Alameda Health System Policies and Procedures Executive Summary For

Alameda Health System Policies and Procedures

Executive Summary for Board of Trustees November 2019 Policies and Procedures Title of Policy Last Next review Document Owner Purpose Summary of History of Review Approved date after Changes Committee Date BOT approval AHS System Policies

Catheter Associated N/A 8/2021 Director of Infection To improve quality of patient care. Document • Departmental Urinary Tract Infection Control To reduce the risk of harm to Integration 8/2019 for Indwelling Urinary patients and SNF residents of Catheters Policy Alameda Health System • Infection (CAUTI) (AHS). Control Committee 8/2019

• CPC 9/2019

• AHS MEC 10/19

• AH MEC 10/19

AHS Sitter Policy N/A 9/2022 Chief Administrative The purpose of this policy is to provide System Wide • Departmental Officer/Chief Nurse guidelines for the care and safety of patients 6/2019 Executive identified as (a) being at risk of suicide, (b) • harm to self or others, and/or (c) gravely Legal review 6/2019 disabled. • CPC

• AHS MEC 10/19

• AH MEC 10/19 9/2019

Alameda Health System Policies and Procedures

Antimicrobial N/A 3/2021 Antimicrobial To define the components of the Minor Revision • Antimicrobial Stewardship Policy Stewardship Chair Antimicrobial Stewardship Program, its Stewardship membership, role, and responsibilities. Committee HGH 6/2019

• Antimicrobial Stewardship Committee SLH 7/2019

• Antimicrobial Stewardship Committee AH 7/2019

• P&T 8/2019

• CPC 9/2019

• AHS MEC 10/19

• AH MEC 10/19

Discharge Medications N/A 8/2021 System Pharmacy Director To provide guidelines and a process for New Policy • P&T 8/2019 Policy which discharge medications will be provided to AHS patients. • VP Patient Services 8/2019

• Legal Review 9/2019

• CPC 9/2019

• AHS MEC 10/19

• AH MEC 10/19 Alameda Health System Policies and Procedures

Standards of Nursing N/A 9/2022 VP Patient Services The purpose of this document is to outline Renewal- No • Departmental Practice the Standards of Nursing Practice for the changes 9/2019 Nursing Division at Alameda Health System (AHS). • CPC 9/2019

• AHS MEC 10/19

• AH MEC 10/19 Page 1

Title: CATHETER ASSOCIATED URINARY TRACT INFECTION (CAUTI) PREVENTION for INDWELLING URINARY CATHETERS POLICY

Department Infection Control Effective Date 2/2012 Campus All Date Revised 2/2012, 8/2015,8/2018 Category Clinical Next Scheduled Review 8/2021 Document Director, Infection Control Executive Responsible Chief Administrative Officer/ Owner Chief Nurse Executive Printed copies are for reference only. Please refer to electronic copy for the latest version.

Purpose

1. To improve quality of patient care. 2. To reduce the risk of harm to patients and SNF residents of Alameda Health System (AHS). 3. To ensure CDC guidelines and best-practice recommendations are followed for patients with indwelling urinary catheters. 4. To provide a single reference document reflecting best practices for preventing CAUTI.

Policy

1. Aseptic insertion, maintenance, and timely removal of Foley catheters reduces the incidence of catheter associated UTIs (CAUTI) and thus their resultant complications. Patients with indwelling catheters at AHS will receive care compliant with recommended strategies to prevent Catheter Associated Urinary Tract Infection (CAUTI) under the professional medical judgment of the provider and recognized CAUTI prevention bundle strategies

2. All inpatients admitted to Alameda Health System acute-care facilities who have or may require indwelling urinary catheters, will follow Nurse Driven Foley Protocol.

3. All patients admitted to Alameda Health System post-acute-care facilities who have or may require indwelling urinary catheters, will follow best practice recommendations for care/maintenance, daily assessment for necessity, and prompt removal.

4. Several components of care can be uniformly recommended for all patients to prevent or reduce risk of CAUTI. These components are: a. Avoid unnecessary urinary catheters 1

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b. Insert using aseptic technique c. Maintain catheters based on recommended guidelines d. Review urinary catheter necessity daily and remove promptly

5. The necessity of a bladder catheter should be addressed by physicians daily as a part of rounds, and by nursing as part of their assessment.

6. Using nurse-driven protocols, nursing staff are empowered to remove catheters when protocol patients no longer meet the appropriate indications

7. Considerations for alternative to indwelling Foleys a. Intermittent straight catheterization with the aid of bladder scanning b. Use of external catheters for patients (males =condom catheters, females = external female catheters)

8. Management of Obstruction: a. If obstruction occurs and it is likely that the catheter material is contributing to obstruction, change the catheter. Do not break the seal and flush.

