proctoring requirements must be met in addition to the core FPPE/proctoring requirements described above.

b. Advanced FPPE/proctoring requires only FPPE/proctoring of the specific procedure which has been identified as having an advanced FPPE/proctoring requirement. Advanced FPPE/proctoring does not require proctoring of the entire episode of patient care.

FPPE/Proctoring Requirements for Consulting Privileges 1. A practitioner who is requesting only consulting privileges will not be required to

meet core FPPE/proctoring requirements. 2. The practitioner requesting only consulting privileges with no procedural privileges

will be required to have his or her first two (2) consultations retrospectively proctored to meet the minimum consulting proctoring requirements.

3. If the consulting practitioner has requested any privileges procedural privileges, then

the applicable procedural FPPE/proctoring requirements must also be met. Assignment of Proctors 1. All members of the Medical Staff who have themselves completed FPPE/proctoring

and hold unrestricted privileges to perform the procedures and/or manage the clinical cases to be proctored, regardless of Medical Staff membership category, may serve as proctors. This includes provisional staff members. Participation as a proctor in the Medical Staff FPPE/proctoring program is a requirement for Medical Staff membership. Failure to serve as a proctor when assigned to do so may result in Medical Staff disciplinary action.

2. FPPE/Proctoring may, with the approval of the Medical Executive Committee or the

Chief of Staff, be performed by Medical Staff members who hold related privileges sufficiently similar to the privileges being proctored to allow them to make prudent and informed judgments regarding competence.

3. If no member of the Medical Staff possessing the requisite expertise is available to

serve as a proctor, arrangements may be made by the department chairperson for FPPE/proctoring by a qualified practitioner who is not currently a member of the Medical Staff.

4. All proctors will be assigned by the department chairperson at the time the

chairperson recommends privileges to the Medical Executive Committee. 5. Whenever reasonably possible, both a primary proctor and an alternate proctor will be

assigned to assure timely availability. More than two proctors may be assigned at the discretion of the department chairperson. Partners or associates may not serve as

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proctors unless a specific exemption is made by the Medical Executive Committee for cause.

Scope and Timeliness of FPPE/Proctoring 1. All core and advanced FPPE/proctoring requirements are to be met through direct

observation of procedures or concurrent review of clinical care. 2. Both core and advanced FPPE/proctoring should include the "first" cases performed

by the practitioner in each category requiring proctoring. 3. All cases which have been performed as an emergency without concurrent

FPPE/proctoring while the practitioner has ongoing concurrent FPPE/proctoring requirements will be referred by the proctor or the Director of Medical Staff Services to the department chairperson, and/or Chief of Staff for review.

Termination of FPPE/Proctorship 1. Termination of FPPE/proctorship requires a report to the Medical Executive

Committee from the department chairperson.

2. A practitioner under FPPE/proctorship, regardless of the reason for FPPE/proctoring or the category of Medical Staff membership, shall remain under proctorship until a recommendation for the removal of FPPE/proctoring requirements has been made by the department chairperson.

3. Termination of FPPE/proctoring requirements is not complete, however, until acted

upon by the Medical Executive Committee and Board of Trustees. Failure to Satisfactorily Complete FPPE/Proctoring Requirements 1. If a provisional staff member fails to satisfy the core FPPE/proctoring requirements

solely because of the failure to perform the required number of cases within the time frame defined in Medical Staff Bylaws and Medical Staff policies, then both the clinical privileges being proctored and the provisional staff member’s membership will automatically terminate unless the FPPE/proctoring time is otherwise extended by the Medical Executive Committee.

Procedure Department Chairperson Duties 1. Recommend practitioner-specific core and advanced FPPE/proctoring requirements

to the Medical Executive Committee at the time the chairperson recommends clinical privileges.

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2. Provide the names of the primary, alternative, and other proctors to the Medical Executive Committee at the time the chairperson recommends clinical privileges.

