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. Alameda Health System CPC Executive Summary to Board of Directors Policies and Procedures April 2, 2020 Chair: Dr. Felicia Tornabene

TOPIC or Last Next review Document Purpose Summary of Changes History of Review TITLE OF POLICY Approved date after Owners Committee Date BOT approval

AHS System Wide Policies & Procedures Accounting of Disclosures 09/2015 05/2023 Bernice Zander, To explain patient’s rights for an • Requirements to track • Departmental: Director, Health accounting of how their PHI has disclosures, especially 03/2020 Information been disclosed outside the entity. those not authorized by • CPC: 04/2020 Management Patients have a right to an the patient • MEC: 04/2020 “accounting of disclosures,” which is • Clarify what needs to be a list of certain types of disclosures disclosed of the patient’s PHI that AHS has • Use Quick Disclosure made to third parties. template AHS Outpatient 01/2020 05/2023 Tina Liu, To help reduce phone calls to ED • Add Advair HFA and • Departmental: ED Discharge Auto- Pharm.D. providers and improve patient Advair Diskus to 03/2020 Substitution Policy satisfaction by allowing pharmacists interchange policy • Pharmacy and to substitute approved product Therapeutics: based on the patents insurance 03/2020 • CPC: 04/2020 • MEC: 04/2020 AHS Subpoena Policy New Policy 05/2023 Sanam Amir The purpose of this policy to • Revised defining the • Departmental: establish a consistent process for process and to be more 03/2020 the delivery and acceptance of all concise • CPC: 04/2020 subpoenas and Public Records Act • Amend grid: recommend • MEC: 04/2020 requests issued to Alameda Health titles and roles instead of System (AHS), officials/agents of names (move names to AHS, or individuals acting on behalf attachment with as of of AHS. date) AHS System Policy 07/2019 05/2023 Kathryn Horner, The purpose of this policy is to • New policy • Departmental: Template Ambulatory VP, Ambulatory establish definitions and procedures • Approved by CPC in May 04/2019 Arrival Policy to address patients who arrive after 2019, but not submitted to • CPC: 05/2019 their scheduled appointment time in MEC and BOT • MEC: 04/2020 Ambulatory Care. Cardiac in 10/2013 05/2023 April Bass, Alameda Health System is • AHS system policy update • Departmental: Adult Units Director, committed to providing safe patient 03/2020 Admissions and care of the highest quality. The • CPC: 04/2020 Registration ‘Cardiac Monitoring in Adult • MEC: 04/2020 Telemetry Units Policy’ is created to empower all healthcare providers to deliver safe, effective, and consistent care to adult telemetry patients using evidence-based practice.

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Alameda Health System CPC Executive Summary to Board of Directors Policies and Procedures April 2, 2020 Chair: Dr. Felicia Tornabene

TOPIC or Last Next review Document Purpose Summary of Changes History of Review TITLE OF POLICY Approved date after Owners Committee Date BOT approval

Charity Care Policy 07/2016 05/2023 April Bass, The purpose of this policy is to • Informational only • Departmental: Director, define the eligibility criteria for 03/2020 Admissions and Charity Care services and to • CPC: 04/2020 Registration provide administrative and • MEC: 04/2020 accounting guidelines to assist with the identification, classification, and reporting of patient accounts as charity care. Conditions of Admissions New policy 05/2023 April Bass, Alameda Health System (AHS) • Informational only • Departmental: Policy Director, recognizes the rights of patients to 02/2020 Admissions and make independent and informed • CPC: 04/2020 Registration decisions regarding their medical • MEC: 04/2020 care. The purpose of the policy is to ensure all patients provide legal consent for services rendered at AHS. Credit Balance Procedure New policy 05/2023 Brenda Fleeks, The purpose of this policy is to define a • Informational only • Departmental: Director, Patient process for the correct identification 03/2020 Financial and resolution of all credit balances • CPC: 04/2020 Services and facilitate the timely refunding of • MEC: 04/2020 overpayments to the patient or other third party. Environmental Noise 12/2010 05/2023 Baljeet Sangha, It is the desire of Alameda Health • Define courtyard/healing • Departmental: Reduction Policy VP, Support System (AHS) to provide an sanctuary use 03/2020 Services environment for optimal healing for • Legal added guidance on • CPC: 04/2020 our patients. As a result we will use • MEC: 04/2020 implement strategies to minimize • Emergency codes, noise and other disturbances in the overhead paging order to minimize anxiety and noise related distractions. Financial Assistance New policy 05/2023 April Bass, The purpose of this policy is to • Informational only • Departmental: Policy Director, document Alameda Health System’s 02/2020 Admissions and Financial Clearance policy and to • CPC: 04/2020 Registration define our process of evaluating the • MEC: 04/2020 patient’s needs for applying for assistance. Financial Clearance Policy New policy 05/2023 April Bass, The purpose of this policy is to • Informational only • Departmental: Director, document Alameda Health System’s 02/2020 Admissions and Financial Clearance policy and to • CPC: 04/2020 Registration define our process of evaluating the • MEC: 04/2020 patient’s needs for applying for assistance. CONFIDENTIAL PROTECTED UNDER CALIFORNIA EVIDENCE CODE 1157 Page 2 of 7

Alameda Health System CPC Executive Summary to Board of Directors Policies and Procedures April 2, 2020 Chair: Dr. Felicia Tornabene

TOPIC or Last Next review Document Purpose Summary of Changes History of Review TITLE OF POLICY Approved date after Owners Committee Date BOT approval

Legal Medical Record 02/2013 05/2023 Bernice Zander, To clearly define the legal medical • More concise • Departmental: Definition Director, Health record for AHS, including which • Legal components for 03/2020 Information information must be sent to HIM for medical records (need to • CPC: 04/2020 Management legal archival. keep paper and electronic • MEC: 04/2020 for 10 years) Medicare Secondary New policy 05/2023 April Bass, The purpose of this policy and • Informational only • Departmental: Payer Policy Director, procedure is to promote the 03/2020 Admissions and importance of completing an • CPC: 04/2020 Registration accurate Medicare Secondary Payer • MEC: 04/2020 Questionnaire (MSPQ) with the Beneficiary to determine if Medicare is the primary or secondary payer source. Medication Area 01/2017 05/2023 Priya Patel To ensure safety and proper • Triennial review • Departmental: Inspections – Pharmacy Pharm.D. potency of medications, all 03/2020 Dept Only Policy medication storage areas will be • Pharmacy and inspected and documented every Therapeutics: month. 03/2020 • CPC: 04/2020 • MEC: 04/2020 Medication Selection, 11/2016 05/2023 Priya Patel To establish how medications are • Triennial review • Departmental: Procurement, and Pharm.D chosen for use in the hospital and to 03/2020 Shortages ensure the consistency in the safe • Pharmacy and and timely procurement of Therapeutics: medication. 03/2020 • CPC: 04/2020 • MEC: 04/2020 Medication: System Drug 07/2017 05/2023 Priya Patel To outline the process for • Triennial review • Departmental: Recall Policy Pharm.D identifying, removing and follow up 03/2020 on all recalled medications. • Pharmacy and Therapeutics: 03/2020 • CPC: 04/2020 • MEC: 04/2020 Advisor Policy New policy 05/2023 Susan The purpose of this policy is to • AHS System policy • Departmental: Caraballo, Care ensure patients are at the 03/2020 Management appropriate level of care and that • CPC: 04/2020 Educator utilization review processes are • MEC: 04/2020 conducted in accordance with regulatory requirements and payor contracts.

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Alameda Health System CPC Executive Summary to Board of Directors Policies and Procedures April 2, 2020 Chair: Dr. Felicia Tornabene

TOPIC or Last Next review Document Purpose Summary of Changes History of Review TITLE OF POLICY Approved date after Owners Committee Date BOT approval

Self Pay and Prompt Pay 03/2016 05/2023 April Bass, The purpose of this policy is to • Informational only • Departmental: Discount Policy Director, document Alameda Health System’s 03/2020 Admissions and Self-Pay Discount Policy in order to • CPC: 04/2020 Registration meet the mission of the Health • MEC: 04/2020 System, satisfy the requirements for the Health System’s participation in specific governmental supplemental programs and adhere to the requirements of Senate Bill No.1276 (enacted September 28, 2014). Alameda Health System recognizes the significant burden placed on individuals and wishes to facilitate the prompt payment of patient financial obligations. System Medications 02/2019 05/2023 Priya Patel To ensure Alameda Health System • Annual review – additions • Departmental: Sound Alike Look Alike Pharm.D (AHS) has a system in place to of vaccines to the 03/2020 eliminate medication errors caused by Ambulatory list. No • Pharmacy and the procurement, storage, dispensing changes to acute care list Therapeutics: and administration of look alike, 03/2020 sound alike medications. • CPC: 04/2020 • MEC: 04/2020 Toy Cleaning Policy 12/2017 05/2023 Dr. Deborah To reduce communicable disease • Revise policy statement • Departmental: Ellis, System transmission risk among patients and procedures 03/2020 Director for seen in ambulatory locations. • CPC: 04/2020 Infection • MEC: 04/2020 Prevention and Control WQ Resolution Policy New policy 05/2023 April Bass, The purpose of the Patient Access • Informational only • Departmental: Director, Patient Work Queue Resolution 03/2020 Admissions and policy and procedure is to ensure • CPC: 04/2020 Registration appropriate work queue ownership, • MEC: 04/2020 accountability and timely resolution.

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Alameda Health System CPC Executive Summary to Board of Directors Policies and Procedures April 2, 2020 Chair: Dr. Felicia Tornabene

TOPIC or Last Next review Document Purpose Summary of Changes History of Review TITLE OF POLICY Approved date after Owners Committee Date BOT approval

AHS Facility Specific Policies & Procedures

Highland Hospital Family Birthing Center 01/2020 05/2023 Karen Meyer, To promote safe administration and • Amend policy statement • Departmental: Magnesium Sulfate RN monitoring of magnesium sulfate • Added ED, if given, 03/2020 for OB therapy in obstetric patients. according to policy • CPC: 04/2020 • Nursing staff – • MEC: 04/2020 medication indication as part of standard Family Birthing Center 03/2020 05/2023 Karen Meyer, To describe processes for screening, • Included use of oral • Departmental: Neonatal Blood Glucose RN, Tiffany assessing, and treating hypoglycemic Glucose gel to treatment 03/2020 Monitoring Howell MD, newborns • Pharmacy and Robert Savio Therapeutics: MD 03/2020 • CPC: 04/2020 • MEC: 04/2020 Family Birthing Center 03/2020 05/2023 Karen Meyer, To promote safe, standardized • New system policy • Departmental: Vacuum-Assisted RN performance of vacuum-assisted • Attending OB/GYN at 03/2020 Vaginal Delivery vaginal deliveries in the Family FBC 24/7 • CPC: 04/2020 Birthing Center (FBC) at Highland • MEC: 04/2020 Hospital. FEMA Oakland Urban 05/2012 05/2023 Tina Liu, In collaboration with the FEMA • Triennial review • Departmental: Search and Rescue Task Pharm.D. agency, Highland Hospital will have • Reflects specific 03/2020 Force -- Pharmacy Dept processes in place to Alameda Health Pharmacy updates due • Pharmacy and Only Policy System (supply pharmaceuticals to to FEMA experience Therapeutics: the Federal Emergency Management • Updating FEMA contacts 03/2020 Agency (FEMA), California • CPC: 04/2020 Emergency Management Agency (Cal • MEC: 04/2020 EMA), and Oakland California Task Force-4 Fluoride 02/2020 05/2023 Karen Meyer, To promote pediatric dental health via • Amend policy from • Departmental: Varnish Application RN consistent and standardized Maternal Child Health to 03/2020 application of Fluoride Varnish (FV). Pediatrics • CPC: 04/2020 • MEC: 04/2020 John George Psychiatric Hospital None N/A N/A N/A N/A N/A N/A San Leandro Hospital None N/A N/A N/A N/A N/A N/A Alameda Hospital

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Alameda Health System CPC Executive Summary to Board of Directors Policies and Procedures April 2, 2020 Chair: Dr. Felicia Tornabene

TOPIC or Last Next review Document Purpose Summary of Changes History of Review TITLE OF POLICY Approved date after Owners Committee Date BOT approval

Wound VAC Review 08/2016 05/2023 Ronica Shelton To outline nursing management of • Update to policy • Departmental: the patient using a VAC System statement 03/2020 • CPC: 04/2020 • MEC: 04/2020 Standardized Procedures CRNA Standardized New 06/20203 Dr. Jordan Provides the policies and guidelines • Added sentence about • Departmental: Procedure/Practice Document Newmark for the care provided to the patients evaluation and review by 06/2020 Prerogatives by Certified Registered Nurse nursing leadership and • CPC: 06/2020 Anesthetists (CRNAs) in the AHS interdisciplinary committee • MEC: 06/2020 Department of . This • Include org chart with dotted establishes the legal authority for line relationships CRNAs to perform certain functions and procedures within the Department.

These standardized procedures were developed collaboratively and approved by the Interdisciplinary Practice Committees whose membership includes , advanced practice providers, nurse anesthetists, nurses, and administrators, and are in accordance with the Nurse Practice Act in the California Business and Professions Code: Chapter 6, Article 2; The Nurse Anesthetist Act in The California Business and Professions Code: Chapter 6, Article 7, Section 2825-2833.6; The California Administrative Code: Title 16, Division 14, Article 7; and California Code of Regulations Title 22, Section 51240 (Medi-Cal).

Copies of the signed standardized procedures will be kept in an operational manual in the offices of the Department of Anesthesiology, and on file in the Medical staff office. Standardized procedures will be

reviewed every 3 years. CONFIDENTIAL PROTECTED UNDER CALIFORNIA EVIDENCE CODE 1157 Page 6 of 7

Alameda Health System CPC Executive Summary to Board of Directors Policies and Procedures April 2, 2020 Chair: Dr. Felicia Tornabene

TOPIC or Last Next review Document Purpose Summary of Changes History of Review TITLE OF POLICY Approved date after Owners Committee Date BOT approval

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ACCOUNTING OF DISCLOSURES

Department Health Information Effective Date 09/2003 Management Campus AHS System Date Revised 07/2009, 11/2011, 02/2013, 09/2015, 04/2020 Category Administrative Next Scheduled 09/2018, 06/2023 Review Document Director, Health Executive Chief Financial Officer Owner Information Management Responsible Printed copies are for reference only. Please refer to electronic copy for the latest version.

POLICY It is the policy of Alameda Health System (AHS) to track all disclosures of Protected Health Information (PHI) for an accounting of disclosures when requested by patients or their personal representatives.

PURPOSE To explain patient’s rights for an accounting of how their PHI has been disclosed outside the entity. Patients have a right to an “accounting of disclosures,” which is a list of certain types of disclosures of the patient’s PHI that AHS has made to third parties.

PROCEDURE Any AHS workforce member who discloses a patient’s PHI MUST obtain and complete a Release of Information form, unless an exception applies as indicated below. Completed Release of Information forms should be added to the patient’s medical record.

1. Requirements for Tracking Disclosures a. AHS workforce members must track disclosures of a patient’s PHI made by AHS or its business associates to certain entities. Examples of such entities include, but are not limited to, the following: i. The California State Department of Health ii. The Center for Medicare/Medicaid Services iii. The Office of the Inspector General of the Federal Department of Health and Human Services iv. The Office of Civil Rights of the Federal Department of Health and Human Services v. Alameda County Department of vi. Authorized Law Enforcement Agencies vii. A Court or pursuant to a subpoena

Page 1 of 3 b. There are, however, exceptions to requirement to track disclosures. These include the following disclosures: i. To carry out treatment, payment or health care operations. ii. To patients regarding their own information. iii. Disclosures made pursuant to a valid authorization. iv. For use in the facility’s directory. v. To family, friends and others involved in the patient’s care, as long as the disclosure if appropriate to their involvement. vi. For notification purposes (to notify a family member, personal representative or other person of the individual’s location, general condition or death). vii. To Federal officials for national security or intelligence purposes. viii. To a correctional institution or law enforcement official that has custody of a patient. ix. As part of a limited data set. x. Disclosures made prior to the compliance date for privacy regulations, which was April 14, 2003.

2. Information Required For Each Disclosure a. The following information must be included for each disclosure on the Release of Information form (separate documents may be attached to the form): b. The date of the disclosure; c. The name of the person or organization that received the information; d. The address of the person or organization that received the information (if known); e. A brief description of the protected health information disclosed (with dates of treatment when possible); and f. At least one of the following two items – i. A brief statement explaining the purpose of the disclosure and the basis on which the disclosure was permitted under AHS policies, or ii. A copy of a written request made by a person or organization to whom disclosure was made where the information was disclosed for one of the public policy reasons permitted in [cross-reference AHS’s policy on using and disclosing protected health information for public policy purposes without consent, authorization or verbal agreement].

3. Requests for accounting of disclosures should be forwarded to AHS’s Health Information Management Services Department for processing within 24 hours of receiving the request.

QUESTIONS ABOUT THIS POLICY If you have questions about this policy, please contact your department supervisor or the Health Information Management Services Department (510-437-4724) immediately.

Page 2 of 3

APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 04/2020 04/2020 Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 04/2020 N/A N/A Council (CPC) Medical Executive Date: N/A 04/2020 04/2020 Committee Board of Trustees Date: N/A N/A

Page 3 of 3

AHS OUTPATIENT PHARMACY ED DISCHARGE AUTO-SUBSTITUTION POLICY

Department Pharmacy and Emergency Effective Date 03/2014 Department Campus AHS System Date Revised 03/2020 Category Clinical Next Scheduled 06/2023 Review Document Manager, System Executive Chief Administrative Officer/ Owner Medication Safety Responsible Chief Nurse Executive Printed copies are for reference only. Please refer to electronic copy for the latest version.

POLICY The Outpatient Pharmacy at the Highland campus will follow automatic substitution policy for prescriptions from for medications that are not covered and only when appropriate alternatives exist as approved by the P&T committee.

PURPOSE Decrease calls to the emergency department providers for routinely prescribed medications that are not covered by insurance and therapeutic alternatives are available within the same medication class. This will in turn improve reimbursement of medications, improve patient adherence, and prevent gaps in treatment.

PROCEDURE 1. Upon receiving a prescription order for a medication that is not covered by the patient’s insurance, pharmacy will auto-substitute for an equivalent drug (dose and strength) that the patient’s insurance will cover. (see Attachment A)

2. A call to emergency department physicians is not required for all approved drugs on this protocol list.

3. For a drug not on the pre-approved auto-substitution list, a provider must be notified of the drug not covered by the patient’s insurance and verbal confirmation from an ED provider/attending is required.

4. The pharmacist will note the date, time and auto-substitution on the prescription including drug name, strength, sig., and quantity. If ED provider approval is needed for medications not on the auto-substitute list, the provider name will be documented on the prescription.

Page 1 of 12

APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 03/2020 Pharmacy and Date: 03/2020 N/A N/A Therapeutics (P&T) Clinical Practice Date: 04/2020 N/A N/A Council (CPC) Medical Executive Date: N/A 04/2020 04/2020 Committee Board of Trustees Date: N/A N/A

Page 2 of 12 Attachment A – Autosubstitution List Per P&T for ED Prescriptions Pharmacy and Therapeutics Committee Department of Pharmacy Services AHS Pharmacy will substitute with formulary drug based on patient's insurance

ACE-Inhibitor and Dose (PO) benazepril fosinopril lisinopril moexipril perindopril quinapril ramipril enalapril (Lotensin) (Monopril) (Prinivil/Zestril) (Univasc) (Aceon) (Accupril) (Altace) (Vasotec) 3.75 mg 1.25 mg 5 mg daily 5 mg daily 5 mg daily 2 mg daily 5 mg daily 5 mg daily daily daily 7.5 mg 10 mg 2.5 mg 10 mg daily 10 mg daily 10 mg daily 4 mg daily 10 mg daily daily daily daily 15 mg 20 mg 5 mg 20 mg daily 20 mg daily 20 mg daily 8 mg daily 20 mg daily daily daily daily 30 mg 40 mg 10 mg 40 mg daily 40 mg daily 40 mg daily 16 mg daily 20 mg BID daily daily daily 20 mg 40 mg BID 40 mg BID daily **All ACE inhibitors (except Monopril) require a 50% reduction in initial dosing for patients with ClCr <30 ml/min.