9. Specimen Collection: b. Obtain urine samples aseptically: i. If a small volume of fresh urine is needed for examination (e.g., urinalysis or culture), aspirate the urine from the needleless sampling port with a sterile syringe/cannula adapter after cleansing the port with a disinfectant. ii. Obtain large volumes of urine for special analyses (not culture) aseptically from the drainage bag. iii. Routine screening of catheterized patients for asymptomatic bacteriuria is not recommended.

10. Irrigation a. Physician’s order is required for irrigation and should include: i. Type of solution ii. Amount of solution b. Irrigation and specimen collection must be performed by licensed nursing staff c. Irrigation sets will be discarded after one use d. Strict asepsis will be maintained e. A closed drainage system will be maintained unless ordered treatments necessitate opening the system f. If the system becomes contaminated through leakage, disconnection or breaks in aseptic technique the collection system must be replaced.

11. Education and Training: Ensure that healthcare personnel and others who perform care and maintenance of catheters are undergo periodic in-service training regarding

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techniques and procedures for urinary catheter insertion, maintenance, and removal.

12. Supplies: Ensure that supplies necessary for aseptic technique for catheter insertion are readily available.

Indications for urinary catheter use:

1. Appropriate Urinary Catheter Use: a. Minimize urinary catheter use and duration of use in all patients, particularly those at higher risk for CAUTI or mortality from catheterization such as women, the elderly and patients with impaired immunity. b. Avoid use of urinary catheters in patients and nursing home residents for management of incontinence. c. Use urinary catheters in operative patients only as necessary, rather than routinely. d. For operative patients who have an indication for an indwelling catheter, remove the catheter as soon as possible postoperatively, preferably within 24 hours, unless there are appropriate indications for continued use. e. Examples of appropriate indications for use include: i. Acute urinary retention or bladder outlet obstruction ii. Need for accurate measurements of urinary output in critically ill patients iii. Perioperative use for selected surgical procedures: § Patients undergoing urologic surgery or other surgery on contiguous structures of the genitourinary tract § Anticipated prolonged duration of surgery (catheters inserted for this reason should be removed in PACU) § Patients anticipated to receive large-volume infusions or diuretics during surgery § Need for intraoperative monitoring of urinary output § Neurogenic bladder patient not performing self-catherization iv. To Assist in healing of open sacral or perineal wounds in incontinent patients v. Patient requires prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures) vi. To improve comfort for end of life care

2. Examples of inappropriate uses of indwelling catheters: i. As a substitute for nursing care of the patient or resident with incontinence. ii. As a means of obtaining urine for culture or other diagnostic tests 3

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when the patient can voluntarily void. iii. For prolonged postoperative duration without appropriate indications (e.g., structural repair of urethra or contiguous structures, prolonged effect of epidural anesthesia, etc.).

3. Proper sterile techniques for Urinary Catheter Insertion will be followed as outlined in line insertion trays, or standard skills nursing manual a. Perform hand hygiene immediately before and after insertion or any manipulation of the catheter device or site. b. Ensure that only properly trained persons (e.g., hospital personnel, family members or patients themselves) who know the correct technique of aseptic catheter insertion and maintenance are given this responsibility. c. In the acute care hospital setting, insert urinary catheters using aseptic technique and sterile equipment. i. Use sterile gloves, drape, sponges, an appropriate antiseptic or sterile solution for peri urethral cleaning, and single-use packet of lubricant jelly for insertion. d. In the non-acute care setting, clean (e.g., non-sterile) technique for intermittent catheterization is acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization. e. If intermittent catheterization is used, perform it at regular intervals to prevent bladder over-distension. f. Use a portable ultrasound device to assess urine volume in patients undergoing intermittent catheterization to assess urine volume and reduce unnecessary catheter insertions. i. If ultrasound bladder scanners are used, ensure that indications for use are clearly stated, nursing staff are trained in their use, and equipment is adequately cleaned and disinfected in between patients 4. Document in patient’s medical record date and time of insertion.

Urinary Catheter Maintenance:

Proper care and maintenance of the urinary catheter will prevent urethral trauma, relieve obstructions, promote patient comfort and personal hygiene and will ensure continued urinary drainage for ambulatory patients with a Foley catheter.

1. Catheter Care: Performed each day by the licensed nurse, and is part of routine perineal care, performed after each bowel incontinence, and /or as needed if secretions build around the urinary meatus

2. Proper Techniques for Urinary Catheter Maintenance:

a. Following aseptic insertion of urinary catheter, maintain a closed drainage system. b. If breaks in aseptic technique, disconnection, or leakage occur, replace the 4

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catheter and collecting system using aseptic technique and sterile equipment.

c. Maintain unobstructed urine flow: i. Keep the catheter and collecting tube free from kinking. ii. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. iii. Empty the collecting bag regularly using a separate, clean collecting container for each patient; avoid splashing, and prevent contact of the drainage spigot with the non-sterile collecting container.

d. Use aseptic technique during any manipulation of the catheter or collecting system. e. Unless clinical indications exist (e.g., in patients with bacteriuria upon catheter removal post urologic surgery), do not use systemic antimicrobials routinely to prevent CAUTI in patients requiring either short or long-term catheterization. f. Do not clean the peri-urethral area with antiseptics to prevent CAUTI while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate.