3. Submit to the Medical Executive Committee, when the practitioner has satisfactorily

completed the FPPE/proctorship requirements, a report recommending termination of the proctorship.

4. Assure that all members under FPPE/proctorship are being proctored in a timely

manner. 5. If the proctor and the practitioner being FPPE/proctored disagree as to what

constitutes appropriate care for a patient, the department chairperson will be asked by the proctor or practitioner being FPPE/proctored to intervene and adjudicate the conflict.

Medical Staff Services Duties 1. Provide to the practitioner in writing the names of the primary, and any other proctors

who have been assigned to the practitioner. 2. Send written notification and proctoring plan to the practitioner who is being

FPPE/proctored and all individuals who have been assigned as proctors. The notification and plan shall include:

a. The name of all proctors b. A list of the types and numbers of procedures and/or clinical cases which must

be FPPE/proctored. c. A copy of the appropriate proctoring forms. d. Copy of the Medical Staff Proctoring Plan which indicates core

FPPE/proctoring requirements for each department and/or additional FPPE/proctoring requirements if indicated.

FPPE/Proctored Practitioner Duties 1. Must assure that the first procedures or medical admissions (core FPPE/proctoring)

and the first performance of any procedures requiring advanced FPPE/proctoring are proctored in a timely manner.

2. Must notify the proctor of each case where care is to be evaluated and do so in

sufficient time to allow the proctor to observe or review concurrently. For elective surgical or invasive procedures where direct observation is required, the practitioner must secure agreement from the proctor to attend the procedure before the procedure is scheduled. If an emergency situation exists and the practitioner must admit and treat a patient, the practitioner must notify the proctor as soon as is reasonably possible to continue with the concurrent FPPE/proctoring process.

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3. Must provide the proctor with the patient’s clinical history, pertinent physical findings, pertinent laboratory and x-ray results, the planned course of treatment or management and the rational for its use.

4. Shall have the prerogative of requesting from the department chairperson a change of

proctor if he/she reasonably concludes that disagreements with the current FPPE/proctor may adversely affect his/her ability to satisfactorily complete the proctorship. The department chairperson shall make his or her recommendation in this matter to the Chief of Staff for final action. This action shall be reported to the Medical Executive Committee at their next regular meeting.

5. May be subject to Medical Staff disciplinary action including the possible loss of

membership and all clinical privileges if he or she admits or cares for a patient without fulfilling FPPE/proctoring requirements.

Proctor Duties 1. The proctor must hold the privileges for the procedure being performed and/or

concurrently observe or retrospectively review the medical management and complete the appropriate FPPE/proctoring form.

2. Procedure FPPE/proctoring should address:

a. The indications and preparation of the patient for the procedure; b. The technical skill demonstrated in performing the procedure; c. Post-procedural management unless proctoring is for an advanced

FPPE/proctoring requirement only. 3. The proctor will be expected to make reasonable accommodation to be available for

cases that require direct observation or concurrent review. 4. Direct observation of procedures or medical admissions may be continued beyond the

minimum FPPE/proctoring requirements, if needed, until the proctor has observed a sufficient number of cases to make an informed judgment regarding the clinical performance of the individual being proctored. A request for additional FPPE/proctoring requirements may be made by the proctor and submitted to the department chairperson for review and referral to the Medical Executive Committee for action.

5. While the proctor’s primary responsibility is to evaluate performance, if the proctor

reasonably believes that intervention is warranted to prevent harm to the patient, the proctor may take whatever action is reasonably necessary to protect the patient. The proctor is authorized at the proctor's sole discretion to delay, postpone, or terminate any treatment and/or procedure and is authorized and requested to take such action as good medical practice warrants. If such an action is required by the proctor, this action shall be immediately reported to the department chairperson and Chief of Staff.

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6. In nonprocedural FPPE/proctoring, the proctor shall observe care and not participate in patient care or act as a consultant on the case.