Angiotensin Receptor Blocker (ARB) and Dose (PO) candesartan irbesartan olmesartan losartan telmisartan eprosartan valsartan (Diovan) (Atacand) (Avapro) (Benicar) (Cozaar) (Micardis) (Teveten) 80 mg daily 25 mg 400 mg 8 mg daily 75 mg daily 20 mg daily 40 mg daily (hypertension) or 40mg daily daily BID ( failure) 160 mg daily 50 mg 600 mg 16 mg daily 150 mg daily 40 mg daily 80 mg daily (hypertension) or 80mg daily daily BID (heart failure) 320 mg daily 100 mg 800 mg 32 mg daily 300 mg daily 80 mg daily 160 mg daily (hypertension) or 160 daily daily mg BID (heart failure)

Page 3 of 12

Alpha-1 Adrenergic Blocker and

Dose (PO) terazosin (Hytrin) doxazosin (Cardura) 1 mg QHS 1 mg QHS 2 mg QHS 2 mg QHS 5 mg QHS 4 mg QHS 10 mg QHS 8 mg QHS

Antihistamine (Non-sedating) and Dose (PO) fexofenadine (Allergra) loratadine (Claritin) 60 mg BID or 180mg Qday 10 mg daily

Antacid and Dose

(PO) Mylanta Maalox ES (Antacid Double Strength) 30 ml 15 ml

Antiplatelet Clopidogrel Prasugrel 75mg qday 10mg qday

Anticholinergic inhaler Atrovent inhaler Incruse Ellipta (umeclidinium) Spiriva inhaler All SIG *max dose 12 inh per day 1 puff (62.5 mcg) once daily 18mcg inh qday All SIG *max dose 12 inh per day

Page 4 of 12

Calcium Channel Blocker and Dose (PO)

nifedipine felodipine (Plendil) amlodipine (Norvasc) (Adalat CC) 2.5 mg daily 30 mg daily 2.5 mg daily 5 mg daily 60 mg daily 5 mg daily 10 mg daily 90 mg daily 10 mg daily

Carbonic Anhydrase Inhibitor and

Dose dorzolamide (Trusopt) brinzolamide (Azopt) 1 drop in affected eye(s) TID 1 drop in affected eye(s) TID

Calcium supplement and dose (PO) Calcium Gluconate 500 mg Calcium Gluconate 650 mg Calcium Carbonate 500 mg Calcium Carbonate 650 mg

H-2 Blocker and Dose nizatidine cimetidine (Tagamet) ranitidine (Zantac) (Axid) 300 mg PO q6h 400 mg PO 150 mg PO BID 150 mg PO BID q12h 300 mg PO daily 800 mg PO daily 300 mg PO daily 300 mg IV q6h 50 mg IV q8h **Famotidine dosing in renal dysfunction: Decrease dose to 20 mg daily for ClCr < 50 ml/min

Page 5 of 12

HMG-CoA Reductase Inhibitor

and Dose (PO) fluvastatin atorvastatin lovastatin rosuvastatin pravastatin simvastatin (Zocor) (Lescol) (Lipitor) (Mevacor) (Crestor) (Pravachol) 20 mg QHS 10 mg QHS 10 mg QHS 5 mg QHS 40 mg QHS 20 mg QHS 20 mg QHS 10 mg QHS 80 mg QHS 10 mg QHS 40 mg QHS 5 mg QHS 40 mg QHS 20 mg QHS 20 mg QHS 80 mg QHS 10 mg QHS 80 mg QHS 40 mg QHS 40 mg QHS 20 mg QHS 80 mg QHS 80 mg QHS 40 mg QHS **Pravastatin is allowed when concurrently used with HIV or transplant medications or if a patient cannot tolerate simvastatin **Simvastatin 80 mg is limited to patients that have been taking this dose for >12 consecutive months and without evidence of myopathy **Common simvastatin DDI: CI with itraconazole, ketoconazole, posaconazole, erythromycin, clarithromycin, gemfibrozil, cyclosporine, HIV protease inhibitors. Not to exceed 10mg/d with amiodarone, verapamil, diltiazem. Not

to exceed 20mg/d with amlodipine, ranolazine

Hydrocodone/acetaminophen and oxycodone/acetaminophen

For combination products hydrocodone/acetaminophen or oxycodone/acetaminophen; auto-substitution will only be made based on the APAP component to APAP 325mg (e.g. Oxycodone/APAP 7.5/500mg will be changed to Oxycodone/APAP 7.5/325mg)

Hydroxyzine 1:1 conversion Pamoate formulation hydrochloride form

Page 6 of 12

Insulin, short acting and Dose lispro (Humalog) aspart (Novolog) glulisine (Apidra) 10 units 10 units 10 units **this applies only for conversion from vials to vials and pens to pen BUT not vials to pens or vice versa

Regular insulin

OK to autobsub between brands or generic regular insulin

Long action insulin 1:1 conversion Insulin glargine (ok to autosub between Lantus and Basaglar as 1:1) Insulin Detemir

**if switching from vial to pens, can automatically dispense pen needles. When switching from pen to vials, can automatically dispense insulin syringes

Lispro insulin Admelog insulin 1 unit 1 unit **if switching from vial to pens, can automatically dispense pen needles. When switching from pen to vials, can automatically dispense insulin syringes

Page 7 of 12

Inhaled corticosteroid/ LABA Advair Advair HFS Airduo Fluticasone Symbicort Dulera Breo Ellipta Diskus Respiclick (aerosol powder)/salmeterol (Serevant Diskus) 100/50- 1 puff 45/21mcg – 55/14mcg- 1 100/50mcg-1 puff 80mcg/4.5mcg- 2 100/5mcg-2 100/25mcg- 1 BID 2 puffs BID puff BID bid puffs BID puffs BID puff qday 250/50- 1 puff 115/21– 2 113/14mcg- 1 250/50mcg-1 puff 80mcg/4.5mcg- 2 100/5mcg-2 100/25mcg- 1 BID puffs BID puff BID bid puffs BID puffs BID puff qday 500/50- 1 puff 230/21– 2 232/14mcg- 1 250- 2 puffs bid/50- 160mcg/4.5mcg- 2 200/5mcg-2 200/25mcg- 1 BID puffs BID puff BID 1 puff bid puffs BID puffs BID puff qday **if pt's insurance does not cover any of the combo inhaler products, please call the physician. Can recommend to physician what patient's insurance will cover and take it as a verbal order if physician agrees to change the order

ondansetron ondansetron tab ODT tab OK to autobsub between regular and ODT tabs based on pt insurance coverage

Prostaglandin Agonist and Dose lantanoprost (Xalatan) 1 drop in affected eye(s) QHS bimatoprost (Lumigan) 1 drop in affected eye(s) QHS travoprost (Travatan) 1 drop in affected eye(s) QHS

Page 8 of 12

Proton Pump

Inhibitor and Dose pantoprazole lansoprazole omeprazole rabeprazole esomeprazole (Nexium) (Protonix) (Prevacid) (Prilosec) (Aciphex) 20 mg daily 15 mg daily 20 mg daily 20 mg daily 20 mg daily 40 mg daily 30 mg daily 40 mg daily 40 mg daily 20 mg BID 40 mg daily 40 mg BID 30 mg BID 40 mg BID

Miscellaneous Therapeutic Drug Conversions Timolol ophthalmic 0.5%- 1 drop BID Metipranolol 1 drop BID Ortho-dienestrol vaginal cream Premarin vaginal cream Cardizem CD Dilacor XR (same dose) Colestipol 5 gm Cholestyramine 4 gm Ciprofloxacin eye drop Ofloxacin eye drop Tobramycin eye oint Gentamicin eye oint

Flurbiprofen eye drop Ketorolac eye drop

Miconazole vag. Cream Clotrimazole vag. Cream Neosporin topical oint Polysporin topical oint (Double antibiotic oint)

SABA inhalers 1:1 conversion Albuterol HFA Levalbuterol HFA

Page 9 of 12

Serotonin 5-HT3 Receptor Antagonist dolasetron (Anzemet) ondasetron (Zofran) 12.5 mg IV/PO q6h 4 mg IV/PO q6h

Steroid Nasal Inhaler and Dose (per

Nostril) Beconase/Vancenase 1 spray BID-QID Beconase AQ 1-2 sprays BID Nasarel 2 sprays BID Flonase 2 sprays daily (non-Medical pts) Nasacort 2 sprays daily OR Veramyst 2 sprays daily (medical pts) Nasacort AQ 2 sprays daily Nasonex 2 sprays daily Triamcinolone [Nasacort AQ] 2 sprays Rhinocort 2 sprays BID daily (for Medical pts) Rhinocort AQ 1 spray daily Vancenase AQ 1-2 sprays daily

Sulfonylureas* Glyburide Glipizide 1.25 mg/day 2.5 mg/day 2.5 mg/day 5 mg/day 5 mg/day 10 mg/day 10 mg/day 20 mg/day (divided in 2 doses)

20 mg/day 40 mg/day (divided in 2 doses) *autosub glyburide to glipizide only

Page 10 of 12

Tetracycline Doxycycline Doxycycline

hyclate monohydrate 100mg BID 100mg BID

Thiazolidinedione and Dose (PO) rosiglitazone (Avandia) pioglitazone (Actos) 4 mg daily 15 mg daily 8 mg daily 30 mg daily (2x15 mg)

Combination antibiotics/steroid ear drops Ofloxacin 0.3% ear drops: 10 drops to affected ear(s) daily for 7 days AND Dexamethasone 0.1% EYE drops: 3 drops to the EAR(s) BID for 7 days

OR Ciprodex ear drop

Ofloxacin 0.3% ear drops: 10 drops to affected ear(s) daily for 7 days AND Prednisolone 1% EYE drops: 2 gtts to affected EAR(s) BID for 7 days

Ofloxacin 0.3% ear drops: 10 drops to affected ear(s) daily for 7 days AND Dexamethasone 0.1% EYE drops: 3 drops to the EAR(s) BID for 7 days

Cipro HC ear drop OR

Ofloxacin 0.3% ear drops: 10 drops to affected ear(s) daily for 7 days AND Prednisolone 1% EYE drops: 2 gtts to affected EAR(s) BID for 7 days

Page 11 of 12 Docusate conversion between different salt forms

Docusate Ca 240mg Docusate Na 250mg

Tiotropium inhaler form interchanges Spiriva HandiHaler vs. Spiriva Respimat

Spiriva HandiHaler 1 capsule (18mcg) inhaled once daily Spiriva Respimat 2 inhalations (5mcg) once daily

Sevelamer conversion between different salt forms

Sevelamer carbonate 800mg Sevelamer HCL 800mg

Advair HFS (2 puffs BID) Advair Diskus (1 puff BID) 45/21 100/50 115/21 250/50 230/21 500/50

Sevelamer conversion between different salt forms

Sevelamer carbonate 800mg Sevelamer HCL 800mg

Page 12 of 12

SUBPOENAS/PUBLIC RECORDS ACT REQUESTS

Department Office of the General Effective Date 03/2020 Counsel Campus AHS System Date Revised 03/2020 Category Administrative Next Scheduled 06/2023 Review Document Legal Affairs Specialist Executive General Counsel Owner Responsible Printed copies are for reference only. Please refer to electronic copy for the latest version.

PURPOSE The purpose of this policy to establish a consistent process for the delivery and acceptance of all subpoenas and Public Records Act requests issued to Alameda Health System (AHS), officials/agents of AHS, or individuals acting on behalf of AHS.

POLICY It is the policy of AHS to comply and fulfill its obligations pursuant to subpoenas or requests under the Public Records Act in a consistent and unified manner. Consistent with this commitment, the Clerk of the Board is hereby designated as the only employee authorized by AHS to accept service of a subpoena and/or other document requests, including Public Records Act requests.

Definitions Subpoena: A subpoena is an order of the court commanding a person to appear as a witness in a legal proceeding. Subpoenas can be issued either by the clerk or deputy clerk of the court, or by an attorney of record in a pending action. − Subpoena Duces Tecum: A form of subpoena to obtain access to records and/or documents. A subpoena duces tecum may also request the appearance of an employee as a witness along with production of the documents/records. − Person Most Knowledgeable: A subpoena may request testimony or information from the Person Most Knowledgeable (also known as a “PMK” request). The person most knowledgeable will be the individual identified and designated by AHS as having the most knowledge on the requested subject matter listed within the subpoena.

Personal Records: Original documents pertaining to the individual listed on the subpoena in the possession of the individual.

Public Records Act Request (PRA): Any request to the organization for access to identifiable, disclosable documents or records (outside of the context of litigation) that are maintained by the organization. A “request” includes communication specifically identifying the request as pursuant to the PRA or communication that indicates response pursuant to the PRA is required.

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Employment Records: Original or copy of documents containing information regarding an employee’s pay, benefits, work schedule, department supervisor, or date of employment in the possession of AHS.

Deposition: A pre-trial discovery device by which one party (through his or her attorney) asks oral questions of the other party or of a witness for the other party.

Summons and Complaints: A complaint is the first document filed with the court by a person claiming legal rights against another. When a complaint is filed, the court clerk will issue a summons, which notifies the defendant that an action has been commenced against him/her/it and that the defendant has a specific time to file an answer or other response. The complaint together with the summons is required to be served on the defendant.

PROCEDURE 1. All subpoenas must be served to the Clerk of the Board of Trustees. Unless otherwise authorized by law, all subpoenas shall be served in person to Clerk of the Board at 1411 E. 31st Street, Oakland, California 94602. The Clerk is located in the Highland Care Pavilion Executive Suite (3rd floor).

2. PRA requests should be submitted to the organization in any manner permitted by the statute and forwarded to the Clerk of the Board of Trustees.

3. Upon receipt, the Clerk of the Board will date-stamp the subpoena/PRA request, and will thereafter forward the subpoena to the Legal Affairs Specialist and PRA requests to the appropriate Associate General Counsel.

4. Upon receipt, the Legal Affairs Specialist will examine and review the subpoena. If the subpoena is legally valid, the Legal Affairs Specialist will forward it to the appropriate department and/or individual. This may include, but is not limited to: • The Medical Records Department – Any and all patient records. • Human Resources – Employee/employment records. • Other – o AHP – If the subpoena is for Alameda Health Partner (AHP) employee, forward the subpoena to AHP Executive Director and their attorney, AHP has their own counsel who handles the subpoenas for their staff. See Appendix A o TBH - If the subpoena is for Traditional Behavioral Health (TBH) employee, email the subpoena to the provider and copy TBH Vice President for Contacts & Development. TBH has their own counsel who assists their providers in responding to subpoenas. See Appendix A o UCSF - If the subpoena is for UCSF contractors, email the subpoenas to the physician and copy UCSF Administrator, Manager and UCSF CHIEF of Surgery. See Appendix A o Residents/Fellows – If the subpoena is for a resident/fellow contact the respective Program Director.

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5. An Associate General Counsel will review PRA requests to determine compliance with the PRA and appropriate disposition.

6. No physician or employee should accept a subpoena related to patient’s care. All subpoenas should be directed to the Clerk of the Board.

7. If an individual named in the subpoena receives the subpoena directly from an attorney or process server, he/she should contact the Legal Affairs Specialist. Similarly, if an employee receives a subpoena or is contacted by an attorney he/she should contact the Legal Affairs Specialist. If warranted, the Legal Affairs Specialist will coordinate a request for legal assistance with the Office of the General Counsel.

8. Responding to Subpoenas/PRA Requests – Any response to a subpoena or PRA request (e.g., objections, production of documents, etc.) will come directly from or will be coordinated directly with the Legal Affairs Specialist or an Associate General Counsel.

9. Restrictions/Limitations – The Clerk of the Board shall not accept subpoenas unrelated to AHS business or employment/services with AHS (e.g., personal matters of employees/volunteers).

APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 03/2020 03/2020 Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 03/2020 N/A N/A Council (CPC) Medical Executive Date: N/A 04/2020 04/2020 Committee Board of Trustees Date: N/A N/A

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Appendix A Contact Information as of April 2, 2020

• AHP: o Karen Black, AHP Executive Director, [email protected] o Michael Gawley, [email protected]

• TBH: o Susana Morales, TBH Vice President for Contracts & Development, [email protected]

• UCSF: o Martha George, UCSF Surgery Administrator, Manager, [email protected] o Gregory Victorino, UCSF CHIEF of Surgery, [email protected].

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AHS SYSTEM POLICY TEMPLATE AMBULATORY ARRIVAL POLICY

Department Ambulatory Services Effective Date 07/2019 Campus AHS System Date Revised 07/2019 Category Ambulatory Services Next Scheduled 06/2022 Review Document Vice President, Executive Vice President, Ambulatory Owner Ambulatory Care Services Responsible Care Services Printed copies are for reference only. Please refer to electronic copy for the latest version.

PURPOSE The purpose of this policy is to establish definitions and procedures to address patients who arrive after their scheduled appointment time in Ambulatory Care.

BACKGROUND • We believe every AHS patient should receive high quality and timely care. • We believe we should accommodate AHS patients arriving late to their appointments as long as it does not interrupt our clinic’s timeliness for other patients.

POLICY Ambulatory Care strives to accommodate all patients who arrive to our clinics for their appointments. Patients who arrive within 15 minutes of their appointment time are on-time for their appointments. Patients who arrive greater than 15 minutes past their appointment time will be accommodated as long as it does not interrupt our timeliness for other patients.

PROCEDURE Ambulatory Care makes every effort to place reminder/confirmation calls to patients in advance of their scheduled appointment.

Patients who arrive on time will be seen in the order they are scheduled. On time patients are prioritized and roomed first.

Late arriving patients will be handled via the following steps: 1) Patients who arrive less than 15 minutes past their appointment time will be registered and accommodated automatically into the schedule.

Page 1 of 2 2) Up until the last hour of the clinic session, patients who arrive more than 15 minutes past their appointment time will be registered and before the session ends may be: a) Seen at the end of the session, or during the session if the schedule allows b) Seen by any service-line provider c) Invited to reschedule if the patient cannot wait

3) During the last hour of the clinic session, patients who arrive more than 15 minutes past their appointment time will be rescheduled unless able to be accommodated by the clinic. a) This situation is the only scenario where the registration and clinic team need to discuss the situation before communicating next steps with the patient or registering the patient.

All late arrival activities will be documented in the practice management system.

APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 02/2019 02/2019 Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 05/2019 N/A N/A Council (CPC) Medical Executive Date: N/A 04/2020 04/2020 Committee Board of Trustees Date: N/A N/A

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CARDIAC MONITORING IN ADULT TELEMETRY UNITS

Department Nursing Effective Date 03/2020 Campus AHS System Date Revised 04/2020 Category Clinical Next Scheduled 06/2023 Review Document Director, Nursing Services Executive Chief Administrative Officer Owner Responsible /Chief Nurse Executive Printed copies are for reference only. Please refer to electronic copy for the latest version.

PURPOSE Alameda Health System is committed to providing safe patient care of the highest quality. The ‘Cardiac Monitoring in Adult Telemetry Units Policy’ is created to empower all healthcare providers to deliver safe, effective, and consistent care to adult telemetry patients using evidence-based practice.

POLICY 1. To provide continuous cardiac monitoring with routine assessment to ensure prompt detection of changes in or rhythm 2. To standardize cardiac monitoring practices and processes in accordance with the American Heart Association ‘Practice Standards for Electrocardiographic Monitoring in Hospital Settings’ 3. To provide technology to support staff, implement safe systems, and prevent alarm fatigue

Components of the policy include education & training, best practices, clinical technology, process, and documentation.