Removal of indwelling urinary catheter: 1. Each day-shift a registered nurse will perform a daily assessment to determine if a patient with an indwelling Foley catheter continues to meet criteria.

2. A physician order is required for removing the Foley for patients who have had: a. Recent urologic surgery b. Bladder injury c. Pelvic surgery (i.e. GYN, colorectal surgery) and/or recent surgery involving structure contiguous with the bladder or urinary tract. d. A medical order stating urinary catheter is to remain in place.

CAUTI prevention assessment flow sheet (see attachment A)

Patient will subsequently be monitored according to the Post Foley Removal assessment flow sheet (see attachment B)

Reference:

Centers for Disease Control (CDC), Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, Healthcare Infection Control Practices Advisory Committee (HICPAC)

Updated CAUTI prevention guidelines issued 2014 by Society of Healthcare Epidemiology of America(SHEA)/Infectious Disease Society of America (IDSA)/American Hospital Association AHA)/ Association for Professionals in

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Infection Control and Epidemiology (APIC)/Joint Commission (JC). Retrieve June 2018 URL: http://www.jstor.org/stable/10.1086/675718

Approvals

System Alameda Hospital Departmental Date: 8/2019 Infection Control Committee Date: 8/2019 Clinical Practice Council Date: 9/2019 Medical Executive Committee Date: 10/2019 10/2019 Board of Trustees Date:

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Title: Sitter Policy

Department All Effective Date 10/2019 Campus AHS System Date Revised 6/2019 Category Clinical Next Scheduled Review 6/2022 Document Chief Administrative Officer/ Executive Responsible Chief Administrative Officer /Chief Owner Chief Nurse Executive Nurse Executive Printed copies are for reference only. Please refer to electronic copy for the latest version.

Purpose The purpose of this policy is to provide guidelines for the care and safety of patients identified as (a) being at risk of suicide, (b) harm to self or others, and/or (c) gravely disabled.

Policy It is the policy of Alameda Health System to (I) screen patients seeking or requiring treatment for emotional or behavioral (psychiatric) disorders, and (II) to determine the need for, frequency and level of monitoring and observation for patients identified as (a) being at risk of suicide, (b) harm to self or others, and/or (c) gravely disabled.

Scope This policy applies to patients who are either (a) receiving care in an inpatient psychiatric unit of an acute care hospital, or (b) receiving care for treatment of an emotional or behavioral disorder in a non-psychiatric setting in an acute care hospital (e.g., critical care unit, medical unit, emergency department, outpatient setting, etc.).1

Procedures

I. Risk Assessment

A. Environmental Risks Each patient care area that is reasonably expected to care for a patient identified as being at risk of harm to self or others, shall conduct an assessment to identify environmental risks. AHS will prescribe the specific assessment tool that may be utilized. An environmental risk assessment shall be completed at least once every three years (or immediately after there is any significant change to the care area and/or patient population(s) served).

