Winchester HospitalNursing Faculty & Student Nurse Orientation Self-Study Module

WINCHESTER HOSPITAL

These materials are divided into four sections: General Information, Safety Information, Patient Care Information and Patient Care Policies. Please read this Orientation Materials and take and complete the attached Orientation post test. You should review your post test with your Nursing Instructor. Nursing Instructors may return their MCCP ticket to Nursing Staff Development Office.

Section 1: General Information Winchester Hospital is a 229-bed independent, not-for-profit, community hospital, north of Boston. . The Winchester Visiting Nurses Association founded it in 1912. The hospital The Hospital has more than 2,600 employees provides services across the life-span and includes a home care department, an outreach to the community through our Center for Healthy Living, and an Accountable Care Organization. The Hospital affiliated with the Lahey Health System in 2014. Winchester Hospital is a community hospital providing a variety of services for in-patients, out-patients and the community.

MissionThe Hospital’s mission is:To CareTo HealTo ExcelIn service to the community Values Winchester prides itself on being the best place to give care and the best place to get care. All employees at Winchester Hospital are expected to exemplify our PROMISE standards:P romoting TeamworkR espectO wnershipM aintaining a Positive attitudeI nitiativeS afety and QualityE mpathy

One aspect of this program is telephone etiquette. Staff is expected to answer the telephone by identifying their department stating their first name, and then asking, “How can I help you?” Telephones should be answered within three rings. If you need to transfer a call, you should give the caller the name and number of the person you are transferring them to and, when you reach the transfer connection, you should tell the recipient who the caller is and what they need.

Other aspects of the PROMISE Program include assisting in keeping the Hospital clean by either picking up litter or alerting Environmental Services to an area in need of cleaning, assisting patients and visitors who seem in need of directions, and lending a hand to others in need of help.

Magnet Recognition

The Magnet Recognition Program, developed in 1994 by the American Nurses Credentialing Center, recognizes health care organizations that provide the very best in nursing care and uphold the tradition within nursing that supports professional nursing practice. The program also provides a vehicle for the dissemination of best practices and strategies among nursing systems. In 2003, Winchester Hospital became the first community hospital in Massachusetts and the first hospital based homecare in the world to earn Magnet Recognition. Winchester Hospital received Magnet re-designation in 2008. In 2013, Winchester Hospital became the first and only hospital in Massachusetts to earn Magnet recognition three times.

A Magnet culture is defined by nursing excellence and exceptional patient care, enabled by an environment rich in interdisciplinary collaboration and teamwork encompassing both clinical (pharmacy, rehabilitation services, medical staff, laboratory and radiology) and non-clinical partners (information systems, human resources, finance and environmental services). While Magnet recognizes nursing excellence and exceptional patient care, it celebrates the interdisciplinary collaboration that is the foundation on which Winchester Hospital is built. Without this collaboration Magnet designation would not be possible.

The benefits of Magnet Designation are: · Greater recognition within the community for nursing and the healthcare

organization· Improved patient care outcomes· Improved patient and staff satisfaction· Improved employee retention and recruitment · Improved relationships between members of the healthcare team

Based on research by Scott, Sochalski & Aiken (1999) Magnet Hospital characteristics include:

• Shorter length of stay• Greater patient and staff satisfaction• Increased positive patient care outcomes• Improved nurse-to-patient ratios• Fewer patient complications• Positive relationships with physicians• Higher education preparation of the RN workforce• Powerful and influential Nursing Leadership• Higher levels of nurse control over practice

Parking You can park in the Hospital’s garage on weekends or holidays. All nursing instructors and students are to park at the Maple Street Parking Lot. Parking on campus is reserved for those working 11PM-7AM or 7AM-11PM. The Emergency Department parking lot is for exclusive use by emergency patients and physicians.

FoodThe Hospital has a cafeteria and Coffee Shop where you can buy food. There are also vending machines on the ground floor of the Hospital.

Dress CodeIt is very important to look professional at all times. Students are expected to be in their school uniform and wearing their school identification badge at all times. As you will be providing patient care, it is critical that you keep jewelry at a minimum, fingernails short and clean, and that you not use a lot of perfume, after-shave or cologne. Hair should be appropriately groomed for the work setting.

Your BelongingsIt is best not to bring valuables to work. If you do have valuables, keep them with you. The hospital does not provide lockers nor does it assume any responsibility for lost or stolen items.

Drug and Alcohol Free EnvironmentWinchester is committed to making sure that the Hospital is alcohol and drug free. If you suspect that someone other than a patient might be impaired by drugs, alcohol, or medications, you are obligated to tell your nursing instructor or on site supervisor who will then report it to the nurse manager.

HarassmentIf you have any concerns about sexual harassment, be sure to speak with your supervisor or call Human Resources.

GiftsIf a patient or a family member offers you a gift, if it is perishable you can accept it on behalf of the department. If it is anything else, you need to tell the patient and/or his family member that you are not allowed to accept the gift. If they insist, accept it and notify your nursing instructor who will contact the nurse manager.

SmokingWinchester Hospital is a smoke free environment. Smoking is not permitted at any of the Hospital locations by patients, employees, or visitors.

Computers and TelephonesThe Hospital provides computer and telephone systems and other such equipment to assist you in doing your job. This equipment and the information they contain are Hospital property and, as such, should only be used for hospital business. Computers and telephones should not be misused. Examples of misuse include, but are not limited to, sexual or ethnic jokes or materials, developing chain letters, making defamatory statements, inappropriate disclosure of confidential information, unauthorized access, or permitting unauthorized access.