7. In procedural FPPE/proctoring, as proctor may act as a surgical assistant for the

practitioner being proctored. 8. The FPPE/proctor must assure the confidentiality of the FPPE/proctoring report form.

The FPPE/proctor report form should be held by the proctor during any periods of concurrent review and should not be attached to the patient's medical record. When FPPE/proctoring is completed, the proctor must deliver the completed FPPE/proctoring form to the Medical Staff Office.

Medical Staff Services Duties 1. Submit a quarterly report to both the Credentials Committee and the Medical

Executive Committee detailing the FPPE/proctorship activity for all practitioners under proctorship.

FPPE/Proctoring Forms

The following FPPE/Proctoring forms are to be utilized when documenting FPPE/proctoring activities: 1. Medicine 2. Emergency 3. Surgery Approvals

Medical Executive Committee Date: 1/19 Board of Trustees Date:

Revised 10/17/18

Alameda Health System – Highland Campus Addendum: Code Blue/Code White Crash Cart Medication Trays & Transport Boxes Department Pharmacy, Central Supply Effective Date Campus HGH Date Revised Unit Next Scheduled Review Manual Clinical Practice Author Code Blue Committee Replaces the following Policies: Responsible Person Pharmacy Director Printed copies are for references only. Please refer to electronic copy for the latest version. 1. During A Code for Acute Care Areas:

a. Primary carts on units have medication tray (see below) b. If additional medications are needed, nurse will call Pharmacy at x44223 option #2 to speak with a pharmacy personnel directly. The

Pharmacy will deliver the back-up crash cart med tray to the area of the code emergently and medications required during a code blue will not require a written prescription.

c. If a backup crash cart is needed for supplies only (Drug Tray not included), nurse will call Central Supply (phone: 44242 OR pager: 510-243-6947). Central Supply will deliver the back-up crash cart to the requested unit or clinic immediately.

d. Central Supply will deliver a replacement crash cart to the coded area after stopping by pharmacy first to have the pharmacy medication tray and crash cart lock attached to the crash cart.

Unit Contact Person

Tray Type Med Tray Locations

5ACT (ICU)

Nurse manager

Adult Code cart 6ACT (SDU) Adult Code cart 7ACT (5E) Adult Code cart 8ACT (7W) Adult Code cart 9ACT (7E) Adult Code cart 4ICN (ICN) Neonate Code cart 4TLD (L&D) Adult Code cart 4TPP (PP) Adult Code cart 3ACT (Cath Lab) Adult Code cart 3ACT (Radiology) Adult Code cart ED Adult Code room (room 5) Pyxis tower

Revised 10/17/18

**note: OR already has back up code blue medications in the medication carts inside each OR suite. PACU will share these supplies for code blues there. OR/PACU responds to code blues there internally

*** NOTE: Central Supply Will No Longer Automatically Respond To Code Blues/Whites 2. During A Code for Outpatient Areas:

a. Primary carts on units have medication tray b. If additional medications are needed, nurse will call Pharmacy at x44223 option #2 to speak with a pharmacy personnel directly. The

Pharmacy will deliver the back-up crash cart med tray to the area of the code emergently and medications required during a code blue will not require a written prescription.

c. If a backup crash cart is needed for supplies only (Drug Tray not included), nurse will call Central Supply (phone: 44242 OR pager: 510-243-6947). Central Supply will deliver the back-up crash cart to the requested unit or clinic immediately.

d. Central Supply will deliver a replacement crash cart to the coded area after stopping by pharmacy first to have the pharmacy medication tray and crash cart lock attached to the crash cart.