1 Note: Sitters are also used for specific Infection Prevention multi-drug resistant identified patients. The use of Sitters for the aforesaid reasons is addressed in the Carbapenem-Resistant Enterobacteriaceae (CRE) Infection Prevention and Control Management Plan. Page 2 of 8 i. Correcting Environmental Risks – AHS shall correct or mitigate environmental risks identified as the result of assessment activities. For purposes of this policy, “correction” means the risk has been remove, and “mitigation” means the risk remains but has been addressed through compensatory mechanism(s). a. Correction of ligature risk is required for psychiatric hospitals and inpatient psychiatric units of general acute care hospitals. b. Mitigation of ligature risk is required for non-inpatient psychiatric care areas of general acute care hospitals. c. Mitigation of other environmental risks is required for all settings. B. Patient Assessment – Identifying and Assessing for Patients at Risk i. Emotional and/or Behavioral (Psychiatric) Disorders – Patient behaviors and assessment of the risk for harm to self or other determines the need for, frequency and level of monitoring and observation. An assessment must be completed on any patient seeking or requiring treatment for emotional or behavioral (psychiatric) disorders in a general acute care hospital (including inpatient care units, outpatient clinics/departments and the Emergency Department). Patients shall be screened and assessed by the RN for the potential risk of suicide at the earliest point of contact possible utilizing the Columbia-Suicide Severity Rating Scale (C-SSRS). . After the assessment, patients should be classified as high, medium, or low risk of suicide. The Joint Commission considers "serious" as equivalent to “high risk.” ii. Patients at Risk – Inpatient and Outpatient Setting – Patients identified as being at risk are to be reassessed at least daily in an inpatient setting, and with each visit in an outpatient setting. For those patients identified at risk, reassessment for changes in behavior will be completed by the RN each shift and PRN. . Conduct or refer for secondary screening and assessment those patients determined to be at risk for suicide. For patients who screen positive for suicide ideations and deny or minimize suicide risk or decline treatment, obtain corroborating information from family, friends or outpatient treatment providers. The use and disclosure of protected health information (PHI) shall be limited to the minimum necessary to corroborate suicidal ideations and/or risk, and shall be done in accordance with applicable State (e.g., CMIA) and Federal (e.g., HIPAA) privacy laws and regulations. . If the RN identifies changes in behavior indicating a greater risk for self-injury or injury to others, the patient will be re-screened for risk of suicide. iii. Staff should encourage patients to verbalize feelings and to alert staff if they experience a change in level of lethality. a. Unresponsive/Unconscious Patients – A patient who is suspected of self-harm but is unconscious, comatose or unresponsive due to his or her medical condition requires assessments by the RN for change in level of consciousness per unit standards. As soon as the patient regains consciousness, the patient will be screened for suicidal risk (in accordance with the Columbia-Suicide Severity Rating Scale (C-SSRS)), and placed on the appropriate level of suicide precaution at that time. II. Management of the Patient at Risk of Suicide, harm to self or others Page 3 of 8 A. Observation of At-Risk Patients – In all general acute care settings (except inpatient psychiatric units), a patient identified as being at risk of harm to self or others shall be placed under the appropriate level of observation. Reasonable discretion will be used to determine the type of Sitter and level of observation necessary to protect patient and others from potential injuries. Staff may initiate a level of observation without a prior physician order. Staff, however, shall immediately notify the patient’s physician. i. Continuous 1:1 Observation – Patients who are assessed with serious/high risk of suicide will be placed on continuous direct line of sight observation for that single patient and no others (one to one observation). . For purposes of this policy, Continues 1:1 Observation means that the patient is within line of sight of a staff member at all times. A staff member is assigned to observe only one patient at all times including while the patient uses the toilet or showers. Depending on the care need, the staff member may need to be at arms-length of the patient. Arms-length proximity is contraindicated for patients at risk of harm to others. For patient’s under 1:1 observation, the doors and curtains are to remain unlocked and open at all times. ii. Continuous Visual Observation — Patients who are assessed as being at moderate risk of harm to self or others will be placed on continuous observation.

. For purposes of this policy, Visual Observation means that the patient is within line of sight of a staff member. At times, more than one patient may be under continuous observation of a single staff member. During times when the patient is using the toilet or is showering, the patient may be outside of line of sight, but a staff member is directly outside the bathroom / shower and the door to the bathroom / shower is unlocked.

B. Low Risk Patients – Patients determined to be at low risk will have observations considered if there is an absence of strong protective factors and based on the individual treatment plan but is not required.

C. Removing / Modifying level of Observation – The decision to remove or modify a level of observation should be a collaborative one between staff, the patient, and the patient's physician. a. Note – A patient who is screened as serious/high risk on initial presentation does not automatically require one to one observation throughout hospital stay. The level of precautions will be based on ongoing assessments and the collaboration of the healthcare team. Documentation in the medical record should clearly reflect decisions for the plan of care. D. Ligature/Safety Risks – If there are any potential ligature or other safety risks present in the patients' care environment, the patient shall be placed on the appropriate level of observation as described above. III. Sitters / Clinical Social Workers / Mental Health Clinicians

A. Sitters will be assigned for observations/safety measures as appropriate. For the purposes of this policy, a Sitter cannot be a family member or significant other but Page 4 of 8 must be someone assigned by the hospital to observe the patient. Sitters’ responsibilities include, but are not limited to: i. Calling and/or yell out in hallway for help by initiating a "Code Gray" with room number if necessary; ii. Accompanying the patient whenever he/she leaves the room/unit for any reason (i.e., receiving tests/procedures in another department, transfer to another unit, etc.); iii. Assisting nursing staff in securing the environment; iv. Summoning nursing personnel to perform any tasks exceeding the scope of their responsibilities; v. Ensuring that all visitors have checked in with nursing staff; vi. Monitoring visitation and inspecting objects/packages brought to the patient by visitors to ensure that potentially harmful items are not given (or accessible) to the patient; vii. Utilizing the "Suicide Risk Safety Attendant Observation Form" and participating in hand-off communications with the oncoming Sitter and the primary RN assigned to the patient; and viii. Immediately reporting to nursing staff any of the following: . Changes in the patient condition; . Observation of warning signs that might indicate imminent action; and/or . Attempts to commit self-harm. B. Clinical Social Worker or the Mental Health Clinician shall be consulted for the evaluation of a patient who presents after a suicide attempt or is assessed to be at risk for suicide. The clinical social worker/mental health clinician/ and or provider will: i. Collaborate with the nursing staff and initiate a plan of care to protect the patient from self-harm and meet his/her immediate safety needs; ii. Complete the mental health evaluation concurrent with medical clearance; iii. Complete a behavioral/mental health assessment and reassess PRN if changes in patient condition; iv. Facilitate consultation with mental health providers if applicable; v. Communicate findings to the care team (e.g., provider, nursing, security); and vi. If the patient meets the criteria for involuntary detention: ▪ Assist in involuntary detention process per state requirements; ▪ Advise the patient of status; ▪ Coordinate daily efforts to place patients into treatment facilities as appropriate; and ▪ Facilitate transfer arrangements to transfer the patient to a designated psychiatric facility as applicable. IV. Environmental Assessment – RN A. Securing the Environment – The RN will provide a safe and secure environment with the assistance of the Sitter by implementing the following measures at a minimum as applicable:

i. All unnecessary equipment and supplies are either removed from the area or placed in a locked cabinet. This includes the following as applicable when possible or not in use: Page 5 of 8 . IV pole (roll or stand mounted) . Oxygen tank and/or holder from area or bed . Flashlight . Gloves . Suction tubing/canister/regulator . Miscellaneous tubing . Supplies/packaging etc. . Computers cables . Bed Control and telephone cords . Computer cables . Call bell with cords (alternate bell without cord may be used) . Fan . Window blind ii. Monitoring equipment (cardiac, BP, pulse oximetry, cuff and any cords/leads are removed whenever not in use); iii. If equipment is necessary, cords are wrapped and tied securely so they cannot be used as a hanging device; iv. Medical pressure gauges and any tubing, masks are removed if not in use; v. Remove plastic trash can or linen liners and replacing with paper bags; vi. Remove items that contain batteries or other objects that may be ingested; vii. Remove sharp objects or place in locked cabinet (needles, instrumentation, scissors, razor, glass items/bottles, and pen/pencil); viii. Sharps disposal containers are removed if possible or affixed in such a way they cannot be accessed. Sharps containers should be kept empty/low by as much as possible; ix. Remove excess linen (fitted sheet, top sheet, draw sheet, pillow case) from the room; x. Remove medications and keeping them out of the patient's room (send any medications brought from home to the hospital pharmacy); xi. Remove disinfectants, chemicals and any solutions, including alcohol based hand gel or place inside locked cabinet or outer hallway for use; xii. Providing finger foods and beverages in paper, Styrofoam or non-rigid plastic containers (Plastic utensils should not be used); xiii. Inventory the patient's belongings and secure them (i.e., security office/facility safe) away from the patient or send home with family. No belongings will be kept at bedside (i.e., clothing/belt, cellphone (optional based on patient status), purse, jewelry, shoes with shoestrings); xiv. Inventory all visitor belongings; V. Documentation A. Document screening and initiate/update the plan of care that outlines suicide precautions and plan for patient safety each shift. B. Document the presence of the Sitter, safety measures implemented, observations of patient's behavior, and assessment findings each shift and with any changes in patient condition. Page 6 of 8 C. Complete "Suicide Risk/High Risk Patient Room Checklist" to secure the environment upon identification of at-risk patient and as part of handoff

communication every shift and transition of care as applicable. D. Complete "Suicide Risk Safety Attendant Observation Form" to document ongoing observations and applicable safety measures.

VI. Physician Notification A. Document in the medical record and notify the physician of any of the following:

i. Escalating suicidal thoughts; ii. Sudden behavioral changes; iii. Anxiety/agitation; iv. Delusions/hallucinations/confusion; v. Aggressive or self-injurious behaviors; vi. Deterioration of physical status; vii. Intent to elope; and viii. Recommendation to lower level of observations/safety measures.

VII. Discharge Planning

A. General Practice – Patient’s at risk shall be evaluated prior to discharge. For all patients with suicide ideation, develop and review discharge safety plan (for patients not being transferred to an inpatient behavioral health unit). At a minimum staff shall: i. Conduct the safety planning by collaboratively identifying possible coping strategies with the patient;

ii. Engage the patient/patient representatives in collaborative discharge planning to promote effective coping strategies; iii. Discuss the treatment and discharge plan with the patient and/or others who are responsible for the patient's well-being; iv. Restrict access to lethal means (secure weapons and medications); v. Provide the number to the National Suicide Prevention Lifeline and to local crisis and peer support contacts; and vi. Develop an individualized care plan that addresses the safety needs of patients deemed gravely disable.