Confidentiality (Please read carefully)Winchester wants to ensure that patients feel comfortable coming to Winchester Hospital; knowing that nothing about their care will be revealed to anyone who should not know. You must keep all patient information confidential. No information of a personal or official nature should be transmitted to anyone other than those authorized to receive it in the course of their duties, including other employees. No electronically printed patient information is to be taken off the unit. Discussion of patient information should be confined to appropriate areas of the Hospital and, in no circumstances, should such discussion occur in public areas. Confidentiality applies not only inside Winchester Hospital, but outside the Hospital in the community as well. Here are some things to remember about confidentiality:

Ø Remember that all information concerning a patient must be held in the strictest confidence.

Ø Do not repeat names, diagnoses, test results, treatment plans, etc., with others who have no business with that information.

Ø Family members and friends do not have an automatic right to information.Ø Keep patient charts in a secure area.Ø Keep voices down. You may need to politely remind others that they are being

overheard.Ø Do not discuss sensitive patient information in elevators, bathrooms,

stairwells, parking lots, the cafeteria, gift shop, or on the shuttle bus.Ø Do not leave confidential information unattended on the computer screen.Ø When using the photocopier, remember to take your original off the plate

before leaving.

HIPAA (please read carefully)HIPAA is the acronym for the Health Information Portability and Accountability Act. HIPAA is a broad series of federal regulations that began in 1996 and is now centered on 1) creating national standard billing codes, and 2) strengthening measures to keep health information, particularly electronic transmissions, private and secure. The Hospital fully supports all efforts to further enhance protection of patient information.

Everyone knows that names and diagnoses are confidential. What is different under HIPAA?In addition to the above, other HIPAA protected heath information can include the dates of a patient’s admission, discharge, birth, or death, e-mail address, medical record number, heath plan number, license plate, phone number, address, last three digits of the zip code, photos, fingerprints, retinal scans, and serial number of any implanted medical device. Not only is the type of information protected but also the mode of communication. Under HIPAA, procedures must be in place to assure the security of sending and receiving certain paper and electronic records, FAX, e-mails, live conversations, and voice-mail messages.

What will patients have to do for HIPAA?Patients will be given a pamphlet describing our privacy practices. They will be asked to give their one-time written acknowledgment of the information what will nursing instructors and nursing students have to do for HIPAA?

Nursing Instructors and nursing students need to have an overall awareness of HIPAA, and of Winchester Hospital’s strict demands concerning patient confidentiality. The nursing instructor nor nursing student can grant requests for information by anyone other than those directly involved in the patient’s care. Copies of Winchester Hospital’s privacy practices are readily available.

Lost and FoundThere is a Lost and Found maintained by Environmental Services and Registration. Environmental Services keeps clothing; Registration keeps valuables. If anything from a patient is stolen, call Security.

Reference ManualsThere are a number of reference manuals available to assist you - Administrative, Infection Control, Material Safety Data Sheets (MSDS), and Safety. Please make sure you locate these manuals when you arrive to your unit. They will be reviewed with you on your assigned unit by your nursing instructor. The MSDS and Infection Control manuals are available on Winnet. See your nursing instructor for help accessing this information.

Section 2: Safety Information

FireAny fire requires a rapid, coordinated effort to prevent injury, loss of life, or property damage. Fires in a medical setting present an even greater challenge because many patients have difficulty in moving and rely on health care workers to assist them. To help protect our patients, visitors, and you, memorize these basic steps:

R - Rescue: remove any person immediately threatened by fire (or smoke).A - Alarm: pull the nearest alarm box, AND dial 3333 (the numbers for off-site locations

are different), state Code Red, give the location of the fire and a brief description of it.

C - Confine: close all doors and windows.E - Extinguish/Evacuate: if there is no personal danger, attempt to extinguish the fire. If

the fire is larger than a trash can, or if you cannot fight the fire with your back to an exit, leave the room.

Using a Fire ExtinguisherEffective use of a fire extinguisher can prevent a small fire from turning into a major one. To use an extinguisher, remember the acronym PASS:

P-Pull the pin between the two handlesA-Aim the nozzle at the base of the fireS-Squeeze the handles togetherS-Sweep the extinguisher from side to side

Additional points about fire extinguishers: Only use an extinguisher if it is safe to do so. If the fire is bigger than a trash can, evacuate the area immediately. Any fire, regardless of size, requires an emergency call and activation of the fire alarm.

When starting your assignment, check for the two nearest fire exits, alarm boxes, and extinguishers. Ask your supervisor what the emergency number is for that location, and ask about your role in case of a fire.

ChemicalsChemicals are all around us. Although most are safe to use, many can be dangerous in certain circumstances. Your health and that of those around you can be harmed if you do not learn about a chemical before using it. Material Safety Data Sheets (MSDS) provide detailed information about the product, including any possible health risks and symptoms of exposure. The MSDS explains emergency first aid, proper spill cleanup, and the chemical’s potential for fire or explosion. Consider the MSDS to be an extended container label; it is the best source for complete product information. The Hospital’s MSDS are kept in yellow and black striped notebooks usually located with other procedure manuals. You may also access MSDS through the hospital’s intranet site, Winnet.

If there is a chemical spill:Ø Determine if anyone is injured and assist him or her. If someone needs urgent

treatment, try to bring the MSDS, if possible, to the emergency room.

Ø Call the Security Department, your supervisor and the Engineering Office.Ø Block off the area so that no one else is exposed to the hazard. Close any

door leading to the area. Wait by the spill area, well out of danger until help arrives.

Ø Determine what the chemical is before rushing in. Ø Find the MSDS for that chemical. Follow directions in the infection control

measures.Ø Do not allow any flames or sparks in the areas.Ø After the danger is over, fill out an Occurrence Assessment Report.