The following key definitions are referenced in this policy: 1. Telemetry Technician (TT): Person certified in cardiac monitoring 2. Telemetry Registered Nurse (RN): Nurse trained in cardiac monitoring 3. Buddy RN: Any telemetry RN other than primary RN who can respond to an alarm 4. Rapid Response Team (RRT): Refer to ‘Rapid response Team’ policy 5. Central Station: The telemetry command center 6. Bedside Monitors: Monitors at patients’ bedside - for viewing only 7. Mirror Monitors: Monitors at nursing stations that reflect the same view as the telemetry command center - for viewing only 8. Telemetry Printers: Printers used to print only telemetry strips 9. Telemetry Hard Chart: The hard copy of the patient’s chart which is a part of medical records 10. Clinical Alarm/Alert: An audible and/or visual signal intended to get someone’s attention

Page 1 of 8 11. Default Setting: Pre programmed settings of the telemetry parameters 12. Suspend Mode: A temporary halt in telemetry monitoring at the Central station during patient transfer

EDUCATION & TRAINING Competency Assessment/Staff Training 1. All telemetry technicians must complete the following: • An ECG arrhythmia certification • Annually pass the ECG rhythm interpretation exam with a score of at least 90% (Lethal Rhythms recognition/passing should be 100%) 2. All telemetry nurses must complete the following: • Maintain Advance Cardiac Life Support certification through the American Heart Association • Annually pass the ECG rhythm interpretation exam with a score of at least 90% (Lethal Rhythms recognition/passing should be 100%) • Be able to demonstrate appropriate lead placement upon hire

BEST EVIDENCE-BASED PRACTICES Recommended Indications for Telemetry • Active cardiac condition • Postoperative period after • Syncope with moderate – high likelihood of cardiac etiology • Resuscitated recently from a cardiac arrest • Acute pericarditis • Hyperkalemia with EKG changes or >6.4mmol/L • Electrolyte abnormalities in the setting of underlying heart disease or QTc >500 milliseconds(ms) • Initiation of Type 1 or 3 anti- arrhythmic drugs for significant arrhythmias • Acute pulmonary embolism with HR >110, SBP<100, ALOC or O2 sat<90%, EKG or Echo changes • Acute decompensated heart failure on IV diuretics with electrolyte abnormalities • Acute cerebrovascular event • Severe alcohol withdrawal

Recommended Indications not Requiring Telemetry • Rate controlled chronic • DVT without PE or PE without persistent vital sign abnormalities or right heart strain • COPD exacerbations • Acute kidney disease or ESRD with stable electrolytes • Asymptomatic PVCs hospitalized for reasons other than cardiac or hemodynamic compromise • SIRS/Sepsis as a surrogate for hemodynamic stability • Mild-moderate Alcohol Withdrawal • Lone prolonged QT in the absence of arrhythmias • Syncope with low suspicion cardiac etiology

Page 2 of 8 • with low suspicion ACS based on normal initial troponin and normal or unchanged EKG

• Patient Care • All patients requiring cardiac monitoring should be informed before the device is placed. • Surrogate decision maker should be informed for patients who are deemed medically incompetent. • All patients have a right to refuse cardiac monitoring provided they rationally understand the risk. • Patients who refuse cardiac monitoring require prompt evaluation by the responsible physician. • Patients who refuse cardiac monitoring despite the physician evaluation and recommendations will require a physician order to discontinue Telemetry monitoring. • Restraints can be considered per the ‘Restraint and Seclusion Use in Acute Care Policy’ • Patients who require cardiac monitoring will have to be monitored on telemetry at ALL times. • Skin hygiene: Clip hair from electrode site if needed. Each site to be cleaned and dried prior to applying electrodes. Electrodes should be changed as needed.

CLINICAL TECHNOLOGY Telemetry Equipment 1. Telemetry box 2. Lead wires 3. Electrodes 4. Telemetry pouch

NOTE: For any issues with the equipment, the TT will contact Bio-medical support

Clinical Alarm Notification System (CANS) Actions 1. Red Clinical Alarm: Requires emergent communication per Escalation Policy. Activate RRT or code blue as necessary 2. Yellow Clinical Alarm: Requires urgent communication per Escalation Policy. RN to check and assess symptoms as appropriate 3. Blue Inoperative Alarm: Requires routine communication per Escalation Policy

Page 3 of 8 Clinical Alarm Alarm Triggers Red Clinical Alarm • Asystole • High pitch • Ventricular fibrillation (Vfib) • Life threatening • Ventricular tachycardia (Vtach) Yellow Clinical Alarm • Tacchycardia >140/min • Low pitch • Bradycardia < 40/min • Non life threatening • PVC’s >14/min • SpO2 < 85% • Pause >2.5 seconds • R on T Pre Ventricula Contraction (PVC) • Pacer not captured • Pacer not paced Blue Inoperative Alarm • ECG leads off • No signal • Cannot analyze • Replace/change battery

Default Alarm Settings: • Heart rate >120/min or Heart rate < 50/min • Asystole, Vfib/Vtach • Ventricular trigeminy, Multifocal PVC’s • Supra ventricular tachycardia, Irregular heart rate and pause • Pacer not captured, pacer not paced • R on T wave PVC • Accelerated ventricular rhythm • Couplets • Atrial fibrillation • SpO2 <88% • Ventricular bradycardia

NOTE: Alarms will be set and controlled only at the central monitor station. All patients will have the default alarm settings. Default alarms will reset, if patient is discharged from the central station. The default setting can be changed according to a physician order.

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Admission

Provider Roles Process Physician • Place telemetry order in Epic with appropriate floor • Review telemetry parameters. Deviation from default requires an order with reasoning. Charge nurse • Dispatch telemetry equipment when needed Telemetry nurse • Receive handoff using Epic no longer than 30 minutes prior to receiving the patient • Inform TT of the new incoming patient • Pick up telemetry equipment and sign log book • Set up telemetry equipment on patient and confirm placement with TT. • Pick up, review and co sign telemetry strip and file it in Hard chart. Telemetry technician • Patients name, room number and MRN to be entered into central monitors • Reconcile telemetry parameters with physician orders. • Parameters to be reviewed with tele RN • Telemetry equipment to be given and logged • Color code patient into GE • Confirm proper placement of equipment with tele RN • Print, measure, interpret, sign and release telemetry strip. Clerk • Notify TT of patient arrival • Pickup telemetry equipment if necessary.

Standardized GE color codes (the rhythm will be):

White New admission Blue Discharge Orange Name alert Olive Green Telebox being used in SDU Red X Patient refusing Purple Atrial fibrillation/flutter Yellow Pacemaker

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Daily Monitoring

Provider Roles Process Physician • Assess the need for telemetry daily Note: Tele monitoring will be automatically • Any change in parameter has to be a written discontinued in 48hrs if order not renewed or telephone order with an • explanation. Change requires communication to the telemetry RN. Charge nurse • Assess the need for telemetry monitoring on a daily basis during the morning huddle Telemetry nurse • Discuss telemetry need with physician if appropriate • Equipment to be checked every shift • Pick up, review and co sign telemetry strip and file it in Hard chart every shift Telemetry technician • Every alarm is to be evaluated with appropriate action taken • Print, measure, interpret, sign and fax telemetry strip every shift. Clerk • Replace telemetry equipment if needed

Discharge

Provider Roles Process Physician • Place order in Epic • Inform telemetry RN Charge nurse • Assist in discharge if necessary Telemetry nurse • Validate discharge order in Epic • Remove equipment from patient • Clean equipment • Place equipment in telemetry drop box • Inform TT of patient discharge Telemetry technician • Update log book once equipment received • Clean equipment • Discharge patient from the central station Clerk • Return telemetry equipment to TT if necessary

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Patient Transfer

Provider Roles Process Physician • Place order in Epic Charge nurse • Assist in transfer if necessary Telemetry nurse • Validate transfer order in Epic • Inform TT of patient transfer • Place patient on transport cardiac monitor • Remove telemetry equipment from patient • Clean equipment • Place equipment in telemetry drop box if patient not returning • Place equipment in the patients room if patient returning back • Upon return follow admission procedure Telemetry technician • Place patient in Suspend mode • Upon return turn off Suspend mode and follow admission procedure Clerk • Inform TT of patient return

Change in Heart Rate or Rhythm

Provider Roles Process Physician • Emergent/Urgent assessment required Charge nurse • Assist in assessment if necessary • Escalate if necessary Telemetry nurse • Emergent/Urgent assessment required • Escalate per Escalation Policy Telemetry technician • Inform telemetry RN • If unavailable, escalate to Charge RN Clerk • Assist in prompt communication if necessary

DOCUMENTATION 1. Telemetry strips • Each strip should include patient name, MRN, PR interval, QRS duration, QT interval and rhythm interpretation • A strip is required on admission, every shift, on discharge and for a noted change • These strips must include both the TT and telemetry RN’s signature, date and time

Page 7 of 8 2. Telemetry technician log book • Accountability Log book to be updated every shift inclusive of missing equipment • Any new change in rhythm is to be documented with action • Any communication with the telemetry RN is to be documented 3. Nursing documentation in EPIC • SBAR format to be used when documenting a change 4. Physician documentation in EPIC

APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department: Date: N/A 03/2020 03/2020 Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 04/2020 N/A N/A Council (CPC) Medical Executive Date: N/A 04/2020 04/2020 Committee Board of Trustees Date: N/A N/A

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CHARITY CARE POLICY

Department Patient Access Services Effective Date 03/2004 Campus AHS System Date Revised 12/2019, 03/2020 Category Finance Next Scheduled 06/2023 Review Document Director, Patient Access Executive Chief Financial Officer Owner Responsible Printed copies are for reference only. Please refer to electronic copy for the latest version.

PURPOSE The purpose of this policy is to define the eligibility criteria for Charity Care services and to provide administrative and accounting guidelines to assist with the identification, classification, and reporting of patient accounts as charity care.

POLICY Alameda Health System will operate in a manner such that no patient shall be denied service due to an individual’s inability to pay. Consistent with this commitment, it is the policy of Alameda Health System (AHS) to provide Charity Care (financial assistance) to qualified low-income uninsured or underinsured patients to whom we provide services in our community. This policy will be administered in a manner consistent with state and federal laws and regulations.

As required by law, AHS shall provide patients with information regarding charity care and other programs during the patient intake process. Patients (and/ or representatives) are expected to cooperate with AHS to determine charity care eligibility and to contribute to the cost of their care based on their ability to pay. It is imperative that the notification of availability, determination, reporting and tracking of charity care are in concert with our mission and our community obligations.

Patients who do not qualify for charity care, but are uninsured, may qualify for the Patient Discount set forth in the current hospital policy separate from this policy.

DEFINITIONS For the purpose of this policy, the terms below are defined as follows:

Patient’s Family [Health and Safety Code §127400(h)]: a) Patients 18 years of age and older – the family includes the patient’s spouse, registered domestic partner and dependent children under 21 years of age. b) Patients under 18 years of age – the family includes the patient’s parent, caretaker relatives, and other children (under 21 years of age) of the parent or caretaker relative.

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Federal Poverty Level (FPL): FPL means the poverty guidelines updated periodically in the Federal Register by the U.S. Department of Health and Human Services. [H&S §127400(b)]

Self-pay patient: A patient who does not have third-party coverage from a health insurer, health care service plan, Medicare, or Medicaid/Medi-Cal, and whose injury is not a compensable injury for Worker’s Compensation, automobile insurance, or other insurance (third party liability) as determined and documented by hospital. Self-pay patients may include charity care patients. [H&S §127400(f)]

Uninsured patient: An “uninsured patient” is a patient who has no third-party source of payment for any portion of their medical expenses, including but not limited to, commercial or other health insurer, health care service plan, Medicare, or Medicaid/Medi-Cal, or third party liability. For the purpose of this policy an “uninsured patient” may include a “self-pay” patient.

Discount payment: Describes the situation where the hospital has determined that the patient does not qualify for charity care (i.e., free or almost free care), but is eligible for a discount and is expected to pay only a part of the bill.

Patient with high medical cost: Is a person whose family income does not exceed the FPL percent if that individual does not receive a discounted rate from the hospital as a result of his or her third party coverage. [H&S §127400(g)]

Qualified Patient: Means a patient who is both (A) a patient who is a self-pay patient, or a patient with high medical cost, and (B) a patient who has a family income that does not exceed the 350 percent of the FPL. [Health & Safety Code § 127400(c)]

PROCEDURES I. Determining Eligibility A. Governmental Assistance 1. In determining whether each individual qualifies for charity care, other county or governmental assistance programs should also be considered. Many applicants are not aware that they may be eligible for assistance such as Medi-Cal, Health PAC, Victims of Crime, California Children Services or the Affordable Care Act benefit plans.

2. AHS shall assist individuals in determining if they are eligible for any governmental or other assistance.

3. Persons eligible for programs such as Medi-Cal, but whose eligibility status is not established for the period during which the medical services were rendered, may be granted charity care for those services. AHS may make the granting of charity care services contingent upon the patient applying for governmental program assistance. This may be prudent, especially if the particular patient requires ongoing services.

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B. Criteria for Charity Care Eligibility – Uninsured Patients A low-income uninsured patient is eligible for Charity Care consideration based on meeting the family income eligibility criteria as established by Alameda Health System’s application of the Federal Poverty Income Guidelines. Full charity care (no payment) applies to all patients at 200% or less of the FPL. AHS has extended the Charity Care services to patients who have family income that does not exceed the 350 FPL. Full discount (“write off”) is provided for individuals and families with annual incomes at or below 200% of the current FPL. Partial discounts are provided for individuals and families with incomes above 200% of the current FPL and at or below 350% of the current FPL. Partial discounts adjust based on gradation in income levels.1

C. Criteria for Charity Care Eligibility – Insured Patients Eligibility for Insured Patients 1. A patient who is insured but has “high medical costs” and who is at or below 350% of the federal poverty level (FPL) is eligible to apply for charity care.

2. Charity care applies to the portion of the bill that is the patient’s responsibility.

3. AHS will determine the patient’s Allowable Medical Expenses according to the limiting formula.

4. If a patient has been assigned Medi-Cal share of cost, the share of cost amount may be eligible for charity care.

5. Patients whose income exceeds 350% of the FPL may be eligible to receive discounts based on AHS’s Prompt Payment Discount policy.

6. Insured patients with high deductible plans, high medical costs or limited coverage who have exhausted their benefit coverage may qualify for charity care or discount payment according to the criteria set forth in this policy or our prompt pay discount policy.

D. Income and Monetary Assets of Patient In determining eligibility under this policy, AHS may consider income and monetary assets of the patient. For purposes of this determination, monetary assets shall not include retirement or deferred compensation plans. Furthermore, the first ten thousand ($10,000.00) of a patient’s monetary assets shall not be counted in determining eligibility, nor shall fifty percent (50%) of a patient’s monetary assets over the first ten thousand dollars ($10,000.00) be counted in determining eligibility. Assets are considered to be: cash, checking accounts, savings accounts, money market funds, certificates of deposits, real estate property, etc. [H&S §127401-5]

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E. Charity Care Application a. Application 1. A low-income uninsured hospital patient who indicates the financial inability to pay a bill for a medically necessary service shall be evaluated for charity care assistance or any other federal, state, or county program.

2. The AHS standardized application form, shown as the “Charity Budget Form” (see Attachment A), will be used to document each patient’s overall financial situation. This application should be available in the primary language(s) of service area (i.e., English and Spanish).

3. If an uninsured hospital patient does not complete the application form within 30 days of delivery, AHS will notify the patient that the application has not been received and will provide the patient an additional 120 days to complete the application. If the application form is subsequently submitted it will be accepted.

4. The patient must make every reasonable effort to furnish the hospital with documentation of income. The documentation requirements are on the charity budget form.

The patient must attest in writing that the information they are furnishing to the hospital is accurate.

b. Charity Presumptive Eligibility AHS understands that certain patients may be unable to complete a Financial Assistance application, comply with requests for documentation, or are otherwise non-responsive to the application process. As a result, there may be circumstances under which a patient’s qualification for Financial Assistance may be established without completing the formal assistance application and/or providing the necessary and required documents for approval. AHS may utilize other sources of information to make an individual assessment of financial need to determine whether the patient is eligible for financial assistance and approval. This information will enable AHS to make an informed decision on the financial need of non-responsive patients utilizing the best estimates available in the absence of information provided directly by the patient. In particular, presumptive eligibility for Financial Assistance may be determined on the basis of individual life circumstances that may include: • Homelessness or receipt of care from a homeless clinic; • Participation in Women, Infants and Children (WIC) programs; • Eligibility for food stamps; • Eligibility for school lunch programs; • Living in low-income or subsidized housing; and • Patient is deceased with no estate.

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c. Homeless Patients: Emergency room patients without a payment source may be classified as charity if they do not have a job, mailing address, residence, including temporary residence, or insurance. However, all other county, state, or government programs must be considered as part of enrollment screening. Consideration must also be given to classifying emergency-room-only patients who do not provide adequate information as to their financial status. In many instances, these patients are homeless and have few resources to cover the cost of their care.

For homeless patients seen in our inpatient or emergency services areas, AHS must ensure financial screening is provided to the patient prior to discharge. This includes but is not limited to screening for charity care. d. Special Circumstances 1. Deceased patients without an estate or third party coverage may be eligible for charity.

2. Patients who are in bankruptcy (filed but an open case) or completed bankruptcy in the past three (3) months may be eligible for charity. e. Time Requirement for Determination of Eligibility 1. While it is desirable to determine the amount of charity care for which a patient is eligible as close to the time of service as possible, in some cases, eligibility is readily apparent and a determination can be made before, on, or soon after the date of service. In other cases, it can take investigation to determine eligibility, particularly when the patient has limited ability or willingness to provide needed information. At any time, if a patient sends confirming information and the application that demonstrate qualification for charity care, then charity care will be indicated. AHS will make every effort to provide a determination of eligibility within 30 days of receiving all requested information and documentation from the patient.

2. Every effort should be made to determine a patient’s eligibility for charity care. In some cases, a patient eligible for charity care may not have been identified prior to initiating external collection action. Accordingly, any collection agency will be made aware of the policy on charity care. This will allow the agency to refer patient accounts back to AHS that may be eligible for Charity Care.

3. After 150 days of no response from a patient to formally determine eligibility the account may proceed to debt collection. If the patient was initially identified as probable charity care and the staff has no public or private record to locate the patient (e.g., homeless with no residence) the case may be classified as charity care. The Director of Patient Financial Services will use appropriate judgment to differentiate charity care based on the criteria in lieu of a bad debt determination. a. Denials and Appeals

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Application Denied No financial assistance is granted under this policy. However, if patient is self-pay, the patient may be eligible according to the prompt pay discount policy.

Appeals In the event of a dispute over the application of this policy, a patient may seek review from AHS Director of Patient Access Services or Director of Patient Financial Services. The patient may also follow the hospital’s complaint policy. The patient will be informed of any decision in writing

4. Contracting with Other Organizations to Determine Eligibility AHS may from time to time contract with other organizations that specialize in assisting patients and their families with qualifying for charity or other sources of funding or insurance enrollment. Organizations (Contractors) are required to abide by the policies set forth by AHS. Patients are given information regarding the availability of assistance from these other organizations and are encouraged to cooperate with the qualifying process. Patients are not expected to incur any costs when utilizing the services of these other organizations.

5. Eligibility Period: The eligibility period is up to six months from the date of the initial eligibility determination, unless over the course of that period the patient’s Family Income or insurance status changes to such an extent that the patient becomes ineligible. This discount may be applied retroactively for up to six months if there were unavoidable delays in determining eligibility.