3. After The Code:

a. The unit nurse will call Central Supply (phone: 44242 OR pager: 510-243-6947) to deliver a replacement crash cart to the requesting unit

i. Central supply will stop by pharmacy first to have the pharmacy medication tray and crash cart lock attached to the crash cart by a Pharmacist or a Pharmacy Technician.

b. The unit nurse must remove the drug tray from the old crash cart before allowing Central Supply to take away the old crash cart. c. Central Supply will take the used crash cart without the medications. d. The unit nurse will place the used crash cart med trays in the unit medication rooms for pharmacy pick up OR in areas without the

medication rooms, notify pharmacy for med tray pick up by a Pharmacist or Pharmacy Technician. e. Pharmacy will replace any back-up med trays as needed via:

i. Pyxis report from pharmacy for units with med trays stocked in the Pyxis towers (5E, SDU, 7E, 7W, ICU) ii. For the units that do not store the back-up med tray in Pyxis, the unit nurse is responsible to call pharmacy to bring up a

replacement back-up med tray after a code if back-up med tray used (9th floor and Cath lab)

4. Crash Cart Broken Lock Process & Procedure: a. If the supplies cart lock is found broken on the units:

i. The unit nurse will notify Central Supply of broken lock. ii. Central Supply will bring a replacement crash cart before taking the old crash cart.

1. Central supply will stop by pharmacy first to have the pharmacy medication tray and crash cart lock attached to the crash cart by a Pharmacist or a Pharmacy Technician.

Revised 10/17/18

iii. The unit nurse must remove the drug tray from the old crash cart before allowing Central Supply to take away the old crash cart with the broken lock.

iv. The unit nurse must contact Pharmacy for a Pharmacist or Pharmacy Technician to pick-up the drug tray. v. Central Supply will check the crash cart, store it in Central Supply as a replacement crash cart until a replacement cart is

needed on the unit to bring it up. b. If the medication cart lock is found broken on the units:

i. The unit nurse shall notify the pharmacy department. ii. A Pharmacist or a Pharmacy Technician will come to inspect the broken lock.

iii. If the medication tray seal is intact, a lock shall be replaced on the medication drawer and the new lock number documented on the crash cart.

iv. If the medication tray seal is broken, the tray shall be removed, replaced with a sealed medication tray, the medication drawer locked and the new lock number documented on the crash cart.

c. If the crash cart only contains one lock for both supply and medication drawers: i. The unit nurse will notify Central Supply of broken lock.

ii. Central Supply will bring a replacement crash cart before taking the old crash cart. 1. Central supply will stop by pharmacy first to have the pharmacy medication tray and crash cart lock attached to the

crash cart by a Pharmacist or a Pharmacy Technician. iii. The unit nurse must remove the drug tray from the old crash cart before allowing Central Supply to take away the old crash

cart with the broken lock. iv. The unit nurse must contact Pharmacy for a Pharmacist or Pharmacy Technician to pick-up the drug tray. v. Central Supply will check the crash cart, store it in Central Supply as a replacement crash cart until a replacement cart is

needed on the unit to bring it up.

5. When the Med Trays or Medication Contents are Soiled with Blood or Bodily Fluids a. Nursing Supervisor or Code Leader to dispose of the medication in pharmaceutical waste bin b. Nursing Supervisor or Code Leader to dispose of the drug tray in biohazardous waste container/bag c. Nurse to notify pharmacy of disposal, patient name and medical record number for whom tray was used

6. Emergency transport boxes a. The purpose of these boxes is to have these available in various areas of the hospital so that medications for code blue/code whites

can be carried to places where there are no crash carts OR during patient transport b. When these boxes are opened and used, the unit nurse will bring these boxes to pharmacy to exchange for a new locked box

Reference:

Revised 10/17/18

Title 22 California Code of Regulations Division 5. Section 71233f, pg 187. Approvals Highland Hospital Pharmacy Department 9/2015, 8/2017, 12/2017, 10/2018 Infection Control 10/2018 System Pharmacy and Therapeutics 10/2015, 8/2017, 10/2018 Medical Executive Committee 12/2015, 9/2017 Board of Trustees 2/2016, 10/2017

System Alameda AHS Core San Leandro Departmental Date: 10/2018 System Pharmacy & Therapeutics