Security Alert: Code PinkInfant abduction is a small, but real, possibility and every hospital employee plays an active role in keeping the babies that we care for safe.Things you can do to decrease the risk of an infant abduction

· Wear your color photo ID badge in the front of your uniform and above the waist· Remind parents/caregivers in the hospital not to leave their babies unattended or

out of their line-of-sight· Keep in mind that the ‘typical’ abductor is a woman between the ages of 14 and

50, carrying something large enough to hold a baby and moving quickly toward an exit

Things that you should do in the event of a real or suspected abduction· Respond quickly if you hear a “Code Pink called (the hospital code for an infant

abduction) o Go to the closest exit immediately. o Open the door and look for someone meeting the above “typical” abductor

profile. o If you see someone that raises your suspicions, ask them to “Stop!” Be

convincing without threatening.o Report anyone who appears suspicious or who may be acting in a

questionable manner to Security, via the Hospital operator (3333). o Be prepared to report a description of the person(s), direction of travel,

type of vehicle, and license plate number.o Other persons exiting the hospital should be asked to remain in the

building until the “all clear” is given. If the person refuses to remain in the hospital and takes steps to leave or advances toward the staff member in a threatening manner, they should be allowed to leave.

o Winchester Hospital employees and law enforcement personnel may be allowed to enter or exit the building after positive identification has been made.

· Remember: Your quick actions are extremely important!

Telephone Failure

In the event that the hospital telephone service is lost, immediately notify the Switchboard (by messenger) and Security. Cell telephones, walkie-talkie radios, messengers and pay telephones can be used until internal telephone service is restored. Nursing units and key supportive areas, e.g., laboratory, pharmacy, have special “Power Failure Phones” to assist with communication during this type of emergency situation. Keep calls to a minimum until the problem has been resolved.

Power FailureIn the event of the loss of power, emergency generators kick in quickly. These generators are capable of providing power to the Hospital for up to ten days. Electrical outlets with a red faceplate are dedicated emergency outlets. Life essential equipment (e.g., ventilators and IV pumps) must always be plugged into red outlets.

Everyone needs to know where their department’s flashlights and extra batteries are kept. Security and Engineering have extra flashlights.

Evacuation ProceduresYou have been told to evacuate patients. Patients who are capable of walking are moved first. Wheel chair patients are moved second. Non-critical bed ridden patients are moved third. Critical bed ridden patients are moved last, as they require the greatest number of staff to move them. Use blankets as improvised stretchers. When patients are moved from their rooms, hang a pillowcase or other piece of linen over the top of the doorframe to “mark” the room as being empty.

Start by evacuating patients to a safe area on the same floor. If you cannot move laterally, go down a floor using the stairs.

Standard PrecautionsAll health care workers must use appropriate barriers to prevent skin, eye, nose, and mouth contact with blood and body fluids. Gloves are the most widely used form of personal protective equipment. Wear them when you anticipate hand contact with blood or body fluids. It is not acceptable to draw blood from a patient unless both hands are gloved. Face shields are required for situations in which splashing is likely. Gowns or aprons should be worn when splashes are anticipated. Ambu bags are used in place of mouth-to-mouth resuscitation and can be found on the Code Cart. All equipment used on patients should be cleaned between patients using the appropriate wipes, either Cavi-Wipes or Bleach wipes.

FINGERNAILS – The following applies to staff whose jobs include: Direct Patient Care, Cleaning and Processing of Equipment, Preparation of Sterile Products, and Handling of Food and Food Products

a. These staff will not wear artificial nails or nail extendersb. They will keep natural nail tips less than ¼ inch long. c. They may wear Nail Polish (either clear or colored) as long as it is in good

condition and not chipped.

Disposing of SharpsUse puncture resistant boxes for disposing of used needles, scalpels, lancers, broken glass or other items that can pierce the skin. Never recap or break off needles, and never reach into a sharps container. Do not use a sharps container that is more than two-thirds full. If stuck by a needle, rinse the area first and then go to the Emergency Department. Fill out an Occupational Injury/Illness report.Exposure to Blood or Body Fluids If an unprotected blood or body fluid exposure occurs, follow these steps:Immediately wash the area with soap and water. Scrub vigorously with lots of lather.If a splash to the eye, nose, or mouth is involved, flush the areas with water.Inform your nursing instructor and then go to the Emergency Department for evaluation. Fill out an Occupational Injury/Illness report. If the source of the exposure is known, list that person’s name on the form.

Tuberculosis (TB)One must wear a special TB mask while caring for a patient with a known or suspected diagnosis of active. Student nurses should not be caring for these patients.

Hazardous Waste Place hazardous waste in red, biohazardous bags or buckets for proper disposal.

Medical DevicesIf a medical device fails, place a red “Equipment Repair” tag on the item with a complete description of the problem. Attach any tubing, plugs etc. used with the device at the time of the problem in a labeled bag. Call the Service Response Center at extension 2500 and remove the machine from service. If a patient injury occurred because of a suspected equipment failure, an Incident Report must be completed with your nursing instructor and contact the supervisor.

Workplace ViolenceWinchester Hospital has zero tolerance for workplace violence. Report any threats, verbal or physical abuse, or weapons (real or simulated) to your supervisor. If the threat of danger is imminent, look for an escape route and contact Security immediately.

Forensic StaffJCAHO uses the term “forensic” to refer to police officers, sheriffs, correctional guards,

etc. Forensic staff must initially report to the Emergency Department, and are to stay with their patient-prisoner at all times.