II. Limiting Expected Reimbursement A. General Rule The maximum payment amount for patients who qualify for charity care or a discounted payment, who do not have insurance coverage, shall be the full in effect allowable Medicare rate fee schedule for the service (s) as calculated in accordance with Medicare payment rules. [H&S §127405(d)]

For any patient who has coverage under a third party insurance plan, that third party insurance contract shall establish the payment rate. If the insured patient qualifies for charity care then the patient’s portion of the payment (Copayment) shall be waived.

Please note that “[n]o health care service plan, insurer, or any other person shall reduce the amount it would otherwise reimburse a claim for hospital services because a hospital has waived, or will waive, collection of all or a portion of a patient’s bill for hospital services in accordance with the hospital’s charity care or discount payment policy, notwithstanding any contractual provision.” [H&S § 127444]

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B. Medi-Cal Denied Patient Days and Non-Covered Services Medi-Cal/CCS and other State of California programs patients are eligible for Charity care write-offs related to denied stays in limited circumstances (e.g., when the admission/services were medically necessary as determined by the treating physician or the patient was not safe to discharge and there is no administrative day payment). The Treatment Authorization Request (TAR) will record the reason for the denial. An example where the write-off is charity is when a Medi-Cal pending application results in a denial as not eligible as a result of not meeting program guidelines. Denials for other reasons such as a physician’s failure to write a discharge order cannot be written off as charity care. Recognizing that the hospital is compensated by Medi-Cal on a per case basis, there will be limited circumstances where a charity care write-off will apply.

III. Limited Debt Collections Activities A. Notice Prior to Commencing Collection Activities The hospital or any assignee of a hospital debt, including a collection agency must provide the patient with a clear and conspicuous notice that includes the required language from the various practice acts and a statement that nonprofit credit counseling services may be available in the area.

B. Collection Practices The hospital and the patient may negotiate the terms of the payment plan. The hospital will not charge interest on the extended payment plan debt. An extended payment plan may be re-negotiated with the patient if the patient fails to make all consecutive payments during a 90-day period. Prior to declaring an extended payment plan irremediable the patient must be:

a. Contacted or attempted to be contacted by telephone (last known number); b. Given notice in writing that the plan may be irremediable (last known address); and c. Informed that there is an opportunity to re-negotiate the payment plan.

C. Advancing Debt and Credit Reporting

Until the payment plan is declared irremediable, no report may be made to a consumer credit reporting agency and no civil action may commence. Any advancing of debt for collection or reporting requires the approval of the Director of Patient Financial Services. Advancing of debt collection and/or Credit reporting shall not occur until after 150 days from the date the payment plan is declared irremediable.

D. Collection Agency If a collection agency identifies a patient meeting AHS charity care eligibility criteria, the patient account may be considered charity care, even if they were originally classified for collection or as a bad debt. Collection agency patient accounts meeting charity care criteria should be returned to the AHS billing office and reviewed for charity care eligibility.

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IV. Charity Care Information- Notice A. Patient Intake Process Except in the case of emergency services, Alameda Health System shall provide patients with information regarding charity care, during the patient intake process, if requested. AHS shall also provide patients with contact information for an AHS employee or office from which the patient may obtain further information about charity care and discount payments. The information provided shall be in the primary language of AHS service area and in a manner consistent with all applicable federal and state laws and regulations. A language is a primary language of Alameda Health System service area if 5% or more of Alameda Health System local population speaks the language.

B. Public Notice and Posting of Charity Care Public notice of the availability of assistance through this policy should be made through each of the following means: Posting notices in a visible manner in locations where there is a high volume of inpatient or outpatient admitting/registration. Notices must be posted in at least the emergency departments, billing offices, admitting offices, and hospital outpatient service settings. Posted notices shall contain the following information: 1. A statement indicating that AHS has a financial assistance policy for low-income uninsured patients who may not be able to pay their bill and that this policy provides for full or partial charity care. 2. Identification of a hospital contact phone number that the patient can call to obtain more information about the policy and how to apply for assistance.

C. Bills and Statements AHS shall include charity care information on bills and statements sent to patients. The information shall include following: 1. If the patient meets certain income requirements the patient may be eligible for a government–sponsored program or qualify for charity care or discount payment from AHS. The income requirements shall be stated on the notice. 2. A hospital phone number that patients may call for further information.

3. Posting notice of the availability of assistance and a contact phone number on AHS web site.

4. Providing uninsured patients a document outlining the types of financial assistance available.

D. Emergency Physicians Billing Notice (applicable at Alameda Hospital and San Leandro Hospital)* AHS shall include a notice with the contact information for independent Emergency Physicians that practice at Alameda Hospital and San Leandro Hospital. These independent physician groups have their own discount policies with eligibility criteria which may differ from AHS policies. Emergency physicians are not required to offer an extended payment plan; but if they do, the plan must be interest free. AHS includes in the notice the name of the physician group, the web site, and a contact phone number the patient may call for additional information. Emergency Physicians are the

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Emergency Physician specialists staffing the emergency department of the hospital. Emergency Physicians are not other specialists who consult in the emergency department by request of the Emergency Physician. [H&S §127450-127462]

V. Reimbursing Overcharges If the hospital erroneously collected the patient portion, from a patient who qualifies for charity care, the patient will be reimbursed the principle. This clause shall not apply if the overpayment is $5 or less. In this case, the hospital shall furnish credit equal to the amount of $5 or under for a period of 60 days.

VI. Not Available for Charity Care Charity care and/or discounts provided by this policy are not available for cosmetic procedures. The application of this policy does not apply to any portion of a patient’s services because of the transfer of a patient to another facility that bill for services under a different Tax Identification Number. The hospital will make every effort to locate a charitable organization that AHS is aware of or has a relationship with to furnish elective procedures.

VII. Authority and Responsibilities A. Authority Authority for decision making with regard to this policy and the progression to formal debt collection is granted to the Director for Patient Accounting and Patient Access Services and/or an individual with such authority at a higher level or rank in the hospital including the Vice President of Revenue Cycle, the Chief Financial Officer and other personnel granted this authority for coverage when the Director or designee is not available.

B. Responsibilities Who Can Grant Charity Care Write-offs: Director of Patient Financial Services, Director of Patient Access Services or their designee

C. Roles and Responsibilities: Procedures must be adopted that clearly address the various responsibilities in the determination of charity care. This includes documentation of any contact with the patient, provision of information, and assistance to the patient making the determination of charity care eligibility, and notifying the patient.

D. Record keeping: Records relating to potential charity care patients must be readily accessible. AHS must maintain information regarding the number of uninsured patients who have received service, the number of financial assistance applications completed, the number approved, the estimated dollar value of the benefits provided, the number denied, and the reasons for denial.

In addition, notes relating to charity application and approval or denial should be entered on the patient’s account

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VIII. Submission to OSHPD Beginning January 1, 2008, and biennially thereafter (every two years) by January 1, AHS shall forward copies of this policy to the Office of Statewide Health Planning and Development (OSHPD). Submission of the policy shall be consistent with the manner prescribed by OSHPD.

Who Can Grant Charity Care Write-offs: Director of Patient Financial Services, Director of Patient Access Services or their designee

Accounting for Charity Care: To allow AHS to track and monitor the amount and type of charity care being granted, the hospital will account for the charity care write-offs and record all transactions as an “administrative write-off.”

Roles and Responsibilities: Procedures must be adopted that clearly address the various responsibilities in the determination of charity care. This includes documentation of any contact with the patient, provision of information, and assistance to the patient making the determination of charity care eligibility, and notifying the patient.

Record keeping: Records relating to potential charity care patients must be readily accessible. AHS must maintain information regarding the number of uninsured patients who have received service, the number of financial assistance applications completed, the number approved, the estimated dollar value of the benefits provided, the number denied, and the reasons for denial.

In addition, notes relating to charity application and approval or denial should be entered on the patient’s account.

Submission to OSHPD: Beginning January 1, 2008, and biennially thereafter (every two years) by January 1, AHS shall forward copies of this policy to the Office of Statewide Health Planning and Development (OSHPD). Submission of the policy shall be consistent with the manner prescribed by OSHPD.

ATTACHMENTS • Attachment A: Charity Care Application • Attachment B: Notification Status

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APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 03/2020 03/2020 Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 04/2020 N/A N/A Council (CPC) Medical Executive Date: N/A 04/2020 04/2020 Committee Board of Trustees Date: N/A N/A

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PATIENT ACCESS CONSENT/CONDITIONS OF ADMISSION

Department Patient Access Services Effective Date 08/2017 Campus AHS System Date Revised 02/2020 Category Administrative Next Scheduled 06/2023 Review Document Director, Admissions and Executive Chief Financial Officer Owner Registration Responsible Printed copies are for reference only. Please refer to electronic copy for the latest version.

PURPOSE Alameda Health System (AHS) recognizes the rights of patients to make independent and informed decisions regarding their medical care. The purpose of the policy is to ensure all patients provide legal consent for services rendered at AHS.

POLICY It is the policy of AHS that consent is required for the general medical care provided to all patients admitted to the hospital for inpatient care or outpatient services, including but not limited to mental illness, therapy, and/or other outpatient services. Consistent with this commitment, all patients (or legal guardian/representative) shall sign the Conditions of Admissions (COA) form, which establishes, among other things, consent to general medical and nursing care, financial agreement, and general terms and conditions for receiving care from AHS.1

PROCEDURE I. General Rule: a. Episodic Care – Consent is obtained each time the patient presents for episodic care, i.e., emergency services, inpatient services, surgical procedures, etc. b. Recurring Visits – For recurring visits, i.e., therapy, individual or group behavioral health care services, consent should be obtained at the initial time of registration and would be valid for 30-days. If the treatment plan is to continue beyond this time period, registration personnel should obtain a new consent once every 30 days. c. Ancillary Services – For services in ancillary areas where the patient was seen in a clinic resulting in an order of routine lab or x-ray, a new consent is not required - same diagnosis, same physician ordering. Otherwise, consent is required for each episode of care.

II. COA Review/Discussion & Documentation:

1 Unless otherwise provided by this policy, all patients (or legal guardian/representative) are required to complete the COA form.

Page 1 of 4 a. The COA form shall be presented and discussed with the patient/legal guardian/representative, at the time of registration. The consent form should be provided in the patient’s language based on AHS’ standard practice. The patient/legal representative should sign the COA form along with registration personnel. The form should also be timed and dated accordingly, and a copy provided to the patient/legal representative. i. Interpreter Services: If the patient requires an interpreter, staff must utilize interpreter services, the language line, or a qualified AHS staff person to review the contents of the document with the patient. The interpreter’s signature or AHS assigned number should be documented on the form as required. b. If the patient cannot sign, staff should follow department established guidelines and the provisions set forth in this policy with respect to minors, patients in custody, adults under conservatorship, and the emergency exception. At a minimum, AHS Registration personnel should shall document the reason (e.g., trauma, altered level of consciousness, etc.) the patient could not sign. The aforementioned shall be confirmed and signed by a witness (e.g., AHS employee). c. Notwithstanding the above, Registration personnel are required to make multiple attempts while the patient is present throughout the episode of care to determine if the condition has changed and allows for the patient to consent. These attempts should be documented in the account notes. If an inpatient, staff should attempt to obtain signature at minimum once daily and document attempts in account notes. d. If the patient refuses to provide consent for treatment, staff should notify the clinical team/charge nurse and obtain witness signature of the event. The Clinical team must be notified to assess and determine if the patient has the legal capacity to refuse consent.

III. Emergency Exception, Minors, Adults in Custody, & Adults under Conservatorships a. Emergence Exception – AHS recognizes that under certain conditions, a health care provider may, without the patient’s consent, provide medical care when the provider reasonably believes that a medical procedure should be undertaken immediately to prevent loss of life, loss of limb or to alleviate severe pain, and there is insufficient time to obtain the consent of the patient or of a person authorized to consent for the patient. The law implies consent in these circumstances on the theory that if the patient were able, or if a qualified legal representative were present, the consent would be given. This exception applies to minors as well as to adult patients.

Consent is also implied when a patient lacks capacity to make a health care decision and treatment is immediately necessary to prevent death or serious disability, or to alleviate severe pain, and there is insufficient time to obtain the consent of a person authorized to consent for the patient.

b. Minors – Minors are patients under the age of 18. Minors presenting for treatment require legal consent from a parent or legal guardian with the exception of the following:

The minor has achieved a status of “emancipation” as established by law The minor is seeking treatment for a statutorily specified medical need; or

Page 2 of 4 There is some other specialized situation recognized by law in which parental consent is not required

If the patient presents and does not qualify under the above, AHS staff must attempt to contact parent or legal guardian and document the account. If unable to reach parent or legal guardian, they should also notify the clinical team/charge nurse to let them know the patient’s legal representative could not be reached.

c. Adults in Custody – A person in the custody of law enforcement must still consent to a non-emergency medical examination, treatment, or procedure. Law Enforcement Officers may request limited medical examinations and tests pursuant to their authority for drug and alcohol tests; however, they cannot consent for patients in custody. If the patient refuses to consent, AHS staff should document the refusal in the medical record and notify the clinical team/charge nurse on duty. d. Adults Under Conservatorship – An adult under a conservatorship may be able to make health care decisions. The determination of who may make health care decisions will depend on whether or not the conservatee has been adjudicated to lack the capacity to make health care decisions. AHS registration or clinical staff should request the documented letter of conservatorship as it should specify whether the patient has been adjudicated to lack the capacity to make health care decisions.

If registration staff obtains the letter, it should be copied and scanned into the medical record under the advanced directive tab.

Registration personnel should always make an attempt to identify and contact the conservator, in known, to provide consent. This attempt must be documented in the account notes as required. If unable to contact, should notify the clinical team/charge nurse accordingly.

REFERENCES CHA Consent Manual Health Care Decisions Law (California Probate Code Section 4600, et seq.)

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APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 02/2020 02/2020 Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 04/2020 N/A N/A Council (CPC) Medical Executive Date: N/A 04/2020 04/2020 Committee Board of Trustees Date: N/A N/A

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CREDIT BALANCE PROCEDURE

Department Patient Accounting Effective Date 06/2011 Campus AHS System Date Revised 03/2020 Category Administrative Next Scheduled 06/2023 Review Document Director, Patient Executive Chief Financial Officer Owner Accounting Responsible Printed copies are for reference only. Please refer to electronic copy for the latest version.

PURPOSE: The purpose of this policy is to define a process for the correct identification and resolution of all credit balances and facilitate the timely refunding of overpayments to the patient or other third party.

POLICY It is the policy of Alameda Health System (AHS) to identify and resolve all patient credit balances in a timely manner.

PROCEDURE: Processing credit balances and overpayments on patient accounts 1. Accounts with a credit balance are to be thoroughly researched within 60 days of posting to determine the cause(s) of the credit.

2. If the credit balance was caused by posting errors such as duplicate contractual entries, misapplied charges/credits, or incorrect patient account adjustments, the representative will correct the adjustment using the appropriate adjustment code.

3. If the credit balance remains following correction of the posting errors, ascertain the party (guarantor, third-party payer) entitled to the refund and refund the balance promptly to the appropriate patient, guarantor or third-party payer in accordance with any regulations or contractual agreements that apply in the processing of the refund.

4. Overpayments due to federally funded payers such as Medi-Cal, Medicare, and CHAMPUS/Tricare, refunds will be processed in accordance to regulations (i.e., offsets, rebill, CIF’s) within thirty (30) days of identifying / validating the credit.

5. Specific federal, state and county funded payors credit reporting rules, refunds and timeframes will be followed as legislated. The Medicare Quarterly Credit Balance report will be completed, approved and submitted, within the required timeframe.

Page 1 of 3 6. Credit balances on self-pay accounts should be reviewed and resolved as quickly as possible, with a goal to have this achieved within 30 days of the initial credit. Self- pay refunds are subject to applicable interest as defined by State Law. 7. Any self-pay account with a balance of $4.99 or less will not require the issuance of a refund to the patient, unless a specific request for the refund is received from the patient or responsible party. These balances can be adjusted to Contractual allowance no later than 60 days from the date the credit was created. (HSC 127440)

Processing Refunds 1. Once it is confirmed that an overpayment has been made and a refund is due the following tasks are performed; a. Obtain all pertinent documents including the EOB, check, money order or credit card slip for patient payments refund request letters b. Complete the “Refund process within the EHR system, and the required documentation.” c. Forward to the applicable authorizing authority for approval.

Approval of Refunds and Refund Check Processing 1. Upon receipt of a “Refund Request Form” the Billing Technician will place a comment on the patient’s account(s) indicating the reason for the refund, who is being refunded and the dollar amount.

2. The form is then forwarded to the Patient Accounting Supervisor/Manager for review for accuracy and completeness.

3. Once all signatures are obtained based on the Signature Authorizations matrix below, the Supervisor/Manager forwards the completed documentation to the Manager, Patient Accounting or designee for processing into the Lawson system.

4. The Patient Accounting Manager, or designee verifies that all back-up documents are attached to the refund.

5. Refunds are documented and processed via an Excel spreadsheet.

6. The refund information is entered into the Epic system to initiate any refund check to an insurer.

7. The original copy of the Refund Request form for direct patient refunds is faxed to Finance to issue a refund check.

8. The original Refund Request form with supporting documents is stored in the Patient Accounting area.

9. Once Finance has processed the refund a Lawson report prints, the check number and check date assigned are recorded on the Excel spreadsheet for entry into the Patient Accounting System.

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Level of Approval Authority for Payment Refunds

Dollar Threshold Required Approval $ 0.01 to $ 4,999.99 Supervisor, Patient Accounting $ 5,000 to $24,999.99 Manager, Patient Accounting $25,000 to $49,999.99 Director, Patient Accounting $50,000 to $99,999.99 Vice President, Revenue Cycle $100,000 and over Chief Financial Officer

APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 03/2020 03/2020 Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 04/2020 N/A N/A Council (CPC) Medical Executive Date: N/A 04/2020 04/2020 Committee Board of Trustees Date: N/A N/A

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HEALTHY ENVIRONMENT/NOISE REDUCTION

Department Administrative Effective Date 01/2011 Campus AHS System Date Revised 12/2010, 04/2020 Category Administrative Next Scheduled 12/2013, 06/2023 Review Document Director, Environmental Executive Vice President, Support Owner Services Responsible Services Printed copies are for reference only. Please refer to electronic copy for the latest version.

PURPOSE It is the desire of Alameda Health System (AHS) to provide an environment for optimal healing for our patients. As a result we will implement strategies to minimize noise and other disturbances in the order to minimize anxiety and noise related distractions.

POLICY It is the policy of AHS to provide vital medical care in a quiet non-disruptive environment free of any conduct and/or activity that disrupt patient care and/or disturbs patients, staff, or visitors. Consistent with this commitment, efforts will be made to minimize noise levels and mitigate the effects of noise to preserve a healing environment. Such efforts will include, but not be limited to overhead pages, portable sound systems or any other type of sound amplification, loud or boisterous conduct, voice volume control in patient care areas, identification of alternative locations for large gatherings or extended verbal communications and equipment maintenance.

PROCEDURE In order to reduce unnecessary noise and to preserve a healing environment, the following procedures shall be adopted and implemented. 1. Overhead Pages/Paging: a. Overhead paging will be restricted to emergencies and as approved by AHS— which may include the announcement of any of the following: i. Emergency Codes • Code Blue • Code Pink • Code Red • Code White • Code Purple • Code Yellow • Code Orange • Code Silver • Code Grey

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• Code Triage Internal • Code Triage External • Code “C” • Trauma Notification and Estimated time of arrival • John George Safety Team Codes • Rapid Response • Heart Alerts ii. Other • Other announcements with approval of administration or the house supervisor. 2. Patient Care Areas a. All discussions held within patient care areas will be held with low volume voice projection. b. Staff members will be expected to ensure communication occur in close proximity to the individual to whom they are speaking. c. Staff members and physicians will be encouraged to refrain from loud discussions, yelling from across the room or unit, and/or any other activity that increases the noise level in patient care areas. d. Volumes on patient radios, televisions, CD and IPod, or any other electronic device must be only loud enough for the patient to hear. e. Cell phone must be kept on vibration mode. Personnel cell phones are not to be used during on duty hours. Visitors must be encouraged to limit cell phone usage in the patient care areas.