VIII. Staff Training

A. Identification of Patients at Risk / Identification of Environmental Risks – AHS shall provide the appropriate level of education and training to staff regarding the identification of patients at risk of harm to self or others, the identification of environmental patient safety risk factors and mitigation strategies.2 Education and training shall be provided to all new staff initially upon orientation, whenever policies and procedures change, and at least every three years thereafter. Training of staff shall include identification of the following suicide risk factors:

2 For purposes of this policy, “Staff” include direct employees, volunteers, contractors, per diem staff and any other individuals providing clinical care. Page 7 of 8 i. Mental or emotional disorders, particularly depression and bipolar disorder; ii. Previous suicide attempts or self-inflicted injury(ies); iii. History of trauma or loss (e.g., abuse as a child, family history of suicide, bereavement, economic loss; etc.); iv. Serious illness, or physical or chronic pain or impairment; v. Alcohol and drug abuse; vi. Social isolation or a pattern/history of aggressive or antisocial behavior; vii. Discharge from inpatient psychiatric care within the first year after, and particularly within the first weeks and months after discharge; and viii. Access to lethal means coupled with suicidal thoughts.

Definitions: Gravely Disabled – For purposes of this policy, “gravely disabled” means a condition in which a person, as a result of a mental health disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter.

Ligature Point – A ligature risk (point) may include anything which could be used to create a sustainable attachment point such as a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include shower rails, coat hooks, pipes and radiators, window and door frames, ceiling fittings, handles, hinges and closures. Common ligature points and ligatures are doors, hooks/handles, windows frames, belts, sheets, towels and shoelaces.

Suicidal – Purposeful self-injury with the intention to kill oneself (suicidal behavior), or, verbalizing plan, intent, and having the means to complete a suicidal act.

Suicidal Ideation (Sl) – Thoughts of being dead or of killing oneself. These would be noted in statements or gestures by the person.

Suicide Precautions – Continuous interventions aimed at providing a safe environment for patients identified at risk for suicide.

Attachments Safety Attendant Observation Form Columbia-Suicide Severity Rating Scale and related Guidelines Suicide Risk/High Risk Patient Room Checklist

References Welfare and Institutions Code 5150 California Hospital Association (CHA) Consent Manual, Chapter 12, sec Vll, Health and Safety Code 1799.111 Joint Commission Accreditation Standards for Acute Care Hospitals — 2018 The Joint Commission Hospital National Patient Safety Goal 15 - 2018 "Detecting and Treating Suicide Ideations in all Care Settings", The Joint Commission Alert #56, 2016 "A follow-up report on preventing suicide: Focus on medical/surgical units and the emergency department", The Joint Commission, SE Alert #46, 2010 OU Medical Center — Protecting our most vulnerable patients — Preventing Patient Suicides; Suicide Precautions: Patient Management policy and procedure - 2010 Medicare Conditions of Participation and Interpretive Guidelines S482.13(c)(2) 2017. The Joint Commission Special Report: Suicide Prevention in Health Care Settings, 2017. Page 8 of 8 Approvals

System Alameda Departmental Date: 6/2019 Clinical Practice Council Date: 9/2019 Medical Executive Committee Date: 10/2019 10/2019 Board of Trustees Date: Page 1

Title: Antimicrobial Stewardship Program Policy

Department Pharmacy Effective Date 7/2019 Campus AHS System Date Revised 07/2019 Category Clinical Next Scheduled Review 03/2021 Document ID Chair, Antimicrobial Executive Responsible ID Chair, Antimicrobial Owner Stewardship Committee Printed copies are for reference only. Please refer to electronic copy for the latest version.

Purpose: To define the components of the Antimicrobial Stewardship Program, its membership, role, and responsibilities.

Policy: The Antimicrobial Stewardship Program (ASP) will promote and monitor compliance with evidence based guidelines or best practices regarding antimicrobial prescribing which may include but not limited to the following activities including those recommended by the CDC’s Core Elements of a Hospital Antimicrobial Stewardship Program Checklist: 1. Streamlining or de-escalation of therapy 2. Educational activities 3. Antimicrobial management protocols and guidelines 4. Surveillance monitoring 5. Review of appropriate utilization of formulary restricted antimicrobials 6. IV to PO Conversions 7. Pharmacokinetic monitoring (e.g., Vancomycin) 8. Renal dose adjustments 9. Automatic stop orders for antibiotics 10. Antibiogram development and distribution

Components of the Antimicrobial Stewardship Program

Antimicrobial Stewardship Committee

1. Membership: a. The Antibiotic Stewardship Committee will be physician directed and chaired by an Infectious Disease physician (or physician who has received specific training in antimicrobial stewardship) with support by a multidisciplinary inter-professional team. b. The voting members of the ASP will include, at a minimum: i. Physician who has received specific training in antimicrobial stewardship ii. Pharmacist who has received specific training in antimicrobial stewardship iii. Representative from Clinical Microbiology iv. Infection Control v. Practicing provider. This member may be the same as above (i)

c. Subcommittees may exist at each facility to address facility-specific needs.

2. The committee will meet at least quarterly.

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a. The presence of the chair (or surrogate chair) and two other voting members of the committee will constitute a quorum sufficient to conduct a meeting* * Alameda Hospital Antimicrobial Stewardship Committee may be a subcommittee of Pharmacy and Therapeutics Committee, whose voting members may serve on the Stewardship Committee.