Section 3: Patient Care Information

Patient’s RightsThe Patient Bill of Rights clearly states that patients have a right to:

Ø Know the name and specialty of the physician responsible for their careØ Have all the information about them kept confidentialØ Have requests handled promptly and adequatelyØ Upon request, receive financial assistance and free careØ See their medical recordØ Refuse to be treated by medical studentsØ Have privacy during medical treatmentØ Provide informed consent before any invasive procedureØ Receive an itemized bill

Ø Receive prompt life saving treatment in an emergency without discrimination or delay on account of economic status

All patients at Winchester Hospital are entitled to receive considerate care that safeguards their dignity and respects their cultural, psychological, and spiritual values throughout their stay. Here are ways we expect you to safeguard Winchester Hospital patients’ rights:

Ø Address the patient by title and last name unless otherwise requested by patient.

Ø Tell the patient your name and professional status. Students must be sure that the patient agrees to be treated by them.

Ø Honor the patient’s refusal of care, and make sure the physician is informed.Ø Provide appropriate covering so as not to expose the patient’s body.Ø Keep doors or curtains closed to assure privacy.Ø Knock on the patient’s door or curtains before entering the room.Ø Request that visitors leave the room while care is being provided.Ø Treat the patient’s belongings with respect and care.Ø Allow the patient to have private conversations with their physician and

others.Ø Keep the patient’s medical record in a secure area.Ø Listen to the patient and make sure that they know you have understood

them.Ø Assess the patient’s level of pain relief and communicate this to the physician.

Age Specific ConsiderationsWhile everyone’s preferences and experiences are unique, all people pass through several developmental stages of life. You need to recognize these phases and adjust the patient’s care to their age.

Infants (birth to 1 year)Infants need to be held closely and spoken to in a gentle voice. They feel more secure when their needs for food, diaper changes, and mental stimulation are consistently met with minimal delay. The need to suck is strong; a pacifier can provide comfort. Include the parents in the infant’s care as much as possible, especially after six months of age.

Toddlers (1-3 years)They need to explore their surroundings while having their safety maintained. Since toddlers have short attention spans, explain procedures in very simple terms immediately before the tasks are performed, and offer distractions during the treatment. Praise the toddler for desired behaviors. A favorite stuffed animal can provide comfort. Encourage the parents to be present as much as possible; a toddler’s greatest fear is separation from their parents.

Preschoolers (3-5 years)This age group needs to have simple reasons and explanations given to them. They have vivid imaginations and take things literally (e.g., a stretcher will stretch them). They like familiar objects and routines. Continue to involve the parents as much as possible, but allow a preschooler to make simple choices.

School age (6-12 years)Children of this age range strive for praise and need to know what is expected of them. They worry about losing control and embarrassing themselves. They like games, reading, craft projects, and contests. They are aware of their bodies and are becoming more modest. They should be offered some input on decisions. Friends and family are important.

Adolescents (13-19 years)Teens need to establish their identities. They like approval but are reluctant to accept criticism or advice. They are afraid of looking foolish, especially to the opposite sex. They will feel more comfortable if you protect their privacy and involve them in their own care. Use correct terminology with this group. Treat the adolescent more as an adult than as a child. Friends have an increasing importance in their lives.

Young adults (20-39 years)The young adult needs information about their health and treatment options. They have

reached physical and sexual maturity, and are working toward career goals. The health professional must respect the young adult’s lifestyle choices and be sensitive to the impact that illness has on the patient’s family and job.

Middle adults (40-64 years)As with a young adult, the middle adult also has a need for information about their health and plan of care. This age group frequently faces the demands of dual caretaking (i.e., caring for young children as well as geriatric parents) and the demands of work. They start thinking about the issues of menopause and retirement. Chronic health problems may develop and be a concern.

Older adults (65 years and over)Older adults need to have their personal identity maintained as they cope with the emotional and physical changes associated with aging. They experience a natural decline in physical abilities but can continue to be active learners if given more time to process and retain the information. Involve the older adult in the decision-making process and support their efforts to maintain a safe independence.

Health Care ProxyPatients need to be asked about any advance directives they have established. Advance directives are instructions patients have given in the event that they become incompetent (that usually means unconscious) and cannot make decisions about their own medical care. Patients also need to be informed that, in Massachusetts, there is a health care proxy law. This law allows patients to appoint someone called a health care agent who can make medical decisions for them if they become unable to do so. It is easy to do. Patients just need a Health Care Proxy form, which the Hospital has available. On the form, patients indicate whom they want to appoint as their proxy and have two witnesses sign the form. (While you cannot be appointed an agent by the patient, you can sign as a witness.)

Patients Who are Hearing-ImpairedIf a patient, or their significant other, needs a Telecommunications Devices for the Deaf (TDD), call the Switchboard for a TDD loaner. The Emergency Department also has a TDD. If the patient, or their significant other, needs a sign-language interpreter, call the Massachusetts Commission for the Deaf and Hard of Hearing at 1-800-249-9949.

Interpreter Services The Hospital guarantees interpreter services free of charge; to access this service please refer to the interpreter services policy in Winnet. If an interpreter is refused, you must complete a Declination of Interpreter Services form and place it in the patient’s medical record.

Culturally Competent CareThe Hospital wants to ensure that the care we provide is sensitive to issues related to culture, race, gender, and sexual orientation. There is a reference guide to cultural issues on each patient floor.

Patient Care in Conflict with Religious BeliefsIf you have a problem participating in care because it conflicts with your cultural or religious beliefs, discuss the issue with your nursing instructor and the supervisor.

Nutrition ServicesWinchester Hospital has both inpatient and outpatient Registered Dietitians (RDs). Outpatient nutrition counseling is available and appointments can be made through Central Scheduling.  Inpatient nutrition consults/referrals do not require a physician’s order. However, consults/referrals must be entered into the Meditech system via order entry.  All diet changes must be entered into the computer before 6 AM, 10:30 AM and 3:30PM.  After these hours, the diet tech should also be notified of any changes.  Breakfast menus after 6 AM must be faxed to the kitchen.    