3. Highland Hospital’s Healing Sanctuary a. Purpose i. Highland Hospital’s Healing Sanctuary (“Healing Sanctuary”) was built to provide a quiet, peaceful, and serene space for healing, retreat and reflection, and individual outdoor enjoyment for its patients, staff, and visitors. Consistent with this commitment, the Healing Sanctuary is designed as a therapeutic garden with areas designed for private reflection, a walking labyrinth to facilitate stress reduction, and a play area for children. The Healing Sanctuary, as designed and built, provides easily accessible and comforting escape from the stress of being a patient, dealing with a loved one’s illness, or working as a health care provider. b. Accessibility i. The Healing Sanctuary is available to all Alameda Health System (“AHS”) patients, staff, and visitors. The Healing Sanctuary is open Monday through Sunday, 9:00 a.m. to 6:00 p.m..

ii. The Healing Sanctuary is intended for individual use on a first-come, first-served basis. The Healing Sanctuary cannot be reserved for any group events or activity without written approval by the CEO.

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c. Space Usage and Restrictions i. Visitors to the Sanctuary are not permitted to engage in any conduct that interferes with another’s quiet enjoyment of the space.

ii. The Healing Sanctuary’s usage must be in compliance with all local, state, and federal laws and all pertinent AHS Policies, such as, but not limited to environment/noise reduction, occupancy limitations, alcohol, smoking, etc. Any activity and/or conduct that conflicts with the intended purpose and use of the Healing Sanctuary, and/or violate any laws or AHS policy is strictly prohibited. Accordingly, individuals who engage in any type of activity that disrupts and/or conflicts with the intended purpose and use of the Healing Sanctuary, and/or violates any law or AHS policy will be asked to cease such activity and/or asked to leave the Healing Sanctuary. AHS reserves the right to suspend or revoke accessibility privileges for anyone that violates the conditions above.

iii. In addition to the above, patients, staff, and visitors must refrain from engaging in any activity/conduct that disturbs and/or distracts from the serenity of the Healing Sanctuary, including: • The consumption of food and beverages disruptive to other users (i.e., group gatherings, public speaking, etc.); • The use of portable sound systems or any other type of sound amplification; • Creating excessive and/or disruptive noise; • Any loud or boisterous conduct (i.e., playing music, loud conversations, etc.).

4. Cleaning Activities a. All activities that require loud machinery will be done before 10 pm (Excluding the Emergency Department). The schedule for such activities will be submitted to the respective unit manager not less than 48 hours prior to the expected activity time. The unit manager will then notify the patients of the planned activity in order to minimize anxiety caused by the noise level. (Note: Cleaning times at other locations may vary depending upon agreed upon arrangements between that particular location and EVS). b. Patient room doors will be closed during all cleaning activities, unless it is the patients express desire to leave the door ajar.

5. Equipment Maintenance a. All equipment will be checked annually and will be maintained in a manner that minimizes noise such as squeaking, bumping, etc. b. Any equipment found to be excessively noisy will be taken out of service and repaired in order to minimize noise levels.’

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c. Personnel who are moving equipment will extra care to ensure that noise related equipment movement as well as vocal noise levels are limited to only what is required for patient care related activities.

6. Violation of this Policy a. Patients and/or Visitors who engage in any type of conduct and/or activity that violates any of the provisions of this Policy and/or violates any local, state, and federal laws or pertinent AHS Policies will be asked to cease such activity and/or asked to leave the premises. AHS reserves the right to suspend or revoke accessibility privileges for anyone that violates any of the conditions above. b. Employees and/or Volunteers who engage in any type of conduct and/or activity that violates any of the provisions of this Policy and/or violates any local, state, and federal laws or pertinent AHS Policies will be asked to cease such activity and/or asked to leave the premises. Unless otherwise provided by law, a violation of this policy may also be subject to disciplinary action, up to and including immediate termination of employment. Each violation and alleged violation of this policy will be handled on an individual basis.

REFERENCES 1. Cabrera, IN & Lee, MH. (2000) Reducing noise pollution in the hospital setting by establishing a department of sound: a survey of recent research on the effects of noise and music in health care. Preventative , 30(4), 339-45. 2. Topf, M. (2000). Hospital noise pollution: An environmental stress mode to guide research and clinical intervention. Journal of Advanced Nursing, 31 (3), 520-8 3. Choiniere, DB. (2010) The effects of hospital noise. Nursing Administration Quarterly, 34(4), 327-33. 4. The Joint Commission Comprehensive Accreditation Manual for Hospitals – EC.04.01.03, EC.04.01.05

APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 03/2020 03/2020 Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 04/2020 N/A N/A Council (CPC) Medical Executive Date: N/A 04/2020 04/2020 Committee Board of Trustees Date: N/A N/A

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FINANCIAL ASSISTANCE POLICY

Department Revenue Management Effective Date 03/2017 Campus AHS System Date Revised 02/2020 Category Administrative Next Scheduled 06/2023 Review Document Director, Patient Executive Chief Financial Officer Owner Accounting Responsible Printed copies are for reference only. Please refer to electronic copy for the latest version.

PURPOSE The purpose of this policy is to document Alameda Health System’s Financial Clearance policy and to define our process of evaluating the patient’s needs for applying for assistance.

POLICY It is the mission of Alameda Health System to maintain and improve the health of all residents.

It is the policy of Alameda Health System to offer patients assistance in determining their eligibility for various programs, including but not limited to: Medi-Cal, Health PAC (HPAC), Charity Care, Covered California, or our Self Pay Discount program to assistance with payment of all or part of their services.

All patients presenting who are self-pay or underinsured will be screened for services at Alameda Health System, including AHS Physician services. Prior to enrollment, staff will verify coverage, or lack thereof, utilizing multiple verification systems i.e. Calwin, One-e-app and other eligibility systems etc., to ensure no coverage and there are no other pending enrollments into these programs. If no coverage is found, the staff will initiate the enrollment process utilizing the financial screening form to assess general requirements, i.e. family size, income, residency, etc.

Based on program guidelines the following documents may be required for program approval i.e.: Proof of income, proof of residency, government issued ID, etc.

If a patient does not qualify for any state, county or other programs, the enrollment staff may offer the Patient Pay Discount. This discount is equal to a discount of 30% off total charges and may require a deposit towards discounted costs. (see Self Pay Policy)

OTHER INFORMATION: N/A

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APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 02/2020 02/2020 Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 04/2020 N/A N/A Council (CPC) Medical Executive Date: N/A 04/2020 04/2020 Committee Board of Trustees Date: N/A N/A

Page 2 of 2

FINANCIAL CLEARANCE POLICY

Department Revenue Management Effective Date 03/2017 Campus AHS System Date Revised 02/2020 Category Administrative Next Scheduled 06/2023 Review Document Director, Patient Executive Chief Financial Officer Owner Accounting Responsible Printed copies are for reference only. Please refer to electronic copy for the latest version.

PURPOSE: The purpose of this policy is to document Alameda Health System’s Financial Clearance policy and to define our process of evaluating the patient’s needs for applying for assistance.

POLICY It is the mission of Alameda Health System to maintain and improve the health of all residents.

It is the policy of Alameda Health System to offer patients assistance in determining their eligibility for various programs, including but not limited to: Medi-Cal, Health PAC (HPAC), Charity Care, Covered California, or our Self Pay Discount program to assistance with payment of all or part of their services.

All patients presenting who are self-pay or underinsured will be screened for services at Alameda Health System, including AHS Physician services. Prior to enrollment, staff will verify coverage, or lack thereof, utilizing multiple verification systems i.e. Calwin, One-e-app and other eligibility systems etc., to ensure no coverage and there are no other pending enrollments into these programs. If no coverage is found, the staff will initiate the enrollment process utilizing the financial screening form to assess general requirements, i.e. family size, income, residency, etc.

Based on program guidelines the following documents may be required for program approval i.e.: Proof of income, proof of residency, government issued ID, etc.

If a patient does not qualify for any state, county or other programs, the enrollment staff may offer the Patient Pay Discount. This discount is equal to a discount of 30% off total charges and may require a deposit towards discounted costs. (see Self Pay Policy)

OTHER INFORMATION: N/A

Page 1 of 2

APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 02/2020 02/2020 Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 04/2020 N/A N/A Council (CPC) Medical Executive Date: N/A 04/2020 04/2020 Committee Board of Trustees Date: N/A N/A

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LEGAL MEDICAL RECORD DEFINITION

Department Health Information Effective Date 07/2013 Services Campus AHS System Date Revised 03/2020 Category Administrative Next Scheduled 06/2023 Review Document Director, Health Executive Chief Financial Officer Owner Information Management Responsible Printed copies are for reference only. Please refer to electronic copy for the latest version.

POLICY It is the policy of Alameda Health System (AHS) that Health Information Management (HIM) will maintain and identify the patient information that must be contained in the legal medical record.

PURPOSE To clearly define the legal medical record for AHS, including which information must be sent to HIM for legal archival.

DEFINITIONS A. Designated Record Set means a group of records maintained by or for AHS that is: (i) The medical records and billing records about individuals maintained by or for AHS; and (ii) Used, in whole or in part, by or for AHS to make decisions about individuals.

B. Legal Medical Record (LMR): The official medical record compiling all notes and authenticated documents concerning a patient’s care. This is the record provided for follow- up care and in response to billing, audits, quality review, legal requests or research requests when appropriate authorization is provided.

C. Source Data: All original information, data or certified copies of such original information contained in source documents.

D. Source Document: Documents in the medical record, which are either the original document, copies or transcriptions certified after verification as being an exact replication of the original document. When original observations are directly entered into a computer system, the electronic record is the source document.

E. Tagged Image File Format (TIFF): An industry standard file format for bitmapped images, often used to exchange such files between dissimilar computers and by scanners when converting pictures to computer form. The name comes from the specification that describes how to store information in blocks called tags. The format accurately depicts the image of scanned paper and is designed to store a complete image of an original paper document.

PROCEDURE 1. The LMR will be comprised of hybrid records – paper and electronic documentation, scanned images and transcription system interfaces from various databases and systems used by AHS. The AHS Electronic Medical Record (EMR) will act as the long-term repository for the patient’s medical history at AHS.

2. All transcribed documents will be signed either on paper or electronically.

3. Only individuals authorized to do so by Medical Staff Bylaws may make entries into the LMR.

4. Medical records documentation is entered into the chart on paper forms or into the electronic record either by scanning, electronic interface or direct entry.

5. Standardized formats are to be used to document all care.

6. The LMR may include test results, exams and other records from other health care providers when necessary for the evaluation of the patient’s subsequent treatment.

7. The LMR may include source data in the absence of documentation or interpretations. When physically required to be stored in a separate location, this information will be given the same level of confidentiality and control as the LMR. Examples of source data include diagnostic films, ECG tracings, treadmill tracings, etc.

8. The minimum content of the LMR shall be: a. Identification data including marital status and religion (optional on part of patient); b. Dates of admission and discharge; c. Legal status regarding behavioral care patients; d. Any emergency care provided to the patient prior to arrival; e. e. The record and findings of the patient’s assessment to include , past history, family history, present illness and physical exam to include a review of systems; f. Reason for admission and statement of conclusions or impressions drawn from the medical history and physical exam; g. Discharge Summary/Note with final diagnosis or diagnostic impression; h. Treatment Plan; i. Evidence of known advance directives; j. Evidence of informed consent for procedures and tests performed for which informed consent is required;

Page 2 of 4

k. Any written or verbal diagnostic and therapeutic orders, procedures and tests performed and their results, if any; l. Anesthesia records m. All operative and other invasive procedures performed, using acceptable disease and operative terminology that includes etiology as appropriate; n. Tissue or surgical reports; o. Progress notes made by the medical staff and other authorized individuals; p. All reassessments, when necessary; q. Clinical observations; r. Response to care provided; s. Documentation of restraints, if used, including type of restraint, time of application and removal t. Consultation reports, when ordered; u. Every medication ordered or prescribed for an inpatient; v. Every dose of medication administered and any adverse drug reaction; w. Each medication dispensed to or prescribed for an ambulatory patient or inpatient at discharge; x. All relevant diagnoses established during the course of care; y. Any referrals or communications made to external or internal care providers and to community agencies; z. Discharge Instructions aa. Autopsy findings, if applicable; bb. Telephone records regarding care, treatment and services; cc. Email communication between provider and patient regarding care, treatment, and services.

9. The legal medical record contains all final, authenticated reports and is used for patient care, legal, research, audit, and billing purposes. It is the responsibility of each clinical unit to ensure that clinical documentation, created in paper format, is forwarded to HIM within 24 hours after the documentation is generated.

10. Historical paper charts for all AHS facilities is stored in an off-site storage facility per AHS Record Retention Policy.

Page 3 of 4

APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 03/2020 03/2020 Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 04/2020 N/A N/A Council (CPC) Medical Executive Date: N/A 04/2020 04/2020 Committee Board of Trustees Date: N/A N/A

Page 4 of 4

MEDICARE SECONDARY PAYER POLICY

Department Patient Access Services Effective Date 03/2020 Campus AHS System Date Revised 03/2020 Category Administrative Next Scheduled 06/2023 Review Document Director, Admissions and Executive Chief Financial Officer Owner Registration Responsible Printed copies are for reference only. Please refer to electronic copy for the latest version.

PURPOSE The purpose of this policy and procedure is to promote the importance of completing an accurate Medicare Secondary Payer Questionnaire (MSPQ) with the Beneficiary to determine if Medicare is the primary or secondary payer source.

POLICY It is the policy of AHS to make every effort in determining if one or more third party payors may be responsible for payment prior to Medicare for services rendered. An MSPQ will be completed for all Medicare patients with the exception of Medicare Advantage Payor plans, based on the following frequency: • For Ancillary, Same Day Surgery and Acute Emergency/Psyhiatric Emergency Services (PES) Department visits the MSPQ must be completed for each visit. • For recurring outpatient visits, following the initial collection, the MSPQ information is obtained from the patient and/or family/representative once every 90 days unless there is a change in patient type related to an accident or other qualifying factors.

PROCEDURE: The following procedures set forth in this policy must be followed to obtain accurate results. • An MSPQ must be completed on all Medicare patients based on the visit frequency outlined above. • The EHR system will prompt the staff to complete the MSPQ when the patient has Medicare coverage. • All patients and/or family/representative must be interviewed to complete the MSPQ form to determine the primary payor. • Patient Access Staff must start the form from Part I and proceed to the next question that follows and/or the next part of the MSPQ according to the patient (family/representatives) responses. • All required questions on the MSPQ must be answered and documented in the EHR system. • Medicare must be listed in the correct priority according to the MSPQ.

Page 1 of 3 • If the MSPQ questions determines that Medicare is the secondary payor, staff must obtain the primary payor information and document the payors information in the appropriate field within the EHR system. • Although Medicare may not be primary, all Medicare information must be obtained and entered into the EHR system correctly. • In the event that the patient and/or family/representative are not available to answer the MSPQ, staff must document their attempts made to obtain the information in the EHR system. If the patient is discharged, Patient Access staff will continue to make attempts at reaching patient and send a certified letter of the document requesting completion. The account should be documented as well.

DEFINITIONS Medicare: Medicare is the federal health insurance program for, People who are 65 or older, certain younger people with disabilities, and/or People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

Medicare Advantage Plans: Are a type of Medicare health plan offered by a private company that contracts with Medicare to provide Part A & B benefits. Most Medicare Advantage Plans also offer prescription drug coverage. If the patient is enrolled in a Medicare Advantage Plan, most Medicare services are covered through the plan.

MSPQ: Medicare Secondary Payer (MSP) is the term generally used when the Medicare program does not have primary payment responsibility - that is, when another entity has the responsibility for paying before Medicare.

Recurring visits: A recurring visit is when a patient receives identical services and treatments on an outpatient basis more than once within a billing cycle such as . Some services do not meet monthly billing requirements even though they are performed daily or weekly such as lab.

OTHER INFORMATION N/A

REFERENCE https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Coordination-of- Benefits-and-Recovery-Overview/Medicare-Secondary-Payer/Medicare-Secondary-Payer

Page 2 of 3

APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 03/2020 03/2020 Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 03/2020 N/A N/A Council (CPC) Medical Executive Date: N/A 04/2020 04/2020 Committee Board of Trustees Date: N/A N/A

Page 3 of 3

MEDICATIONS: MEDICATION AREA INSPECTIONS

Department Pharmacy, Nursing Effective Date 01/2017 Campus AHS System Date Revised 03/2020 Category Clinical Next Scheduled 04/2023 Review Document Director, Pharmacy Executive Chief Administrative Officer/ Owner Operations Responsible Chief Nurse Executive Printed copies are for reference only. Please refer to electronic copy for the latest version.

PURPOSE To ensure safety and proper potency of medications, all medication storage areas will be inspected and documented every month.

POLICY

Medications maintained on the nursing unit or other areas of the hospital/clinic where medications are dispensed, administered or stored, are inspected at least monthly by the Director of Pharmaceutical Services or their registered pharmacist designee. Any irregularities are to be reported to the Nurse Manager of each patient care unit or their designee.

PROCEDURE 1. All medication unit inspections are completed by a licensed Pharmacist

2. Medications are reviewed and inspected in all designated areas of the hospital including but not limited to: a. Automatic Dispensing Machines b. Medication rooms c. Shelves d. Procedure carts e. Treatment carts f. Cabinets g. Drawers

3. All outdated medications will be removed and replaced if they are still necessary to be kept on floors.

Page 1 of 4 4. The inspection should reflect aspects of medication distribution and storage including: a. Appropriate medication has been returned to the pharmacy, including: i. Medications of discharged Patients Medications discontinued for patients currently in the hospital ii. Outdated medications b. Open single-dose (refer to multi-dose policy) vials are immediately discarded. c. Multi-dose vials (with preservatives) if open, are initialed and dated in accordance with manufacturer’s recommendations or 28-day beyond use date, whichever shorter. d. Labels are clean and legible, and only authorized labeling is present. e. Medication Carts are neat, orderly, stocked, locked, and controlled substances are properly stored and locked. f. Medication room is neat, clean and orderly, properly stocked, and locked. i. Medications stored at the temperature range specified by the manufacturer package insert. ii. External medications stored separately from internals and injectables. g. Medication refrigerator and freezer is clean, frost and odor free, and maintained at an appropriate temperature. i. Refrigerator temperatures range from of 36-46oF and Freezer temperature ranges from -58oF to +5 oF. ii. No food is stored in the medication refrigerator. iii. Temperature logs are kept current. iv. Vaccines stored according to CDC guidelines. h. Crash carts are sealed and medication trays are not outdated. i. Visible availability of: i. Poison control telephone number ii. Weight and volume conversion charts posted iii. Antidote chart posted iv. Campus formulary available v. Look Alike and Sounds Alike medication chart vi. High Risk and High Alert medication chart j. The pharmacist will complete the inspection form (see Medication Area Inspection Form below). k. Immediately after inspection findings will be e-mailed or discussed with the Nurse Manager or charge nurse. l. The original inspection form will remain in the pharmacy for at least 3 years. m. Notices of recurring issues for any area will be forwarded to the Director of Nursing.