10/2018

Patient Care Leadership Team Date: 10/2018 Clinical Practice Council Date: 12/2018 Medical Executive Committee Date: 1/2019 Board of Trustees Date:

Revised 10/17/18

Medication contents of cash cart/code box

Filled by: _______________________________ Date: _____________________ Checked by (pharmacist): _______________________________________ Date:______________________

Quantity Medication Expiration

3 Adenosine 6 mg/2 mL inj (Adenocard®)

4 Amiodarone 150 mg/3 mL amp/vial (Cordarone®)

3 Atropine 1 mg/10 mL syringe

3 Calcium Chloride 10% 1 gm/10 mL syringe

1 Dextrose 50% 25 Gm/50 mL syringe

1 Dopamine 400 mg/250 mL D5W

1 Epinephrine 1 mg/mL, 1:1000 30 mL MDV

6 Epinephrine 1 mg/10 mL, 1:10,000 syringe

1 Glucagon 1 mg/1 unit vial with diluent

1 Magnesium Sulfate 50% 5Gm/10 mL

3 Naloxone 0.4 mg/mL 1ml (Narcan)

2 Norepinephrine 1 mg/1 mL, 4 mL SDV

1 Phenylephine 10 mg/mL, 1 mL SDV

1 Phenylephine 10 mg/mL, 5 mL SDV

2 Sod Bicarb. 8.4% 50 mEq/50 mL syringe

2 Vasopressin 20 units/mL (1mL) inj

1 D5W 50 mL BAG

1 D5W 100 mL BAG

1 D5W 250 mL BAG

1 NORMAL SALINE 250 mL BAG

AHS Adult Crash Cart

Patient Addressograph

Nursing: Stamp with patient’s name, place in medication box and return to pharmacy

Revised 07/2016

Tray #:

Revised 10/17/18



3 Adenosine 6 mg/2 mL inj (Adenocard®)

4 Amiodarone 150 mg/3 mL amp/vial (Cordarone®)

1 Atropine 0.4mg/mL (20mL) vial – to be compounded per instructions

2 Calcium Chloride 10% 1 Gm/10 mL syringe

1 Dextrose 10% 250mL bag

1 Dextrose 50%, 25g per 50mL

1 Dopamine 400 mg/250 mL bag – due to vial shortage

1 Epinephrine 1 mg/mL, 1:1000 30 mL MDV


1 Glucagon 1 mg/1 unit vial with diluent

1 Lidocaine 2g in 500mL D5W (4mg/mL concentration)

2 Lidocaine 1%, 10mg/mL syringe

1 Magnesium Sulfate 50% 5Gm/10 mL

6 Naloxone 0.4 mg/mL 1mL (Narcan)

7 Sod Bicarb. 4.2%, 5mEq/10 mL syringe

4 Vasopressin 20 units/mL inj

AHS PEDs Crash Cart

Patient Addressograph


Tray #:

Revised 10/2015

Revised 10/17/18



1 Atropine 0.4mg/mL (20mL) vial – to be compounded per instructions

2 Calcium Gluconate 10% 1 Gm/10 mL inj (4.65meq/10mL)

1 Dextrose 10% 250mL Bag


2 Naloxone 0.4 mg/mL 1mL vial (Narcan)

2 Sodium Bicarb. 4.2%, 5mEq/10 mL syringe

4 Sterile Water PF 10mL

AHS Neonatal Crash Cart

Patient Sticker


Tray #:

Revised 10/2015

AHS OB Procedure Cart

Patient Addressograph Tray #: Area dispensed to:

Revised 10/17/18

The following medications are in the 9W Pyxis Refrigerator under “OB PPH Emergency Kit”, to access:

• Log in to pyxis • Hit “remove meds” button • Hit “kit” button at the bottom of the screen • Choose the “OB PPH Emergency Kit” • Remove the below meds