On-call coverage for consults is available on weekends and holidays.  Diet Technicians/Associates are assigned to each inpatient unit and provide coverage 7 days a week.  They assist with passing/collecting trays, feeding patients, and collecting/correcting menus. Diet technicians also chart on low and moderate risk patients.  Passing trays and feeding patients is a shared responsibility and must be worked out among the health care team on the floor.  Intake amounts are recorded by the staff member who removes the tray from the patient’s room.

Initial inpatient nutrition screening is completed by the Registered Nurse during the admission assessment process.  Nutrition services will prioritize nutrition assessments based upon the initial screening.  It is important that all fields of the nutrition screen be completed.  Dietary is responsible for patient education on all major food-drug interactions.  Nursing is responsible for patient education on all minor & moderate food-drug interactions.  Educational materials are located on the units or can be printed out from the computer. All inpatient nutrition documentation is electronic, except for the initial pediatric nutrition assessment; this is a paper document.

Occurrence ReportsIf a patient is injured, or there is an unusual or unexpected event not considered part of the Hospital’s normal operations, you need to complete an Electronic Occurrence Assessment Report (E-OAR). Contact your immediate supervisor anytime you need to

complete an Occurrence Assessment Report with your nursing instructor and supervisor.

Elder, Domestic, or Child AbuseSpeak to your supervisor immediately if you have concerns that a patient may be a victim of elder, domestic, or child abuse.

Section 4: Key Patient Care ResponsibilitiesPolicies can be accessed on Winnet on line. Below are examples of a few Patient Care Services policies that you are encouraged to review:

Administration of medicationsStudent Nurse PolicyGlucose, Blood Monitoring

Patient Admission Assessment Initial assessments of patients must be completed within twenty-four (24) hours of admission. Ideally, the assessment is completed within 12 hours. A registered nurse completes the admission assessment and ensures that all appropriate referrals are initiated. Clinical referral notifications may be delegated to non-RN staff.

Documentation of Patient Progress and Focus ChartingFocus charting is the method of documenting patient care at Winchester Hospital. Focus charting is based on patient assessment data and identification of patient priority needs. Patient progress on these foci is documented using Focus DARP formatted progress notes. The format of DARP notes is D = data from assessment; A = actions (interventions) taken; R = patient’s response to the interventions, and P = plan of care developed as a result of patient’s response to the initial interventions. A focus that is not resolved prior to discharge is addressed in a follow-up plan in a discharge note and any referrals.

Code 99 Response PlanAll patient care staff is responsible for activating the Code 99 Response System and initiating basic life support for breathless, pulseless patients. Dialing 3333 and informing the operator that there is a Code 99 and the location initiates the Response System. If on A4 or other pediatric areas, you must specify Adult or Pediatric Code 99.

Rapid Response TeamThe Rapid Response Team (RRT) consists of clinicians who are experienced at assessing patients’ symptoms and the trajectory of their health. The team is continuously and readily available to any provider who wants a second opinion about a

patient, especially one showing signs of potential decline.

The RRT is composed of an ICU nurse and a respiratory therapist who will respond to a call for assistance. This team will assist the staff nurse in assessing and stabilizing the patient and with organizing information that needs to be communicated to the patient’s physician. The team also functions in the role of educator and supporter to the staff. The team does not take over the responsibility for the patient. That remains the staff nurse function. The team is also not used as a transport service for the unit. We also have a pediatric rapid response team with guidelines. The pediatric rapid response team will have the pediatric ED physician and a pediatric ED nurse respond to the unit also.

Guidelines for activating the RRT:• Acute mental status change• Seizures• Respiratory rate <8 or >24• SpO2 <90% on FiO2 of 50% or greater• SBP <90• Heart rate <40 or >130• Failure to respond to treatment• Acute significant bleed• Any specific reason the RN is concerned• There may also be subjective information in that “there’s just something off about

this patient” or “I think the patient is going sour”

These are only guidelines for calling for a RRT consult. Staff should look at trends in their patients rather than looking at just one number at a time.

The SBAR communication tool is how we are going to be giving information to the rapid response team. This is also how we should be conveying information to the physicians. Communication will be from the staff nurse to the physician as the staff nurse is not relinquishing responsibility of patient care. SBAR allows for easy communication and provides structure to the conversation. The nurse must first gather all the data so that the issue is thoroughly addressed. It allows for an easy and focused way to set expectations for what will be communicated between members of the team, which is essential for developing teamwork.

Situation: why you are calling Background: reason for admission, problem, med/surg historyAssessment: current vital signs, lab data, assessment, what you think is wrong if you knowRecommendation: Request what you want, clarify orders, when will MD come, when

should you call again

SBAR is the recommended technique for giving any type of report or hand-off to another care provider or for when calling physicians about any patient issues.

This is the process to use when you have a patient that may be having some issues and warrants a call to the rapid response team.

1. Call 3333 to initiate the team, leave the room number and your name2. The RRT will respond within 10 minutes or less3. Communicate your issues using SBAR format4. RRT will assess the patient 5. RRT will initiate protocol6. Staff nurse will communicate using SBAR to attending physician7. RRT may involve the intensivist as indicated8. Depending on patient condition, RRT will document and leave unit, usually within

20 minutes of arrival on unit9. Staff nurse will continue to care for patient10.RRT will follow-up later11. If necessary, another call may be made to initiate another RRT

Pyxis Access: All Nursing Instructors are given access to the pyxis system for administering medications. The nursing instructor must pass the recommended med tests before permission is given for access. Paper work will be filled out with Nursing Staff Development after the test is passed. Students can only give meds with their instructor’s complete supervision. Paper work will be filled out and sent to the designated individual in pharmacy for access. The RN will use the special login noted on the pyxis access form to set up their password and to get their bio-id on the machine.