REFERENCES TJC MM 03.01.01 EP 18 Title 22 70263 (q10)

Page 2 of 4

APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 03/2020 03/2020 Pharmacy and Date: 03/2020 N/A N/A Therapeutics (P&T) Clinical Practice Date: 04/2020 N/A N/A Council (CPC) Medical Executive Date: N/A 04/2020 04/2020 Committee Board of Trustees Date: N/A N/A

Page 3 of 4

ALAMEDA HEALTH SYSTEM MEDICATION AREA INSPECTION FORM

Site: □ Alameda □ Fairmont □ Highland □ John George □ San Leandro □ Wellness Clinic ______

Location: ______DATE: ______

PASSED FAILED N/A AREA OF REVIEW MEDICATION ROOM Medication carts/units/room locked at all times Medication room is neat and clean. And Medication Storage door not left opened. No drugs are found outside of designated area. Expired medications not present. All open MDV medications labeled with correct BUD (i.e. 28 days.) Medication stored properly • internals separated from externals • items requiring refrigeration properly stored Only approved medication stored in automatic dispensing machine or floor stock area, at approved levels. Sound Alike Look Alike medications (SALAD) are stored separately from each other and clearly labeled according to hospital policy. Discontinued medication(s) returned to the Pharmacy. Open single-dose vials not present. All medication labels are clean, complete and legible. No medication samples present MEDICATION CARTS/KITS Current medication list on cart/kit posted properly All medication in date (not expired) Medication cart/kit properly locked Crash cart nursing log completed daily with lock numbers recorded. REFRIGERATOR Temperature of refrigerator and Freezer recorded by working thermometer and monitored at a minimum daily within USP 797 standards. Manually checked medication Refrigerator temperature log is posted and up to date. Refrigerator properly locked or located in a secure medication room. Refrigerator contains no food or non-pharmaceutical items. CONTROL SUBSTANCES For non ADM area’s, controlled substance cabinet properly locked. MISCELLANEOUS Poison control telephone number displayed. Sound Alike Look Alike List displayed if applicable High Alert List displayed if applicable Metric/Apothecary conversion table displayed. Medication references current and available. Formulary available Antidote chart posted All problems detected in previous rounds are corrected.

Comments/Corrective Action:

______Nursing Representative______Date:______

Pharmacy Representative: ______Date:______

Page 4 of 4

MEDICATIONS: SELECTION, PROCUREMENT, AND SHORTAGES

Department Pharmacy Effective Date 06/2016 Campus AHS System Date Revised 03/2020 Category Clinical Next Scheduled 06/2023 Review Document Director, Pharmacy Executive Associate Chief Medical Owner Services Responsible Officer/Chief Nurse Executive Printed copies are for reference only. Please refer to electronic copy for the latest version.

POLICY To establish how medications are chosen for use in the hospital and to ensure the consistency in the safe and timely procurement of medication.

PROCEDURE Selection: 1. The P&T committee establishes a hospital formulary for administration. 2. Consideration for medication addition/deletion from the formulary include but are not limited to: a. the indication for use. b. the evidence based effectiveness c. the ease of administration. d. the potential for medication errors including look-alike / sound-alike names and adverse outcomes. e. drug interactions f. sentinel event advisories g. the potential for abuse, if appropriate. h. the populations served i. the overall cost of therapy relative to existing . j. Adverse drug events 3. The formulary will be available to all staff on the intranet. 4. The Pharmacy & Therapeutics Committee will review the Formulary no less than annually 5. The hospital has the following process for procurement of a medication not available in the pharmacy or temporary procurement of a medication not on the formulary: a. Non – formulary medication: i. For non-formulary medications, the pharmacist will call the prescriber to determine if an alternative formulary item can be substituted. ii. If no other formulary drug is suitable or the medication is unavailable for administration, the pharmacy staff will obtain the non-formulary medication from their pharmacy wholesaler. If the medication is needed STAT, the pharmacy can first call other AHS to borrow the medication. Please refer to “Medications: Borrowing and Loaning

Page 1 of 3 Between AHS Inpatient Pharmacies Policy.” If the STAT non-formulary medication is not available from the other AHS pharmacies, pharmacy staff will call other area hospital pharmacies and arrange for pick-up via: AHS contracted courier service. Borrowing from outside AHS Inpatient Pharmacies, please refer to “MEDICATION: DRUG SUPPLY CHAIN SECURITY ACT POLICY” under “Borrow & Loan Between non-AHS facilities” section b. All items obtained must be labeled with the name of drug and strength, manufacturer, lot number, and expiration date. c. For those products loaned from pharmacies under a different ownership, the pharmacy will be required to obtain the Transaction Information (IT), Transaction Statement (TS) and Transaction History (TH)

PROCUREMENT 1. Purchasing a. All Pharmaceutical purchases will be made from an approved pharmaceutical supplier or manufacturer to ensure the quality of purchased product and minimize counterfeit medications. b. Alameda Health System pharmacies will purchase only licensed products. c. Medications will be purchased using the specified wholesaler contract or directly from the manufacturer, unless the medication is listed on the AHS Drug Shortage List. These medications may be ordered through a secondary licensed wholesaler until they are no longer short from the specified wholesaler. d. Medications purchase outside AHS contracted wholesaler, please refer to ““MEDICATION: DRUG SUPPLY CHAIN SECURITY ACT POLICY” under “Authorized Trading Partner” and inquire 3 T information. e. Medications requiring refrigeration will be accepted only if delivered in an appropriate temperature regulated container (i.e. insulated container with coolant). f. Drug samples are not to be procured on any AHS campus/clinic.

2. Shortages a. Upon notification of a potential manufacturer shortage, the buyer or designee will contact all wholesalers distributing and manufacturers producing the medication for information regarding availability, the reason for the shortage, and estimated release date. If the drug is available, a 30-day supply, as determined by current usage, will be purchased. b. The pharmacy will contact appropriate health care professionals and inform them of the shortage. c. Pharmacists will discuss the pharmaceutical alternatives with physicians as new orders are received for shortage drugs and if possible, therapeutic auto- substitutions will be approved in advance by appropriate Chairman/Physician Committee. d. The pharmacy will notify the Pharmacy & Therapeutics Committee and facilitate product substitution or alternative therapeutic recommendations.

Page 2 of 3 e. When a drug shortage or the acquisition of a drug not on the formulary results in a change in the usual nursing practice in obtaining and administering the drug to patients, pharmacy services will communicate those changes to nursing service and provide education as needed. a. A standardized system wide medication shortage list will be made by pharmacy and communicated to the providers, pharmacists, nurses and pharmacy technicians via intranet, email and discussed at P&T. b. This list will contain severity of shortage, availability of the products and/or alternatives available, potential release dates and implications that the shortage may have. c. In the event the hospital must prioritize the use of the medication for those patient’s most in need, there will be discussion between Pharmacy and Physicians whose patient’s primarily use such medication to determine the most appropriate dispensing of the medication. This may include but not be limited to: limiting its use in only certain Nursing units, use for only certain treatment modalities, limiting the maximum dose and logging out and tracking use by Pharmacy.

REFERENCES Title 22 – 70263 (Q63) State Board of Pharmacy The Drug Supply Chain Security Act (DSCSA)

APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 03/2020 03/2020 Pharmacy and Date: 03/2020 N/A N/A Therapeutics (P&T) Clinical Practice Date: 04/2020 N/A N/A Council (CPC) Medical Executive Date: N/A 04/2020 04/2020 Committee Board of Trustees Date: N/A N/A

Page 3 of 3

MEDICATION: SYSTEM DRUG RECALL POLICY

Department Pharmacy Effective Date 07/2017 Campus AHS System Date Revised 03/2020 Category Clinical Next Scheduled 06/2023 Review Document Manager, System Executive Chief Administrative Officer/ Owner Medication Safety Responsible Chief Nurse Executive Printed copies are for reference only. Please refer to electronic copy for the latest version.

POLICY Pharmacy department promotes patient safety by immediate removal of unstable, improperly labeled, or otherwise unsuitable drugs for patient administration. The pharmacy department shall be responsible for the initiation and coordination of removing all medications identified for recall.

PROCEDURE 1. Upon receipt of “Drug Recall Bulletins” the pharmacy buyer or pharmacy technician designee will, within 72 hours, check pharmacy stock, each nursing station/patient care area and for class I and Class II agents, the sterile compounding log to identify any current patients who have received the product. 2. Purchase histories are obtained to identify affected product in stock. 3. The buyer or pharmacy staff designee will document “total number in stock” or “none in stock”, whichever is applicable on the bulletin or manufacturer’s return slip. a. For departments that have an automated dispensing machine, the pharmacy technician will remove/return all recalled medications for the pharmacist to sign off. b. Upon removal from storage areas, recalled medications will be quarantined in a designated area in the pharmacy until disposition. Documentation will be given to the pharmacy buyer and the Pharmacist-in-Charge (PIC) for verification. c. The following documentation will be completed for each recalled items: a. Date notified b. Date action taken c. Action taken: areas inspected, quantities removed, notification of shipment to wholesaler/manufacturer, notifications to prescribers and staff (if necessary),other actions required by the recall notice, law or regulation, and organizational policy 4. The documentation will be completed by the buyer, the Pharmacist-in-Charge (PIC) or a pharmacist designee. 5. The buyer or pharmacy technician designee will process all paperwork, and notify the Pharmacist-in-Charge (PIC) or Pharmacy Director in case of any pertinent recalls. 1. Pertinent recalls will be defined based on FDA classification Class I – III.

Page 1 of 2 FDA Classification of Recalls: a. Class I Recalls: Dangerous or defective products that could cause serious health problems or death. b. Class II Recalls: Products that may cause a temporary health problem or medically reversible adverse health consequences. c. Class III Recalls: Products that are unlikely to cause adverse health consequences but violate FDA regulations

6. The pharmacy buyer or pharmacy technician designee is responsible for the proper handling and/or shipping of all recalled items. 7. If deemed appropriate, the medical staff will be informed through the AHS email system orat System P&T meeting, 8. Patients who may have received Class I or II recalled medications will be notified of the recall. 9. Pharmacy buyer to email risk management at [email protected] at the end of each recall investigation.

REFERENCES TJC MM05.01.17

APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 03/2020 03/2020 Pharmacy and Date: 03/2020 N/A N/A Therapeutics (P&T) Clinical Practice Date: 04/2020 N/A N/A Council (CPC) Medical Executive Date: N/A 04/2020 04/2020 Committee Board of Trustees Date: N/A N/A

Page 2 of 2

PHYSICIAN ADVISOR UTILIZATION MANAGEMENT

Department Care Management Effective Date 04/2017 Campus AHS System Date Revised 03/2020 Category Administrative Next Scheduled 06/2023 Review Document Director, Care Executive Vice President, Care Owner Management Responsible Management Printed copies are for reference only. Please refer to electronic copy for the latest version.

PURPOSE The purpose of this policy is to ensure patients are at the appropriate level of care and that utilization review processes are conducted in accordance with regulatory requirements and payor contracts.

POLICY Alameda Health System (AHS) will follow Centers for MediCare and Medicaid Services (CMS) guidelines that require documented evidence that each hospital day is individually adjudicated through the utilization review process. If a clinical documentation review does not meet medical necessity, the RN Care Manager will refer cases to an external or internal Physician Advisor as appropriate. The Physician Advisor will perform a secondary review of clinical documentation to determine if admission, continued stay or discharge review is indicated. The secondary review will be performed by a or Osteopathy with a current active medical license in the state of California.

PROCEDURE 1) The RN Care Manager will conduct and document an initial (when indicated), admission, continued stay & discharge review utilizing InterQual criteria to determine if patient’s clinical documentation meets medical necessity and level of care.

2) If clinical documentation does not meet InterQual criteria, the RN Care Manager will contact the Attending or designee to resolve the inconsistency by: a. Physician entering appropriate medical orders for level of care in the Electronic Health Record (EHR); and/or b. Physician entering additional supporting documentation in the EHR; and c. RN Care Manager communicates with the Health Plan to confirm medical necessity and obtain authorization as indicated.

Page 1 of 3 3) If the additional clinical documentation does not support medical necessity by meeting InterQual criteria and the patient has ongoing medical issues, the RN Care Manager will notify the Attending or designee that the case will be considered for secondary review. The RN Care Manager will: a. Refer the case to their Department Manager or designee who will review the case to determine if secondary review is indicated. i. The Department Manager or designee will review the medical record, verify the InterQual is accurate, make determination for secondary review and inform the RN Care Manager of the decision. b. Refer case to external or internal Physician Advisor as directed by the Department Manager or designee. c. RN Care Manager will document all related actions and outcomes in the EHR under the Secondary Review Request of the Care Management Module.

4) The RN Care Manager will refer the following cases to the Department Manager or designee to evaluate for external secondary review physician when InterQual is not met: a. Observation status cases that are within 24 hours who do not meet medical necessity. Refer to Physician Advisor requesting determination of: i. The patient stay is appropriate for admission; and/or ii. Meets medical necessity to convert to inpatient status. b. When Managed Care Plan do not certify service dates despite Physician peer to peer communication. c. Self-pay cases when Patient Access is unable to verify. d. TAR-free MediCal cases that are in the acute hospital setting. e. MediCal pending cases that are in the acute hospital setting. f. HPAC cases with MediCal pending application.

The RN Care Manager will refer to external secondary review physician upon direction by the Department Manager or designee. The RN Care Manager will document all determinations to not refer to secondary review physician by entering the Denied day or Administrative day in the EHR.

5) The RN Care Manager will refer the following cases to the Department Manager or designee to evaluate for internal secondary retro review physician when InterQual is not met: a. Self-Pay verified by Patient Access; Charity; and HealthPac without MediCal pending application. b. MediCal Insurance becomes approved post discharge of patient. c. Skilled Nursing Facility (SNF) level of care recertification. d. MediCare one day stays. e. Acute Rehab cases when admission criteria is not met upon admission or criteria is not met for continued stay.

Page 2 of 3 6) The RN Care Manager will not refer cases for secondary review physician when placement or other ongoing barriers (i.e. delay in surgical interventions or imaging) are occurring for a patient who still requires in-patient stay. Documentation of efforts and outcomes will be documented in the EHR under progress notes. a. Avoidable Day documentation will be entered into Midas.

7) All documentation for Physician Advisor referrals, determination and communication with Attending Physician, and other related interventions, will be documented in the EHR.

8) On-going referrals that were previously referred to external secondary review will continue until completed or reopened as retrospective.

REFERENCES AHS System Physician Advisor Escalation Process Workflow AHS Utilization Review Policy 8/2019 CMS Conditions of Participation 42: Utilization Review 482.30 DHCS TAR Exempt Hospital Participation Agreement 8/2016

APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 03/2020 03/2020 Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 04/2020 N/A N/A Council (CPC) Medical Executive Date: N/A 04/2020 04/2020 Committee Board of Trustees Date: N/A N/A

Page 3 of 3

SELF-PAY AND PROMPT PAY DISCOUNT POLICY

Department Patient Access Services Effective Date 03/2004 Campus AHS System Date Revised 03/2020 Category Administrative Next Scheduled 06/2023 Review Document Director, Admissions and Executive Chief Financial Officer Owner Registration Responsible Printed copies are for reference only. Please refer to electronic copy for the latest version.

PURPOSE: The purpose of this policy is to document Alameda Health System’s Self-Pay Discount Policy in order to meet the mission of the Health System, satisfy the requirements for the Health System’s participation in specific governmental supplemental programs and adhere to the requirements of Senate Bill No.1276 (enacted September 28, 2014). Alameda Health System recognizes the significant burden placed on individuals and wishes to facilitate the prompt payment of patient financial obligations.

POLICY: It is the policy of Alameda Health System to offer discounts from full charges for patients who are uninsured or underinsured and do not qualify for any other federal, state, or county programs.

The discount is applied against facility (inpatient, outpatient and ancillary) and Alameda Health System physician services rendered at Alameda Health System including emergency physicians. This discount policy excludes cosmetic services, not deemed medically necessary.

PROCEDURE SELF PAY DISCOUNT Alameda Health System offers a 30% discount off full charges for patients that do not qualify for any other federal, state, or county programs.

Payment terms, including the amount of the monthly payments or duration of the payment terms will be negotiated with either Patient Access or Patient Financial Services staff.

PROMPT PAY DISCOUNT

For patients who qualify for self-pay discounts and agree to pay their balance within 30 days of receiving a statement, AHS will offer 40% off full charges.

Page 1 of 3 Discounts will be recorded as an administrative adjustment, using the applicable administrative adjustment transaction code in the Alameda Health System financial billing and reporting systems.

This policy may be subject to change as a result of new state and federal legislation. All revisions will be approved by the appropriate oversight department and/or Executive Personnel.

The Charity Policy is separate from this Self-Pay Discount Policy and addresses Alameda Health System patient payment obligations when financial means meet qualifications.

A patient may choose to make a payment at the time of service or pay the bill in full according to above. The initial estimate may differ from the final statement of charges received and this should be communicated to the patient at the time of estimation.

If the patient balance for the prompt pay discount is not paid in full according to the agreement, charges will revert back to the standard 30% discount.

Patients qualify for a self-pay discount at the time of service or initial financial screening. This discount may be applied retroactively if there were unavoidable delays in determining eligibility or patient cost sharing amounts.

NON-CONTRACTED PAYER DISCOUNT For patients that have insurance coverage with a PPO payer not contracted with Alameda Health System, AHS may offer a discounted rate off professional charges when practical. The out of pocket expense to the patient may be discounted down to the estimated out of pocket expense for the same or similar services at a Participating Provider.

AHS staff will calculate the difference between the in-network provider benefit and the non- participating provider benefit. Again, the discount to be considered is the difference between in vs. out of network patient responsibilities (co-payments and deductibles).

The Patient Access team will forward accounts for adjustments to the Patient Financial Services team designee via an excel document. PFS staff will review accounts and make necessary adjustments.

TERM GUIDELINES 1. “Self-pay patient” means a patient who does not have third-party coverage from a health insurer, health care service plan, Medicare, or Medicaid, and whose injury is not a compensable injury for purposes of workers’ compensation, automobile insurance, or other insurance as determined and documented by the hospital.

2. Documentation - Patients must make reasonable effort to provide Alameda Health System with documentation of insurance coverage.

Page 2 of 3 3. Negotiation – Alameda Health System and the patient can negotiate the terms of the payment plan.

4. Extended Payment - The Self-pay component of this policy may be extended in writing on a case by case basis with approval by Revenue Cycle Leadership personnel.

5. Subsequent Patient Qualification for Charity Program - If a patient who has entered into a Discount Agreement subsequently qualifies for the Charity Program, the Charity program shall replace the Discount Agreement.

6. Account Collections – Patients that do not meet the agreed upon payment terms will have their accounts turned over to a collection agency according to AHS policy. The collection agency will not offer any discounts without the prior approval of Alameda Health System Management. Any approval must be in writing.

EXPECTED DEPOSIT(S)

Primary Care Services $150.00 Specialty Care Clinic Services $250.00 Special Procedure/Elective 20-50% of estimated discounted fee Interventional 50% of estimated discounted fee In-Patient (Elective Services) 50% of estimated discounted fee Emergency $400.00

APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 03/2020 03/2020 Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 04/2020 N/A N/A Council (CPC) Medical Executive Date: N/A 04/2020 04/2020 Committee Board of Trustees Date: N/A N/A

Page 3 of 3

SYSTEM MEDICATIONS: LOOK ALIKE, SOUND ALIKE

Department Pharmacy, Nursing, Effective Date 05/2017 Medical Staff Campus AHS System (exception Date Revised 02/2019, 03/2020 Park Bridge and South Shore to refer to internal policies) Category Clinical Next Scheduled 03/2019, 06/2021 Review Document Manager, System Executive Director, Pharmacy Owner Medication Safety Responsible Operations; Chief Medical Officer; Chief Administrative Officer/Chief Nurse Executive Printed copies are for reference only. Please refer to electronic copy for the latest version.

PURPOSE To ensure Alameda Health System (AHS) has a system in place to eliminate medication errors caused by the procurement, storage, dispensing and administration of look alike, sound alike medications.