**Diazepam inj must be removed separately from Pyxis when needed


2 Calcium gluconate 1g vials

1 Hydralazine 20mg/mL vial

1 Labetalol100mg/20mL (5mg/mL) vial

1 Magnesium sulfate 20g/500mL bag

2 Magnesium sulfate 50%, 5gm/10mL, 10mL vials

5 Misoprostol 200mcg tab

1 Naloxone 2mg/2mL syringe

1 Nitroglycerin spray 0.4mg/spray

2 Oxytocin 30 units/500mL bag

4 Oxytocin 10 units/mL, 1mL vial

3 Nifedipine 10mg, Immediate Release tabs

1 Terbutaline1mg/mL vial

Pyxis items in the OB Code Kit

Quantity Medication

1 Hemabate 250mcg ampule (refrigerator in zip-lock bag)

2 Methergine 0.2mg/mL ampule (refrigerator in zip-lock bag)

5 Misoprostol 200mcg tab


Revised 10/17/18

Filled by:_______________________________ Date: _____________________ Checked by (pharmacist):_______________________________________ Date:________________________

AHS ADULT TRANSPORT/CODE BOX

Generic drug name Quantity RSI meds grouped together Etomidate 2mg/mL 1 Rocuronium 10m/mL 1 Succinylcholine 20mg/mL (5 ml) syringe

2

Lidocaine 2% 100mg/5mL syringe 1 Adenosine 6mg/2mL 3 Amiodarone 150mg/3mL 2 Flumazanil 0.5mg/5mL 1 Glucagon 1mg = 1 IU diluents 1 Midazolam 10mg/2mL (Versed) 1 Naloxone 0.4mg/mL 1 Nitroglycerin 0.4mg (1.50) 1 x 25 Vasopressin 20 units/mL 2 Angiocath starter kit* 1 Phenylephrine 100mcg/mL (10ml) syringe

1

*20G 1 ¼” Catheter x2, 18G 1 ¼” catheter x2, IV starter kit with ChloraPrep (DYND74260) x2

Generic drug name Quantity Atropine 1mg/10mL syringe 2 Calcium chloride 10% 1g/10mL syringe 1 Dextrose 50% 25g/50mL syringe 1 Epinephrine 1:10000 1mg/10mL syringe 2 Sodium bicarbonate 50mL syringe 1 Dopamine 400mg/250mL bag 1 Lidocaine 2g/500mL bag 1 Normal saline 10mL 3 Sterile water 10mL 3 **Empty syringe 1mL, 3mL, 5mL, 10mL**

1 EACH

Oral glucose gel 15g 1

Revised 4/2016

Revised 10/17/18

Pediatric Transport Box Medication Quantity Expiration Date Adenosine 6mg/2mL (Adenocard) 3 Amiodarone 150mg/3mL (Cordarone) 2 Dextrose 10% 100mg/mL (5mL) 1 Etomidate 2mg/mL (10mL) 1 Glucagon 1mg= 1 I.U. (with diluent) 1 Glucose gel 15 gm 1 Midazolam 10mg/2mL (Versed) 1 Rocuronium 10mg/mL (10mg) (Zemeron) 1 Succinylcholine 20mg/mL (10mL) 1 Vasopressin 20 units/mL 2 Atropine 0.25mg/5mL syringe 2 Calcium chloride 10% 1gm/10mL syringe 1 Dextrose 50% 25gm/50mL syringe 1 Epinephrine 1:10,000 1mg/10mL syringe 2 Lidocaine 1% 50mg/5mL syringe 1 Sodium bicarbonate 4.2% 5mEq/10mL syringe 1 Dopamine 400mg/250mL bag 1 Lidocaine 2gm/500mL bag 1 Normal Saline 10mL 3 Sterile water 10mL 3 Filled by: ___________________________________ Date:_______________ Checked by:_________________________________ Date:_______________

Revised 10/17/18

Neonatal Transport Box- Pharmacy Section Pharmacy Section ONLY Epinephrine 1:10,000 (0.1 mg/mL) 10mL Syringe- 1 ea____ (√) (Dose of Epinephrine= 0.1 to 0.3 mL/KG of Epinephrine 1:10,000 IV) Expiration Date:______________ Signature of employee locking transport box:________________ Green lock #:________________ Date Locked:_____________