Administration of MedicationsAll medication orders must include the date and time written, the medication dose, route, and frequency of administration. Any incomplete and unclear order must be clarified prior to administration. At the beginning of each shift, the on coming nurse must check the medication orders written on the previous shift and sign the doctor’s order sheet, including the date and time that this “medication check” was done. The transcription of any new orders must be verified prior to administering the first dose.

I.V. TherapyA physician’s order is required for initiation of and any changes in IV Therapy. IV venipuncture is performed by the IV Therapy nurse or by a nurse deemed competent to do so. Saline locks are flushed with 2 ml’s of Normal Saline at least every 8 hours and before and after IV Medication administration. The standard KVO rate is considered to

be 20 mls per hour. Large volume IVs and ones with medication added must be infused with an infusion pump. IV solutions are changed every twenty-four (24) hours. IV sites are changed every ninety-six (96) hours unless contraindicated. Maintenance IV tubing is changed every 7 days and is labeled with the label indicating the date and time it was hung. Solutions, tubings and changed IV sites must be labeled with date and time initiated or changed. Total parenteral nutrition tubings are changed, timed and dated every twenty-four (24) hours. Transparent dressing and micropore tape (unless contraindicated) are used for IV site dressings. Here are some additional guidelines:

· A physician's order is required to use veins in the lower extremities of an adult.

· Peripheral IV's are inserted by 1) an IV nurse or 2) a nurse who is IV-certified at Winchester Hospital and has demonstrated competency in IV insertion.

· IV orders are renewed daily. · IV saline locks are ordered by a physician and are renewed every 96

hours or are discontinued. · Tubing used for blood products and lipid emulsions are discarded after

each use; blood tubing can be used for two consecutive blood transfusions only or 4 hours of infusion time, whichever comes first.

· All IV solutions have to be infused using the Alaris pump guardrails · All IV solutions are infused on an infusion pump using the IV maintenance

setting for IV fluids or the appropriate setting for infusing any medications or fluids via the correct pump setting.

· IV locks are flushed with 2 ml's normal saline every 8 hours and before and after each medication administration.

· IV sites are changed every 96 hours and PRN except for those with poor venous access, care and comfort status and pediatric patients (18 yrs and under)

Pain Management Upon admission, all patients are assessed for the presence of pain, within the past twenty-four (24) hours to two (2) months. A comprehensive pain assessment is completed on reports of pain within that time interval, and a pain plan of care is established. Pain intensity levels and degree of relief is assessed using a pain scale, every four (4) hours and 30-60 minutes after a pain intervention. Approved age appropriate scales to measure pain intensity and relief are found in all areas where patients are assessed. Patients are provided pain management education, and educational pamphlets are available as a resource tool. Documentation of education must be completed. Pain intensity levels are documented on the clinical record as the fifth vital sign and a level of 4 or above require an intervention. If the intensity is 4 or above for greater than 8 hours, after implementing a plan of care, collaboration with a Physician is required. Non-licensed personnel will identify pain intensity levels when

taking vital signs, and will report a level of 4 or above to a licensed nurse for a pain assessment to be initiated. The Anesthesia Service or Alternative Therapies may be utilized for patients experiencing unrelieved pain, with a Physician’s order.

Patient Controlled AnalgesiaThe patient’s attending physician orders and evaluates the effectiveness of Patient Controlled Analgesia (PCA). The attending physician may initiate an acute pain service consult if the patient’s pain cannot be effectively managed. PCA orders are renewed every twenty-four (24) hours. PCA orders include loading dose, PCA dose, lockout time, 4-hour limit and total mg/ml of medication for infusion. In the case where a patient cannot activate the PCA dose delivery system due to impaired mental condition or physical dexterity, a demand dose should not be ordered or an alternative method of pain management must be considered.

Licensed nurses maintain, monitor and document IV analgesia therapy. RN’s initiate PCA therapy, change dosage and give bolus doses. Two licensed nurses verify and document correct drug and concentration, correct rate and programming of PCA when PCA is initiated or a dose/rate change is made.

At the completion of the shift, the nurse totals the dose received, the number of demands and doses delivered and clears the shift total. If the PCA narcotic is not completely used, discard the remainder according to Policy “Automated Medication Dispensing System (PYXIS) and Controlled Substances.

Please refer to the policy for monitoring guidelines and parameters. Please look at our policy on the protocol for High Risk Medications on the Winnet site.

Wound Healing/Pressure Ulcer PreventionWinchester Hospital has two Certified Wound, Ostomy and Continence Nurses (CWOCN). To consult these nurses for skin or wound care concerns, please call the consult line at extension 8502 and leave a brief message with the patient’s name, unit, who is consulting and the reason for the consult. Nurses, as well as physicians, can consult the CWOCN. All patients that have a Stage II or greater pressure ulcer are required to have a consult from the CWOCN. All patients need to have a full skin assessment completed on admission and daily thereafter. All wounds need to be measured and documented on upon assessment of findings every three days.

The Pressure Ulcer Risk assessment that is used at Winchester Hospital is the Braden Scale; this is to be completed on all patients on the admission assessment and then on a daily basis. Any patient that is found at risk (a Braden score total of 18 or below) needs to have the Pressure Ulcer Prevention Protocol in place. Please refer to the Patient Care Service (PCS) policy, Pressure Ulcers, Prevention of, for any questions.

Staging of Pressure Ulcers is based on the staging system as described by the National Pressure Ulcer Advisory Committee (NPUAP). Please refer to the Skin and Wound Care Reference Manual, found on each of the inpatient nursing units, for a detailed description of the staging system. This information can also be found at the following website: www.npuap.org.