POLICY 1. To assist with the reducing the likelihood of medication events associated with Look Alike/Sound Alike medications, AHS will make every effort to comply with the following risk reduction strategies: a. Pre-printed order forms or order sets will be used whenever possible. b. Prescribers should not give verbal or telephone orders for sound alike look alike medications and chemotherapeutics. c. Computer screen selection and automatic dispensing machine screens (ADM’s) will use Tallman Lettering to display easily confused medications whenever possible. d. Medications labels will include both generic and trade names to make them easier to distinguish whenever possible. e. Separate look-alike or sound-alike medications in the pharmacy and in the automated dispensing machine in the units. 2. Problematic medications and safety strategies identified will be instituted per the guidelines referenced below.

Page 1 of 9

PROCEDURE 1. The Institute of Safe Medication Practices (ISMP) will be reviewed to identify those medications to add to AHS Sound Alike Look Alike List. 2. At least annually, AHS Pharmacy and Therapeutics Committee will review and update (if needed) the list of look-alike/sound alike drugs used by the organization 3. AHS will regularly provide information to professional staff on drugs that have been determined to be problematic through published reports or internal issues.

REFERENCES The Joint Commission Medication Management MM.01.02.01 Institute for Safe Medication Practices: ISMP’s List of Confused Drug Names https://www.ismp.org/tools/confuseddrugnames.pdf

APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 03/2020 03/2020 Pharmacy and Date: 03/2020 N/A N/A Therapeutics (P&T) Clinical Practice Date: 04/2020 N/A N/A Council (CPC) Medical Executive Date: N/A 04/2020 04/2020 Committee Board of Trustees Date: N/A N/A

Page 2 of 9 ACUTE CARE HOSPITALS MEDICATIONS SAFETY STRATEGY ALPRAZolam LORazepam • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label amanTADINE amioDARONE • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label buPROPion buSPIRone • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label Captopril Carvedilol • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label CeFAZolin – CefTRIAXone – CeFOXitin – CefoTEtan – • Store separately from each other in different cubies in the ADM. CefTRIAXone - CefTAZIdime • Tallman lettering and Auxiliary label CeleBREX Cerebyx • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label carBAMazepine OXcarbazepine • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label CISplatin (Platinol) CARBOplatin (Paraplatin ) • Pre-printed order forms are used to clearly identify medication being ordered. • Stored solely in the pharmacy. • Products are separated by at least one shelf and clearly marked. • No medication abbreviations are accepted. • Orders are double checked by two pharmacists and two nurses prior to administration. DOPamine DOBUTamine • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label DOXOrubicin DAUNOrubicin • Pre-printed order forms are used to clearly identify medication being ordered. • Stored solely in the pharmacy. • Products are separated by at least one shelf and clearly marked. • No medication abbreviations are accepted. • Orders are double checked by two pharmacists and two nurses prior to administration. FOSphenytoin PHENYtoin (Dilantin) • Store separately from each other in different cubies in the ADM. (Cerebyx) • Tallman lettering and Auxiliary label glipiZIDE glyBURIDE • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label

Page 3 of 9 MEDICATIONS SAFETY STRATEGY Heparin HEPARIN (pediatric • Stored in limited supply in Automated Dispensing machines. strength versus adult) • Double checked by pharmacy before restocking Automatic Dispensing Machine (ADM) • Heparin drip requires double RN signature during medication administration and each dose titration hydrALAZINE hydrOXYzine • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label HYDROcodone OxyCODONE (immediate • Store separately from each other in different cubies in the ADM. release) • Tallman lettering and Auxiliary label HYDROmorphone morphine • Dispensing of these medications are controlled and tracked through the (Dilaudid) (Astramorph, Duramorph) Automated dispensing machines. • Stored in the ADM in different cubies and/or different drawers. • Tallman lettering. Insulin products HumuLIN • Only approved insulin products are stocked in the nursing unit to limit the • Lantus and HumaLOG variety. Lente NovoLOG • The removal of insulin doses are recorded and tracked through the automated • Humalog and NovoLIN dispensing machines. • Humulin • All insulin short acting medications are available as vials while insulin long acting • Novolog and medications are available as pens whenever possible. • Novolin • All insulin medications are patient specific and clearly marked with auxiliary • Humalog and labels to differentiate the products and are patient specific (except for the ED). • Novolog • Tallman lettering • Novolin 70/30 and • Novolog Mix • 70/30 LamoTRIgine LevETIRAcetam • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label LevETIRAcetam LevOCARNitine • Store separately from each other in different cubies in the ADM. (Keppra) • Tallman lettering and Auxiliary label levoFLOXacin levETIRAcetam • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label

Page 4 of 9 MEDICATIONS SAFETY STRATEGY MetFORMIN metroNIDAZOLE • Store separately from each other in different cubies in the ADM. (GLUCOPHAGE) (FLAGYL) • Tallman lettering and Auxiliary label Dexamethasone Dexmedetomidine • Store separately from each other in different cubies in the ADM. • Auxiliary Label methylene blue VisionBlue • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label MS Contin (morphine OxyCONTIN (extended • Store separately from each other in different cubies in the ADM. extended release) Release) • Tallman lettering and Auxiliary label niCARdipine NIFEdipine • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label predniSONE prednisoLONE • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label PACLitaxel (Taxol) DOCEtaxel (Taxotere) • Pre-printed order forms are used to clearly identify medication being ordered. • stored solely in the pharmacy. • Products are separated by at least one shelf and clearly marked. • No medication abbreviations are accepted. • Orders are double checked by two pharmacists and two nurses prior to administration. PHENYLephrine NOREPInephrine • Store separately from each other in different cubies in the ADM. (Neo-Synephrine) (Levophed) • Tallman lettering and Auxiliary label riFAMpin riFAXimin • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label soluCORTEF soluMEDROL • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label Tdap Dtap • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label vinCRIStine (Oncovin) vinBLAStine (VELBAN) • Pre-printed order forms are used to clearly identify medication being ordered. • stored solely in the pharmacy. • Products are separated by at least one shelf and clearly marked. • No medication abbreviations are accepted. • Orders are double checked by two pharmacists and two nurses prior to administration.

Page 5 of 9 Ambulatory Care, Behavioral Health, and Long Term Care

MEDICATIONS SAFETY STRATEGY buPROPion busPIRone • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label citalopram Celecoxib (CeleBREX) • Prescribers will give verbal or telephone orders only when truly necessary. hydrobromide (CeleXA) • Staff to read back all orders, spell the product name, and state its indication. • Whenever possible, prescribers will include brand and generic names when writing orders and use computer generated or typed prescriptions. cloNIDine (Catapress) ClonazePAM (Klonopin) • Prescribers will give verbal or telephone orders only when truly necessary. • Staff to read back all orders, spell the product name, and state its indication. • Whenever possible, prescribers will include brand and generic names when writing orders and use computer generated or typed prescriptions. Concentrated: Conventional: • Concentrated oral morphine solutions are only dispensed upon receipt of an morphine oral liquid morphine oral liquid order for a specific patient (not as unit stock). Roxanal, MSIR • The concentrated solution is segregated from the other concentrations in the Pyxis C2 Safe. • Concentrated solutions are purchased and dispensed in dropper bottles and dispensed as unit dose for inpatients. chlorproMAZINE chlordiazePOXIDE • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label DULoxetine FLUoxetine • Store separately from each other in different cubies in the ADM. PARoxetine • Tallman lettering and Auxiliary label Insulin products HumuLIN • Only approved insulin products are stocked in the nursing unit to limit the • Lantus and Lente HumaLOG variety. • Humalog and NovoLOG • The removal of insulin doses are recorded and tracked through the automated • Humulin NovoLIN dispensing machines. • Novolog and • All insulin short acting medications are available as vials while insulin long acting • Novolin medications are available as pens. • Humalog and • All insulin medications are patient specific and clearly marked with auxiliary • Novolog labels to differentiate the products and are patient specific (except for the ED). • Novolin 70/30 • Tallman lettering and • Novolog Mix • 70/30 Page 6 of 9 MEDICATIONS SAFETY STRATEGY lamiVUDine lamoTRIgine • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label Terbinafine (LamISIL) Lamotrigine (LaMICtal) • Prescribers will give verbal or telephone orders only when truly necessary. • Staff to read back all orders, spell the product name, and state its indication. • Whenever possible, prescribers will include brand and generic names when writing orders and use computer generated or typed prescriptions. ThioTHIXine thioRIDazine • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label traZODone traMADol • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label Nefazodone (Serzone ) Quietapine (SEROquel) • Prescribers will give verbal or telephone orders only when truly necessary. • Staff to read back all orders, spell the product name, and state its indication. • Whenever possible, prescribers will include brand and generic names when writing orders and use computer generated or typed prescriptions. Olanzapine (ZyPREXA) Cetirizine (ZyrTEC) • Prescribers will give verbal or telephone orders only when truly necessary. • Staff to read back all orders, spell the product name, and state its indication. • Whenever possible, prescribers will include brand and generic names when writing orders and use computer generated or typed prescriptions. Hep A Vaccine Adult Hep A Vaccine Pediatric • For those campuses that carry both Adult and Pediatric doses, adult dosing (HAVrix) (HAVrix) syringes will be labeled “Adult” • ADULT dose syringes stored on separate shelf from pediatric dose syringes • Pharmacist to double check all syringes & dosage prior to loading in Pyxis • Nurses to confirm ADULT and dosage prior to administration Hepatitis A Vaccine Hepatitis A/B Vaccine • Stored separately from each other on different shelves when possible in (HAVrix) (TWINrix) refrigerated • Pharmacist to double check all syringes & dosage prior to loading in Pyxis • Nursing to confirm name and dosage prior to administration

Page 7 of 9 SOUND ALIKE – LOOK ALIKE MEDICATIONS

(Ambulatory, Long Term Care and )

buPROPion – busPIRone

citalopram (CeleXA) – celecoxib (CeleBREX)

concentrated morphine oral liquid - conventional morphine liquid

chlorproMAZINE – chlordiazePOXIDE

DULoxetine – FLUoxetine

DULoxetine – PARoxetine

Insulin Products – HumuLIN, HumaLOG, NovoLOG, NovoLIN

lamiVUDine – lamoTRIgine

Terbinafine (LamISIL) – lamoTRIgine

thioTHIXine – thioRIDazine

traZODone – tramadol

nefazodone (Serzone) –quietapine (SEROquel)

olanzapine (zyPREXA) – Cetirizine (zytrTEC)

Hep A Vaccine Adult – Hep A Vaccine Pediatric

Hepatitis A Vaccine HAVrix - Hepatitis A/B Vaccine TWINrix

Rev. 3/2020

Page 8 of 9 SOUND ALIKE – LOOK ALIKE MEDICATIONS

ALPRAZolam – LORazepam amanTADINE – amioDARONE buPROPion - buSPIRone captopril - carvedilol carBAMazepine – OXcarbazepine ceFAZolin – cefTRIAXone – ceFOXitin – cefTAZidime - cefoTEtan celeBREX - cerebyx CISplatin – CARBOplatin Dexamethasone - Dexmedetomidine DOPamine – DOBUTamine DOXOrubicin – DAUNOrubicin glipiZIDE – glyBURIDE FOSphenytoin – PHENYtoin Heparin adult strength – Heparin Pediatric strength hydrALAZINE – hydrOXYzine HYDROcodone –oxycodone HYDROmorphone – morphine Insulin Products – HumuLIN, HumaLOG, NovoLOG, NovoLIN levETIRAcetam - levOCARNitine lamoTRIgine - levETIRAcetam levoFLOXacin – levETIRAcetam methylene blue - VisionBlue metformin – metroNIDAZOLE MS Contin – oxyCONTIN niCARdipine - NIFEdipine PACLitaxel – DOCEtaxel PHENYLephrine – NOREPInephrine predniSONE – prednisoLONE soluCORTEF - soluMEDROL Tdap – Dtap vinCRIStine – vinBLAStine Rev. 3/2020

Page 9 of 9

TOY CLEANING

Department Infection Control Effective Date 03/2020 Campus AHS System Date Revised 03/2020 Category Clinical Next Scheduled 06/2023 Review Document Director, Infection Executive Chief Quality Officer Owner Control Responsible Printed copies are for reference only. Please refer to electronic copy for the latest version.

PURPOSE To reduce communicable disease transmission risk among patients seen in ambulatory locations.

POLICY Toys provide comfort and diversion for Alameda Health System (AHS) patients and/or visitors but may also serve as a source of infection. To reduce communicable disease transmission risk among AHS patients and/or visitors in ambulatory and inpatient locations, all toys provided by AHS must be in compliance with these guidelines.

DEFINITIONS 1. Hospital-approved disinfectant: EPA-registered disinfectants approved by Infection Control to meet the overall needs of the healthcare facility for routine cleaning and disinfection; used according to the manufacturer’s recommendations for amount, dilution, and contact time sufficient to remove pathogens from surfaces of rooms where colonized or infected individuals are housed.

2. Stationary toys: Toys affixed to tables, walls, ceilings, floors, casework, or that are not easily moveable by the patient

3. Moveable toys: Moveable toys (e.g. books, blocks, dolls, etc.) are discouraged for communal use. Provide toys/items that the patient can take home. Therapeutic items used for distraction, instruction, etc. must be cleaned after each use or given to patient.

PROCEDURE 1. Clean stationary toys with hospital approved disinfectant at least once per day when in use.

2. Handle movable toys (including books) in one of three ways after each use: a. Cleaned/disinfected with hospital-approved disinfectant b. Given to the child c. Discarded

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3. Soft toys (e.g., stuffed, including mobile with stuffed toys) are single-patient use only and labeled with child’s name (if inpatient). Communal soft toys are not permitted.

4. Toys used in isolation rooms will remain with the patient throughout the visit, then handled as in 2 above.

5. Staff will follow the Standard and Transmission-Based Precautions

CLEANING AGENTS 1. Hospital-approved disinfectant a. Wipe toys with disinfectant. b. Follow label directions for contact time, and allow to air dry

2. Use soap and water for cleaning visibly soiled hands or toys a. Wash with soap and water using friction. b. Rinse with water and dry.

3. Use alcohol (70%) for small and/or minimally soiled toys that are mouthed or contaminated. a. Wipe with alcohol wipe and allow to air dry (water rinse is not necessary)

References

1. Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.

APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 03/2020 03/2020 Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 04/2020 N/A N/A Council (CPC) Medical Executive Date: N/A 04/2020 04/2020 Committee Board of Trustees Date: N/A N/A

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WQ RESOLUTION POLICY

Department Patient Access Effective Date 03/2020 Campus AHS System Date Revised 03/2020 Category Administrative Next Scheduled 06/2023 Review Document Director, Patient Access Executive Chief Financial Officer Owner Responsible Printed copies are for reference only. Please refer to electronic copy for the latest version.

PURPOSE The purpose of the Patient Access Patient Work Queue Resolution policy and procedure is to ensure appropriate work queue ownership, accountability and timely resolution.

POLICY Patient Access staff are required to review and resolve assigned patient workqueues daily to ensure all accounts are resolved or escalated timely. Patient workqueues are populated due to errors, bypassed warnings, and/or missing compliance requirements during the registration and enrollment process. Area/site leader will provide staff with daily work queue assignments through various means, i.e. scheduling templates etc. The expectation is that the accounts are resolved daily and the staff submit their resolutions on the account resolution document.

PROCEDURE 1. Accounts at the patient level will be assigned and resolved daily 2. Staff will access the patient work queues through the EHR home page 3. Based on assignment, staff will review each account on the workqueue to determine the error hitting the account and provide/update the account for resolution appropriately 4. At the end of each shift, staff will submit all accounts resolved and removed off the workqueue using Work queue resolution will be monitored during business hours by the site supervisor.

Account Resolution 1. If staff are unable to resolve an account or edit, they should do the following: a. Review EPIC instructions for resolving accounts within EPIC (depending on what type of edit) b. Check to see if there is a department tip sheet c. Check to see if there is a policy surrounding process d. Refer to supervisor/manager with clear and concise details of edit and process and/or barriers with resolving

Page 1 of 2 e. If the edit cannot be resolved by the supervisor, it should be escalated to the manager for review f. If the account cannot be resolved at this escalation point, the manager will consult the department director for next steps.

GUIDELINES: 1. Patient Access is responsible to resolve Patient Work Queue edits daily and ensure these work queues are not backlogged 2. An account should not remain on the work queue longer than 24 hours without resolution or escalation 3. All Patient Access staff are responsible for all patient work queues within their unit and can/will be assigned to work queues based on department operational need.

APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 03/2020 03/2020 Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 04/2020 N/A N/A Council (CPC) Medical Executive Date: N/A 04/2020 04/2020 Committee Board of Trustees Date: N/A N/A

Page 2 of 2

FAMILY BIRTHING CENTER MAGNESIUM SULFATE THERAPY FOR OBSTETRIC PATIENTS

Department OB/GYN Effective Date 10/2002 Campus Highland Hospital Date Revised 10/2002, 01/2006, 03/2011, 09/2014, 03/2020 Category Clinical Next Scheduled 06/2023 Review Document Director of Nursing, Executive Vice President, Patient Care Owner Family Birthing Center; Responsible Services; Associate Chief Chair, OB/GYN Medical Officer; Chief Medical Officer Printed copies are for reference only. Please refer to electronic copy for the latest version.

PURPOSE To promote safe administration and monitoring of magnesium sulfate therapy in obstetric (OB) patients.

POLICY Magnesium sulfate is a high-alert medication that is ordered for obstetric indications by physicians experienced in the use of magnesium sulfate in the OB population, and administered by registered nurses (RNs) familiar with same. 1. Overview Magnesium sulfate is the drug of choice to prevent and treat seizures in a pregnant patient with preeclampsia or eclampsia, to provide fetal neuroprotection when preterm birth is anticipated before 32 weeks’ gestation, and to prolong pregnancy in preterm labor (not more than 48 hours). Magnesium sulfate may be used during preterm labor to gain time to accrue the benefits of antenatal corticosteroid administration in patients at risk of preterm delivery in the next 7 days; however, tocolysis is not recommended beyond 34 weeks’ gestation or before 24 weeks’ gestation. In some cases, tocolysis can be considered at 23 weeks’ gestation.

Magnesium sulfate depresses the central nervous system (CNS) by interfering with the release of acetylcholine at the synapses. This interference depresses the vasomotor center, decreasing CNS irritability, thereby reducing the risk of maternal seizure activity. Magnesium sulfate relaxes smooth muscle, which reduces the frequency and intensity of uterine contractions. The effect on intracellular metabolism, cell death and injury, and blood flow to the brain may account for the medication’s fetal neuroprotective qualities when administered to patients at risk for preterm birth. Studies have shown that magnesium sulfate administered for neuroprotection before preterm birth reduces the severity and risk of cerebral palsy in surviving infants.

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Fetal magnesium levels tend to correlate with maternal levels, and a transient decrease in fetal heart rate (FHR) variability and accelerations may occur. At birth, some newborns may demonstrate neurologic or respiratory depression. Therefore, a team of caregivers trained in neonatal resuscitation must be present at the delivery.

Although magnesium sulfate may be administered by intramuscular (IM) injection in low resource settings, it is generally administered intravenously to achieve a more immediate onset of action and to control the dose more accurately. IV magnesium sulfate should always be infused by piggyback, so it can be discontinued as necessary while the primary line remains functional.

The U.S. Food and Drug Administration advises against the use of magnesium sulfate injection for longer than 5 to 7 days for patients in preterm labor. Administration beyond 5 to 7 days may cause low calcium levels and bone abnormalities in the fetus. The shortest duration of treatment that can result in fetal harm is not known.