Revised 10/17/18

MALIGNANT HYPERTHERMIA MEDICATION CART

Medication Quantity Expiration Date Calcium Gluconate 10% vial 1g/10mL 2 Dextrose 50% syringes, 25g/50mL 2 Epinephrine 1:10,000 syringes, 1mg /10mL 4 Furosemide 100 mg/10mL vials 4 Lidocaine 2% syringes, 100mg /5 mL 4 Normal Saline 500mL IV bag 1 Sodium Bicarbonate 8.4% syringes, 50mEq/50 mL 5 Dantrolene 20mg vial 36 Sterile Water 100mL vials (for dantrolene reconstitution) 36 Filled by: ___________________________________ Date:_______________ Checked by:_________________________________ Date:_______________

Effective: TBD

Title: UCSF East Bay Surgical Residency AHS community hospitals

Page 1 of 2

Department Medical Staff / GME Effective Date Campus SLH and AH Date Revised Unit Next Scheduled

Review

Category Document Owner Replaces the following Policies: Refer to Routing Sheet

Executive Sponsor

I. Purpose

To define the parameters of the professional graduate education program provided through the University of California San Francisco (UCSF) sponsored East Bay Surgical residency program, and the accompanying patient care activities that occur during the rotation at San Leandro Hospital and Alameda Hospital

II. Scope

To describe the roles, responsibilities, and patient care activities of the participants of the graduate education program. This policy applies to all stakeholders affected by the UCSF East Bay Surgical residency program at San Leandro Hospital and Alameda Hospital.

The UCSF East Bay Surgical Residency program maintains the same governance structure, including program director, at all affiliated clinical sites within Alameda Health System. The scope of this policy does not include the governance structure, or the program rules that apply to all trainees, at all AHS clinical sites.

III. Definitions

A. Attending: UCSF East Bay faculty members, who are licensed independent practitioners with appropriate clinical privileges at the facility

B. Trainees: Resident physicians working under the supervision of the Attending

C. Direct Supervision: the supervising physician is physically present with the trainee and patient.

IV. Policy

1. Participants of the program will adhere to all facility policies. 2. The Attending is the initial contact, and ongoing primary contact, for all patient

care provided by this service. 3. Attendings are the only individuals that may supervise the trainees. 4. All patient care performed by the trainee will occur under direct supervision of the

attending.

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Effective: TBD

Title: UCSF East Bay Surgical Residency AHS community hospitals

Page 2 of 2

a. Within the parameters of this policy, the supervising Attending makes the decision about each Trainee’s progressive involvement in specific patient care activities.

5. Attendings and Trainees must inform each patient of their respective roles in that patient’s care, when providing direct patient care.

6. Trainees will be PGY3 or PGY4 level. 7. Trainees will be on-site as needed only.

a. The Attending will initiate contact with trainee when services are needed. 8. All trainee entries into the medical record must be signed with the inclusion of the

trainee’s level. i.e.: PGY3 or PGY4. 9. All trainee patient care orders, or other entries in the patient’s medical record,

must be co-signed by the Attending before considered actionable.

V. References

1. Affiliation Agreement Between the Regents of the University of California and Alameda County Medical Center

2. Joint Commission Standard MS.04.01.01 – GRADUATE MEDICAL EDUCATION PROGRAMS

3. ACGME Common Program Requirements 4. ACGME General Surgical Program Requirements

Approvals

System Alameda AHS Core

San Leandro

Departmental Date:

Patient Care Leadership Team Date: 12/2018

Clinical Practice Council Date: 12/2018

Medical Executive Committee Date:


SLH AH

Graduate Medical Education Committee

Date:

Medical Staff Committee Date:

Medical Executive Committee Date:


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policy approval workflow

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