3. Responsibilities of the committee a. Develop and publish antibiograms annually a. Develop, update and publish an empiric therapy guide for management of common infection syndromes annually b. Review and update the antimicrobial formulary annually c. Develop and review antimicrobial-related policy and procedure d. Review antimicrobial usage and develop means for improvement e. Assess and modify ongoing stewardship activities as needed f. Develop/update and implement evidence based practice protocols and guidelines that incorporate local microbiology and resistance patterns

4. Reporting – Pertinent reports from the Antibiotic Stewardship committee will be presented at the following committees annually a. P&T Committee – Annually and PRN based upon the content of ASP discussion b. Medical Executive Committee - Annually c. Infection control – Annually d. Quality and Safety Council- Annually

5. Education a. Practitioners and staff education i. Upon hire and annually thereafter

Empiric Therapy Guide 1. The Antibiotic Stewardship Committee at each campus will annually formulate and publish an Empiric Antimicrobial Therapy Guide (ETG). The ETG will contain the following information: a. Bacterial antibiograms from the previous calendar year b. Empiric antimicrobial therapy recommendations for common infectious diseases and syndromes c. Prophylactic antimicrobial regimens for surgeries d. Dosing recommendations for common antimicrobials

2. Adherence to the recommendations in the ETG will be strongly encouraged. Alternate therapy might be warranted and in such situations, providers are encouraged to document in the Electronic Health Record.

3. Recommendations in the ETG will represent consensus of the Antimicrobial Stewardship Committee from evidence-based recommendations, and will incorporate the thoughts and views of campus prescribers in relevant fields of practice. The Antibiotic Stewardship Committee will solicit the input of prescribers in relevant fields of practice as a part of all changes and updates to the ETG.

Retrospective or Prospective Antimicrobial Audit

1. A list of antimicrobials deemed at high risk of inappropriate use will be selected by the Antibiotic Stewardship Committee to be targeted for retrospective or prospective audit. This list shall be reviewed at least once yearly by committee. Antimicrobials may be added or removed from the targeted list at the discretion of the committee.

2. Use of the targeted antimicrobials will be reviewed by pharmacist to ensure use of appropriate drug, dose and duration of therapy. The pharmacist may review the charts of identified patients

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for appropriate use of antimicrobials and may order procalcitonin levels when appropriate to aid in decision making regarding initiation/continuation of antimicrobial therapy. In conjunction with the medical team, decisions will be made regarding appropriate use of the targeted antimicrobials, including (but not limited to): a. Appropriate drug i. Drug indicated for confirmed and/or suspected pathogens ii. Drug spectrum of activity necessary for confirmed and/or suspected pathogens iii. Duplicate coverage and/or multiple drugs warranted (if applicable) b. Appropriate dose i. Adjustment for renal/hepatic function ii. Adjustment for body size iii. Adjustment for indication/ site of infection c. Appropriate duration i. Continued coverage necessary for specified indication ii. Duration of therapy defined where possible d. Recommend Infectious Disease consult

3. All recommendations by the pharmacist shall be communicated to the medical team (except per pharmacy renal dosing adjustment and IV to PO conversion policy). All final decisions regarding use of antimicrobials will be the responsibility of the patient’s primary medical team.

4. A review of the prospective audit program shall be conducted by the pharmacist quarterly, and will assess impact on antimicrobial utilization and opportunities for improvement. This assessment shall be presented to the Antimicrobial Stewardship Committee and to the pertinent hospital committees for review.

D. Formulary Restrictions 1. A list of restricted antimicrobials shall be made available to healthcare providers 2. Utilization of the restricted antimicrobials will be reviewed annually

References: 1. Antimicrobial Stewardship Standard -The Joint Commission Standard MM.09.01.01-2017 https://www.jointcommission.org/assets/1/6/New_Antimicrobial_Stewardship_Standard.pdf

2. California Department of Public Health Antimicrobial Stewardship Program Toolkit-2015 https://www.cdph.ca.gov/programs/hai/Documents/ASPToolkit2015FINAL_ADA.pdf

3. CDC- Core Elements of Hospital Antibiotic Stewardship Programs https://www.cdc.gov/getsmart/healthcare/pdfs/core- elements.pdf

Approvals

System Alameda Hospital Antimicrobial Stewardship Date: 7/2019 Committee System Pharmacy & Therapeutics Date: 8/2019 Clinical Practice Council Date: 9/2019 Medical Executive Committee Date: 10/2019 10/2019 Board of Trustees Date:

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Title: Discharge Medications Policy

Department Pharmacy Effective Date 9/2019 Campus Highland Hospital, San Leandro Date Revised 8/2019 Hospital, Alameda Hospital Category Clinical Next Scheduled Review 8/2021 Document System Director of Pharmacy Executive Responsible Chief Administrative Officer/ Owner Chief Nurse Executive Printed copies are for reference only. Please refer to electronic copy for the latest version.