Negative Pressure Wound Therapy (V.A.C.) machines are kept in Central Materials Supply (CMS). To obtain a V.A.C, please call CMS with the patient information. When a V.A.C dressing is discontinued, please contact KCI at 1-800-275-4524 (contact information also located on machine) for pick up of used machine.

Please refer to the PCS policy Specialty Bed / Support Surface Rental for any questions pertaining to obtaining specialty beds.

Purposeful RoundingPurposeful hourly rounding is an evidence based nursing practice that was originally studied and published by a consulting research group known as the Studer group*. This research demonstrated improved patient outcomes when the practice of hourly rounding was implemented. There was a significant reduction in the use of patient call lights, a reduction in patient falls, a reduction in nosocomial pressure wound development, an increase in patient satisfaction, and an increase in employee satisfaction when this practice was used.

The process is as follows:The patient is not awakened to complete a rounding event, however, some practice components, such as evaluation and addressing of the environmental needs, can be completed. The rounding event includes some very specific practice components. It is important to use the word “rounding” with patients (and families) when you are there to do your rounding. This educates the patient and family as to the process and also enhances the trust and satisfaction perception that this practice establishes. The specific practice components of the rounding event are: the 4P’s and 4 T’s:

·Pain – prn meds are to be offered at time due·Physical needs – offer and provide toileting assistance·Positioning – reposition or encourage patient to reposition self·Precautions·Trash- empty when appropriate·Table-make sure it is near the patient·Telephone·TV/Light

Make sure the environment is comfortable and the following items are within easy reach:

Call lightTelephoneTV remote and bed light switchKleenex box and waterBedside tableGarbage receptacle

Ask in your own words something that conveys this statement “is there anything I can do for you before I leave? I have the time while I am here in the room.”This proactive approach of hourly rounding, when done consistently by all staff on the unit, will promote excellence in care, help meet our patient’s needs and improve nurse-sensitive patient outcomes (prevention of both nosocomial pressure wound development and falls). The keys to success are consistency, team work and communication.

*Meade, C., PhD, et al. Effects of nursing rounds on patient’s call light use, satisfaction and safety. AJN, September 2006, Vol. 106, No.9

Fall Prevention Any patient at risk for falls is identified with yellow sticker on their hospital identification bracelet. All in-patients are assessed for fall risk using the Morse Fall Scale. When a patient is identified as being at risk for falls, they are given a pair of yellow slipper socks to wear. In addition, the patient’s medical record is flagged with a yellow falls sticker. These visual cues alert the healthcare team that this patient is at risk for falls and extra precautions should be taken. Once identified at risk, an individualized care plan, with appropriate nursing interventions, must be initiated. Restraint Safety DevicesWinchester Hospital is committed to an environment that minimizes the use of restraints but maximizes patient safety. The use of restraints will be limited to situations with adequate, appropriate clinical justification based on assessed needs when other less restrictive measures have been found to be ineffective. Application of restraints will be limited to those patients whose behavior may cause an interruption in their medical treatment or in emergency situations where the patient is in danger of injuring themselves or others. Students do not care for patients in restraints.

Definition of restraints includes any method of physically or restricting a person’s freedom of movement or normal access to one’s own body. Please refer to the Restraint Policy on Winnet entitled, Restraint and Seclusion of.

National Patient Safety Goals Each year the Joint Commission publishes a list of National Patient Safety Goals (NPSGs) to help healthcare facilities provide the safest care possible. You are

responsible for knowing how your clinical area implements/supports the current NPSGs. The following is a summary of the current NPSGs:

Identify patients correctly§ At Winchester Hospital, the two patient identifiers used are the patient’s name

and date of birth § Eliminate transfusion errors (a third identifier utilizing the patient ‘s medical

record number is also utilized)

Improve staff communication§ Structure added to hand-off communications. SBAR format adopted: Situation,

Background. Assessment, Recommendations.§ Only use approved abbreviations § Telephone Order Read Back (TORB) and Verbal Order Read Back (VORB)

initiated. Please refer to the online policy concerning this process.§ Use procedure when a Critical Value (out of normal range) is identified: Notify

MD within an hour and have them ‘repeat back ‘the results. Dates and times of all notifications and actions to be documented.

Improve medication safety/ use medications safely§ All meds and solutions on the sterile field to be labeled. § Reduce harm from anticoagulation therapy (protocols, pre-mixed, food and drug

interactions, IV pumps, education)§ Record and pass along correct information about a patient’s medicines. Find out

what medicines the patient is taking. Make sure the patient knows what medications to take when they are at home.

Accurately and completely reconcile medications across the continuum§ Healthcare facilities must have a process to compare the meds that the patient

has been taking with the meds we are about to provide. The patient’s meds need to be compared or reconciled, on admission, transfer and discharge

Use alarms safely§ Make improvements to ensure that alarms on medical equipment are heard and responded to on time.

Reduce the risk of health care associated infections

· Reduce the risk of health care associated infections by practicing appropriate hand hygiene

· Wash hands by rubbing vigorously for 15 seconds with soap and water when hands are visibly dirty, contaminated with blood or body fluids, before eating and after using the bathroom

· Sanitize your hands with an alcohol-based hand cleaner at other times when

hand hygiene is needed.

Hand hygiene should be performed before and after EVERY patient contact even if gloves have been worn.  It may be necessary to wash hands between tasks on the same patient to prevent contaminating a clean area.

Hand hygiene is the most important measure to reduce the risk of transmitting an infection to another patient or to yourself.  Our patients are expecting their healthcare providers to wash or sanitize their hands prior to touching them.