Purpose: To provide guidelines and a process for which discharge medications will be provided to AHS patients

Policy: AHS hospital pharmacies will provide medications to patients upon discharge for high risk and HPAC patients in compliance with federal and state laws relating to patient inducement and other laws and regulations as may be applicable. Accordingly, AHS shall not offer waivers of coinsurance or deductible amounts as part of any advertisement or solicitation. AHS as an organization and its employees shall not routinely waive coinsurance or deductible amounts, and shall only waive such amounts after determining in good faith that the patient is in financial need, and after making reasonable efforts to collect the cost- sharing amounts from the patient.

Procedure:

a. Provider will e-prescribe discharge medication order in the electronic health record for high risk and/or HPAC patients b. Pharmacy will dispense the medication upon receiving the order and deliver to patient care area c. Nursing will provide patient medication education

1. Non-24 hour pharmacies a. In the event that patients are discharged after hours, providers can e-prescribe to an outside pharmacy if the patient has insurance b. Providers and nurses can contact the AHS pharmacist on-call for unique patient cases

2. Collection of patient financial obligation (e.g. co-pay, deductibles share of cost)

a. Pharmacy will provide an invoice at the time of dispensing for patient financial obligation based on patient insurance type and medication coverage b. Pharmacy will collect at the bedside or patient will have an option to pay via mail or in-person within 30 days c. Pharmacy will make a reasonable and genuine attempt to collect all co-pays

3. Financial Assistance

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a. If the patient is not able to afford the financial obligation, then the patient will be referred to Patient Financial Services to determine eligibility for coverage under Charity Care.

b. AHS will absorb the cost of charity care for prescription medications and will not pass this financial cost to the payer.

References

The Anti-Kickback Statute: 42 U.S.C. 1320a-7b , et seq.

The Civil Monetary Penalty Statute: 42 U.S.C. 1320a-7a, et seq.

Approvals

System Alameda Hospital Pharmacy and Therapeutics Date 8/2019 Clinical Practice Committee Date 8/2019 Medical Executive Committee Date 10/2019 10/2019 Board of Trustees

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Title: STANDARDS OF NURSING PRACTICE

Department Nursing Effective Date 12/2011 Campus All Date Revised 11/2011, 9/2019 Category Clinical Next Scheduled Review 9/2022 Document VP Patient Services Executive Responsible Chief Administrative Officer/ Chief Owner Nurse Executive Printed copies are for reference only. Please refer to electronic copy for the latest version.

Purpose

The purpose of this document is to outline the Standards of Nursing Practice for the Nursing Division at Alameda Health System (AHS).

Background:

Our philosophy of nursing practice is based on the Patient Centered Care Model, the ANA Nursing Code of Ethics and Interpretive Statements and the California Registered Nurse Scope of Practice. We also endeavor to practice the art and science of nursing in a manner that represents the nursing profession in the most positive light, ensures patient safety and optimal care quality.

As nurses at AHS, we use our skills and knowledge to extend the hospital’s mission to every patient and family we serve regardless of their ability to pay.

We use ANA standards of care, standards of professional performance, and evidence- based decision making to guide us in our delivery of care. To enhance patient outcomes, we make a commitment to nursing practice councils, continuous quality improvement activities, and nursing research.

We believe evidence-based decision making is enhanced by nurses’ taking responsibility for their professional practice. We support professional development through nurse practice councils, succession planning, ongoing education and skills enhancement, which are conducive to independent and proactive critical decision making.

We provide educational opportunities to encourage staff development and to ensure, initiate, drive, and sustain safe, high quality care. We encourage utilization and participation in systematic investigation and nursing research to support evidence-based practice, impact or change existing practices, and to develop and contribute to generalizable knowledge.

We work collaboratively with other healthcare team members, serving as care coordinators and team leaders. We provide interventions specific to the patients we serve. We endeavor to support the Pillars of Success and put forth deliberate effort to enhance Page 2 of 2

overall services and be positive stewards of the health care resources provided to us. Those pillars are: Quality, Finance Service, People, Growth and Community.

We view every person as a special and unique individual and we value and respect their diversity. We recognize that illness is complex and this complexity requires a collaborative approach, with all departments maintaining a seamless continuum of care. We hold ourselves accountable for respecting the privacy, personal dignity, and cultural beliefs of each patient.

We recognize the contribution that each patient and their family make to their own care experience. We endeavor to consistently show our patients respect, kindness, understanding, and courtesy, as well as deliver individualized, and personal care.

As we interact daily valuing one another — we promote satisfaction on an individual, interpersonal, and social level for all. This fosters trusting relationships, making Alameda County Medical Center a provider of choice for the community and an employer of choice for nurses and other health care providers.

Approvals

System Alameda

Hospital

Departmental Date: 9/2019

Clinical Practice Council Date: 9/2019

Medical Executive Committee Date: 10/2019 10/2019

Board of Trustees Date: 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.