§ Prevent multi-drug resistant organism infections§ Prevent central line associated blood stream infections§ Prevent surgical site infection

Identify safety risks inherent in the institution’s patient population§ The organization identifies patient at risk for suicide

Prevent mistakes in surgery Make sure the correct surgery is done on the correct patient and at the correct place on the patient’s body. Mark the correct place on the patient’s body where the surgery is to be done. Pause before the surgery to make sure that a mistake is not being made.

Dangerous Abbreviations

The following abbreviations are not to be used in the medical record:Abbreviation/Dose

ExpressionMisinterpretation Correct Term to Use

ABBREVIATIONS NOT TO BE USED

MS04, MgS04 or MS

Confused for one another. Can mean morphine sulfate or magnesium sulfate

Write “morphine sulfate” or “magnesium sulfate”

U or u Mistaken as a zero (0) or a four (4) causing a ten-fold overdose or greater

Use “unit”

IU Misread as IV (intravenous) or 10

Use “international units”

g Mistaken for “mg” when handwritten

Use “mcg”

Trailing Zero (X.0mg), Lack of Leading Zero (.Xmg)

Decimal point is missed Never write a zero by itself after a decimal point and always use a zero before a decimal point

qd, qid, qod Mistaken for each other. The period after a “q” can be mistaken for an “I”

Write “daily”, “four times a day” and “every other day”

TIW Mistaken for three times a day resulting in an overdose or mistaken for twice a week resulting in an underdose

Write “3 times weekly”

cc

(for cubic centimeters)

Mistaken for units when poorly written

Write “ml” for milliliter

In my role as a student at this institution, I acknowledge that I have read the Orientation Materials and have asked any questions which I might have. I understand before providing care I need to read any applicable policy and procedure. I agree to be responsible for my safety and that of others while at Winchester Hospital.

I also understand the importance of customer service to the organization and my obligation to demonstrate the PROMISE (service excellence) philosophy to patients, visitors, volunteers, physicians, and employees. I also understand my responsibility to keep all patient information confidential.

Please print out your MCCP site ticket and give to your nursing clinical instructor to show you have completed all the required reading for this orientation. You must complete before administering care at the hospital. If you are an instructor or precepting student please send to Nursing Staff Development.

By completing this orientation module I am agreeing to comply with the policies and information as taught.

Nursing Orientation Self Study Module Post Test

This test must be completed after reading through the Nursing Orientation Self Study Module.

Examination SummaryThis examination contains 20 question(s).You must answer l00% correctly or 20 out of 20 question(s) in order to pass this examination.Please select the best response.Please return to your Clinical Instructor upon completion.

1. The alert used at Winchester Hospital for a fire is Code Red.

AnswersA. TrueB. False

2. Which of the following is the alert used for a cardiac arrest at Winchester Hospital?

AnswersA. Code GreyB. Code 99C. Code 33D. None of the above

3. The alert used for a potential infant abduction is Code Pink.

AnswersA. TrueB. False

4. What resource lists information about the chemicals found in the workplace?

AnswersA. The Patient Care Services Policy BookB. The Environment of Care Manual

C. The Material Safety Data Sheets (MSDS) ManualD. None of the above

5. What is the best way to prevent the spread of infection?

AnswersA. Wearing glovesB. Hand washingC. Wearing a maskD. None of the above

6. The first action to take if you are stuck by a needle is to rinse the affected area and go to the Emergency Department.

AnswersA. TrueB. False

7. What is the goal of HIPAA?

AnswersA. To keep patient health information private and secureB. To establish national patient safety goalsC. To recognize hospitals that provide the very best in patient careD. To define employee competence

8. Standard precautions do not apply to patients under the age of three years.

AnswersA. TrueB. False

9. In the event of a building evacuation, patients who are capable of walking are moved last.AnswersA. TrueB. False

10. What answer best describes purposeful rounding done by RNs?

AnswersA. Performed on some patientsB. Performed on every patientC. When the patient calls

11. What are the two patient identifiers used for in-patients at Winchester Hospital?

AnswersA. Name and date of birthB. Address and phone numberC. Mother’s name and date of birthD. Name and medical record number

12. When do medications need to be reconciled?

AnswersA. Admission and dischargeB. Admission, discharge and transferC. Admission and transferD. Discharge and transfer

13. Which of the following abbreviations cannot be used in the medical record?

AnswersA. BID and POB. IM and BIDC. NPO and mlD. CC and QD

14. SBAR is a communication technique used when communicating a problem or in any hand-off situation. What does SBAR stand for?

AnswersA. Situation, Background, Assessment, RecommendationB. Safety, Blood Type, Action, ResponseC. Situation, Blood Type, Assessment, ResponseD. Steps Taken, Blood Type, Action, Recommendation

15. Nursing admission assessments must be completed within 24 hours of admission.

Answers

A. TrueB. False

16. Nursing progress notes are written using the DARP format. DARP stands for what?

AnswersA. Details, Action, Recommendation, PlanB. Details, Action, Re-evaluation, ProgressC. Data, Action, Response, PlanD. Data, Assessment, Response, Plan

17. To activate the Rapid Response Team, the number called is:

AnswersA. 2222B. 1212C. Respiratory STATD. 3333

18. I need to have either my Nurse Manager or the patient’s physician approve activation of the Rapid Response Team.

AnswersA. TrueB. False

19. What is the fall risk sock color and what is the fall assessment tool used at Winchester Hospital?AnswersA. Yellow socks; Morse Fall ScaleB. Red Knights; Morse Fall ScaleC. Falling Star Program; Hendrich Risk Assessment ToolD. Red Socks Program; Hendrichs Assessment Tool

20. What situation is a violation of a patient’s rights?

AnswersA. Talking about a patient in the cafeteriaB. Putting a robe on the patient when walking in the hallwayC. Telling the patient your name and how long you will be caring for themD. None of the above

(Please review with your nursing instructor during orientation)