2. Requirements for administration Magnesium sulfate is a high-alert medication with potential for patient harm if used incorrectly. As such, the following safety precautions are observed when magnesium sulfate is being administered on the FBC: a. Patients receiving magnesium sulfate are managed by an obstetrician-gynecologist physician (OBGYN). Patients previously under the care of the certified nurse midwife (CNM) are transferred to the care of the OBGYN physician if magnesium sulfate is required. Transfer of care is documented in the patient’s medical record by both the transferring and the receiving provider. b. A physician’s order is required for magnesium sulfate. c. Intravenous infusion of magnesium sulfate is initiated by a registered nurse (RN) with training in the administration of magnesium sulfate d. Highland pharmacy provides magnesium sulfate solution for administration in the Family Birthing Center care areas e. Magnesium sulfate is labeled with “High Alert Medication” labels f. Intravenous magnesium sulfate administration is done via infusion pump g. Magnesium sulfate therapy can be initiated and adjusted only in the following FBC patient care areas: i. Labor and delivery ii. Antepartum/postpartum unit iii. OB Triage iv. Operative suites v. Post-anesthesia recovery area h. Patients on magnesium sulfate may visit their infants in the Intensive Care Nursery (ICN) with their infusions running. Magnesium is not initiated, nor are doses adjusted, while patients are in the ICN. i. Patients on magnesium sulfate are accompanied by a registered nurse during transport from one area to another within the unit or hospital, without exception. Once arrived, IV lines and infusing medications are double-checked

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by two RNs (see dual verification process in Procedure section). j. Patients receiving magnesium sulfate are cared for at a 1:1 nurse - patient ratio until delivered. After delivery, they may change to a 1:2 nurse-patient ratio if determined stable by the physician. k. In the event that magnesium sulfate is urgently required for seizure prophylaxis or treatment in an obstetric patient who presents to Highland Hospital’s emergency department and is unstable for transport to the Family Birthing Center, it may be ordered by an emergency department attending physician and administered by emergency department registered nurses (RNs) according to this policy and procedure, while awaiting the arrival of an OBGYN physician and FBC RNs.

PROCEDURE 1. Preparation a. Before the infusion is initiated, the patient is informed of possible side effects, as well as signs and symptoms of toxicity. The patient is asked to report such signs or symptoms to staff immediately. b. Two (2) licensed healthcare professionals independently double check the six rights of medication safety (right patient, medication, dose, route, time, and documentation) and infusion pump settings at the bedside, whenever an infusion of magnesium sulfate is initiated, upon any change in dosage, at bag change, and at handoff (shift report). c. Dual RN verification is documented in the Medication Administration Record (MAR) section of the patient’s medical record by both verifiers. d. Changes to infusion rates and/or infusion pump settings are per physician order and are carried out using the double verification process. Such changes and double verification process are documented in the medical record by both verifiers. e. Monitoring of patient response to therapy is ongoing. Frequency of assessment is determined by diagnosis, dosage, psychological and physiological response to magnesium, and serum magnesium levels (if ordered by provider). f. Patients on magnesium sulfate for preeclampsia or eclampsia are fluid restricted to less than or equal to 100 ml per hour combined IV & oral intake, unless otherwise ordered by physician g. Patients on magnesium sulfate are on strict intake and output monitoring. Strict I&Os do not require an indwelling Foley catheter with urometer unless ordered by the physician.

2. Monitoring Serum Magnesium a. Routine serum magnesium levels are not required for asymptomatic patients who are being assessed for toxicity every one to two hours with normal findings. b. The therapeutic range for serum magnesium levels is thought to be 4.8-8.4 mg/dL (4- 7 mEq/L), although a clear threshold concentration for prevention of seizures is not known. c. Serum magnesium levels are obtained every six hours as an adjunct to clinical assessment in patients who have: i. A seizure while receiving magnesium sulfate

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ii. Clinical signs/symptoms suggestive of magnesium toxicity (e.g., absent patellar reflex, respiratory rate less than or equal to12 breaths/minute) iii. Renal insufficiency (creatinine greater than 1.1 mg/dL [110 mmol/L]) d. If magnesium toxicity is suspected, the maintenance dose is decreased or discontinued, the physician is notified immediately, and a serum magnesium level is checked. e. If the serum level is greater than 9.6 mg/dL (8 mEq/L), the infusion is stopped, and serum magnesium levels are determined at two-hour intervals. The infusion can be restarted at a lower dose when the serum level is less than 8.4 mg/dL (7 mEq/L)

3. Initiation of Magnesium Sulfate (see also Elsevier Skills: Magnesium Sulfate [Maternal- Newborn] - CE) a. Verify the absence of contraindications to magnesium sulfate administration, including hypocalcemia, myasthenia gravis, or renal failure b. Educate patient about common transient side effects of magnesium sulfate (maternal flushing, lethargy, headache, muscle weakness, neonatal hypotonia) c. Obtain standard concentration magnesium sulfate IV infusion (maintenance) bag and the premixed bolus bag from the pharmacy d. Perform a baseline assessment and document in the patient’s medical record before administration: i. Vital signs, including oxygen saturation (SpO2), which is monitored continuously during magnesium sulfate infusion ii. Deep tendon reflexes (DTRs) including presence and degree of clonus iii. Level of consciousness iv. Breath sounds v. Intake and output vi. Weight on admission and daily vii. Fetal heart rate and uterine activity e. Ensure that calcium gluconate is readily available i. Usual dosage: 1 mL of 10% calcium gluconate given IV push over 1-2 minutes. May repeat to a maximum of 10 mL ii. Calcium chloride 1 gm may be substituted, given as directed by physician order f. Program infusion pump to run the bolus dose as ordered by physician (typically 4 to 6 grams over 20 to 30 minutes) g. Obtain second RN verification and documentation of correct medication and dose, pump settings, and tubing connections before administration and with any dose or rate change h. Connect the magnesium sulfate as an intravenous piggyback into the mainline at the most proximal port to the primary venipuncture site, unless oxytocin is also infusing i. If oxytocin is administered concurrently with magnesium sulfate, the oxytocin is connected at the most proximal port and magnesium sulfate at the second most proximal port j. Remain at the bedside during the bolus dose to monitor patient for side effects and adverse drug reactions

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k. At the completion of the bolus dose, disconnect the IV tubing used for the magnesium sulfate bolus, then perform another assessment l. Prepare the infusion pump to administer the maintenance magnesium sulfate infusion as ordered (typically 1 to 2 grams/hour) m. Piggyback maintenance magnesium sulfate IV into mainline fluid at the closest port to the primary venipuncture site. n. A second RN must verify the correct medication and dose and check all pump settings and tubing connections prior to administration

4. Ongoing Assessment (see also Elsevier Skills: Magnesium Sulfate [Maternal-Newborn] - CE) a. Following initiation of magnesium sulfate, vital signs are assessed every 15 minutes for one hour, then every 30 minutes for one hour, and hourly thereafter. b. After the initial two hours of monitoring described above, assess and document the components of baseline assessment 4 a. through 4 e. hourly, plus i. Volume and rate of magnesium sulfate ii. Intake and output a) Patients on magnesium sulfate for preeclampsia/eclampsia or with renal compromise have intake and output monitoring recorded every hour. b) Patients receiving magnesium sulfate for other indications have intake and output monitoring recorded every 2 hours. c. Assess fetal heart rate and uterine activity according to physician orders, or more often as dictated by stage of labor and other clinical indications (see AHS policy and procedure Family Birthing Center Fetal Monitoring [formerly MCH Fetal Monitoring]) d. Report any abnormal assessment findings to physician promptly. Abnormal findings include: i. Urine output less than 30 ml/hr ii. Respiratory rate less than 12 breaths/min iii. SpO2 level less than 95% on room air iv. Persistent hypotension v. Absence of DTRs vi. Abnormal laboratory findings, including serum magnesium level (if ordered) above the therapeutic range of 4.8 to 8.4 mg/dL (4-7 mEq/L) vii. Altered level of consciousness or difficulty arousing patient viii. Significant changes in maternal or fetal status e. Collect laboratory specimens for serum magnesium levels if ordered f. Monitor patient for signs of magnesium toxicity, including severe respiratory depression, decreased level of consciousness, respiratory arrest, and cardiac arrest. If present: i. Notify physician immediately ii. Discontinue magnesium sulfate iii. Obtain and immediately administer calcium gluconate per orders iv. Draw a stat serum magnesium level

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v. Monitor , pulse, respirations, deep tendon reflexes and level of consciousness every 5 minutes until stable. g. Monitor postpartum mother for signs of uterine atony, such as boggy uterus, elevated fundal height, or excessive lochia h. Stable antepartum and postpartum patients on magnesium sulfate have vital signs, deep tendon reflexes, and oxygen saturation assessed every hour, or as ordered i. Postpartum patients on magnesium sulfate for preeclampsia or eclampsia remain on magnesium sulfate for 24 hours post delivery, or as ordered by the physician

REFERENCES 1. American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice, Society for Maternal-Fetal Medicine (SMFM). (2010, reaffirmed 2016). Committee opinion number 455: Magnesium sulfate before anticipated preterm birth for neuroprotection. Retrieved September 3, 2019, from https://www.acog.org/- /media/Committee-Opinions/Committee-on-Obstetric- Practice/co455.pdf?dmc=1&ts=20160715T1925048172 2. American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice, Society for Maternal-Fetal Medicine (SMFM). (2016, reaffirmed 2018). Committee opinion number 652: Magnesium sulfate use in . Interim update. Retrieved September 3, 2019, from https://www.acog.org/-/media/Committee- Opinions/Committee-on-Obstetric- Practice/co652.pdf?dmc=1&ts=20151223T1847584273 3. American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins—Obstetrics. (2016, reaffirmed 2018). Practice bulletin number 171: Management of preterm labor. Interim update. Obstetrics & Gynecology,128(4), e155-e164. doi:10.1097/AOG.0000000000001711 4. California Maternal Quality Care Collaborative (CMQCC). (2014). Improving health care response to preeclampsia: A California quality improvement toolkit errata 5.13.14. Retrieved September 3, 2019, from https://www.cmqcc.org/resource/cmqcc-preeclampsia- toolkit-errata-51314 5. Elsevier Skills. (2019). Magnesium sulfate (maternal-newborn)-CE. Retrieved January 6, 2020, from https://point-of- care.elsevierperformancemanager.com/skills/1131/extended- text?skillId=MN_032Institute for Safe Medication Practices (ISMP). (2014). ISMP list of high-alert medications in acute care settings. Retrieved September 3, 2019, from http://www.ismp.org/sites/default/files/attachments/2018- 01/highalertmedications%281%29.pdf 6. Institute for Safe Medication Practices (ISMP). (2017). 2018-2019 Targeted medication safety best practices for hospitals. Retrieved September 3, 2019, from https://www.ismp.org/sites/default/files/attachments/2017-12/TMSBP-for- Hospitalsv2.pdf

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7. UpToDate. (2019). Preeclampsia: Management and prognosis. Retrieved January 6, 2020, from https://www.uptodate.com/contents/preeclampsia-management- and- prognosis?search=magnesium%20sulfate&source=search_result&selectedTitle=3~148&us age_type=default&display_rank=2

APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A N/A 02/2020 Pharmacy and Date: 03/2020 N/A N/A Therapeutics (P&T) Clinical Practice Date: N/A N/A 03/2020 Council Medical Executive Date: N/A N/A 04/2020 Committee Board of Trustees Date: N/A N/A

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FAMILY BIRTHING CENTER NEONATAL BLOOD GLUCOSE MONITORING

Department Pediatrics Effective Date 04/2015 Campus Highland Hospital Date Revised 04/2018, 03/09/2020 Category Clinical Next Scheduled 06/2023 Review Document Family Birthing Center, Executive Vice President, Patient Owner Director of Nursing; Responsible Care Services; Associate Chair, Pediatrics Chief Medical Officer; Chief Medical Officer Printed copies are for reference only. Please refer to electronic copy for the latest version.

POLICY The Family Birthing Center (FBC) consistently screens asymptomatic at-risk neonates and all symptomatic neonates for hypoglycemia. Ongoing monitoring and treatment for neonatal hypoglycemia are performed in a standardized fashion to promote euglycemia in newborns admitted to the FBC.

In accordance with our Baby Friendly Hospital designation, the FBC prioritizes supplementation with expressed breast milk (EBM) or glucose gel (when appropriate) over artificial milk for infants requiring treatment of hypoglycemia.

PURPOSE To describe processes for screening, assessing, and treating hypoglycemic newborns.

BACKGROUND Asymptomatic healthy term appropriate-for-gestational-age infants born after normal pregnancy and delivery do not require monitoring of blood glucose. Transient hypoglycemia in the first few hours of life is common and self limited and does not have long term sequelae. Infants who have persistent or recurrent hypoglycemia may be at risk for delayed neurodevelopment. Only infants at risk of significant hypoglycemia are screened and appropriate interventions provided as indicated. Assessment for potential hypoglycemia is ongoing throughout the newborn’s hospital stay.

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PROCEDURE Equipment Specifications 1. Alameda Health System uses the Precision Xceed Pro Glucose machine, which provides reliable and accurate bedside glucose monitoring for infants. 2. This is a whole blood reading, so results may be 10-15% lower than the actual serum value. 3. Hematocrit values may also affect results, with hematocrit greater than 55mg/dl producing falsely low values and hematocrit less than 35mg/dl producing falsely elevated levels.

Heelstick (see also: Elsevier Skills Heel Stick (Neonatal)-CE) 1. Warm heel with heel warmer for 10 minutes prior to obtaining blood sample. 2. Hold infant’s foot in dorsiflexion with non-dominant hand and clean heel with alcohol swab. 3. Puncture skin on medial or lateral aspect of heel with sterile disposable lancet and wipe with dry sterile gauze. 4. Wipe off first drop of blood. 5. Gently touch end of test strip to blood sample until beep is heard. 6. Dry puncture area and (cover with a Band-Aid). 7. Document the glucose reading, intervention (if any), and notification of pediatrician (if indicated). 8. In the ICN, blood for glucose monitoring may also be obtained via venous blood draw or from a venous or arterial umbilical catheter provided dextrose is not infusing. a. Allow drop of blood to form at the tip of syringe. b. Apply drop of blood to target area at end of test strip

Management of Symptomatic Infants 1. Infants are monitored throughout admission for signs of hypoglycemia. 2. The signs of hypoglycemia are non-specific but may include a. Jitteriness/tremors b. Cyanosis c. Seizures d. Apnea e. Tachypnea f. Weak or High-pitched cry, irritability g. Floppiness/decreased tone/lethargy h. Poor feeding i. Eye rolling

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3. If any of these symptoms are present, the Registered Nurse (RN) obtains a blood glucose level immediately and notifies the attending pediatrician of symptoms and blood glucose results. RN documents findings and nursing actions in the patient’s medical record. 4. Symptomatic infants with blood glucose less than 40 mg/dl are evaluated for administration of IV dextrose in the ICN. 5. Infants with cyanosis, apnea, or seizures are transferred immediately to ICN, and the attending pediatrician is notified without delay.

Management of At-Risk Asymptomatic Infants 1. Neonatal hypoglycemia occurs most commonly in infants who are a. Preterm (<37 weeks) b. Small for gestational age (SGA) c. Large for gestational age (LGA) d. Born to a diabetic mother (IODM) 2. These infants, as well as others with less common causes of hypoglycemia, are placed on the blood glucose monitoring protocol by the attending pediatrician. 3. At-risk infants have an initial feeding within one hour of birth. The initial feeding should be breast milk unless there is a contraindication to breast feeding or mother plans to formula feed only. 4. An initial blood glucose screening is done 30 minutes after first feed (no later than 90 min of life) OR by 60 minutes of life if unable to feed. a. If initial blood glucose is less than 20 mg/dl: i. Transfer baby to ICN for serum blood glucose measurement and IV dextrose infusion. ii. Notify the attending pediatrician immediately with the results. iii. Document the findings and nursing action in the patient’s medical record. b. If initial blood glucose is 20-40 mg/dl: 1. For breastfeeding infants at or greater than 35 weeks, administer 0.5ml/kg of 40% Dextrose gel as follows:Use weight based table in algorithm (max dose is 2.5ml) 2. Wipe inside of cheeks with 2x2 gauze sponge to dry 3. Apply 0.5 ml of gel to gloved finger and massage into infant's cheek (buccal mucosa); repeat in alternate cheek and continue alternating until entire dose is given ii. Alternative treatment: 5ml/kg of standard formula or expressed breast milk (EBM) (if available within 15 minutes) is fed via finger feed, bottle, or supplemental nursing system (SNS) as tolerated. iii. Repeat blood glucose in 45 to 60 minutes after the glucose gel or feeding.

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iv. If baby does not have a coordinated suck or swallow and/or does not tolerate the feeding, transfer the infant to the ICN and notify pediatrician. Document findings and nursing actions in the patient’s medical record. c. If initial blood glucose is greater than 40mg/dl: i. Encourage on demand breastfeeding or formula feeding at least every 2- 3 hours. ii. Continue to check blood glucose before each feeding. 5. In the first 4 hours of life and after initial blood glucose: a. If blood glucose is less than 25mg/dl: i. Transfer the infant to the ICN for dextrose infusion and notify pediatrician. b. If blood glucose is 25-40 mg/dl: i. For breastfeeding infants at or greater than 35 weeks, administer 0.5ml/kg of 40% Dextrose gel as follows: 1. Use weight based table in algorithm (max dose is 2.5ml) 2. Wipe inside of cheeks with 2x2 gauze sponge to dry 3. Apply 0.5 ml of gel to gloved finger and massage into infant's cheek (buccal mucosa); repeat in alternate cheek and continue alternating until entire dose is given ii. Alternative treatment: Feed the infant 5ml/kg of standard formula or expressed breast milk via finger feed, bottle, or supplemental nursing system (SNS) as tolerated. iii. Recheck the blood glucose 45-60 minutes after the glucose gel or feed. iv. If the blood glucose remains less than 40mg/dl after the second glucose gel or feeding: 1. Notify pediatrician and transfer infant to ICN for dextrose infusion. 2. Document findings and nursing actions in patient’s medical record. 6. Between 4 and 24 hours of life: a. If blood glucose is less than 35 mg/dl i. Notify pediatrician and transfer baby to ICN for dextrose infusion. ii. Document findings and nursing actions in patient’s medical record. b. If blood glucose is 35-45 mg/dl i. Feed 5 ml/kg of standard 19cal/oz formula or EBM and recheck blood glucose 45-60 minutes after feeding. ii. If infant does not tolerate feeding, or repeat blood glucose remains less than 45 mg/dl 1. Notify pediatrician and transfer infant to ICN for dextrose infusion.

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2. Document findings and nursing actions in patient’s medical record. c. If blood glucose is greater than 45mg/dl, continue to encourage on demand breast or bottle feeding at least every 2-3 hours and check blood glucose before each feed.

Discontinuation of Monitoring 1. Infants who are born to a mother with diabetes and/or who are large for gestational age a. Continue blood glucose monitoring before each feeding for at least 12 hours. b. Discontinue monitoring after 12 hours if last two consecutive blood glucoses before feeds are greater than 45 mg/dl. c. Continue monitoring beyond 12 hours of life until two consecutive pre-feed blood glucoses are greater than 45 mg/dl. 2. Infants who are preterm (less than 37 weeks) or small for gestational age are at risk for more prolonged hypoglycemia. a. Continue blood glucose monitoring before each feeding (at least every 2-3 hours) for a minimum of 24 hours. b. Discontinue monitoring at 24 hours of life only if the last two consecutive blood glucoses before 24 hours of age are greater than 45mg/dl. c. Continue monitoring beyond 24 hours of life until two consecutive pre-feed blood glucoses are greater than 45 mg/dl.

Intensive Care Nursery (ICN) Admission 1. Infants that are admitted to the ICN are at high risk for neonatal hypoglycemia and are screened as outlined above in this policy. 2. These include, but are not limited, to infants who are SGA, LGA, preterm, IODM, and infants with 5 minute Apgar scores less than 7. 3. For any ICN infant with symptoms of hypoglycemia: a. Immediately begin blood glucose monitoring and notify pediatrician. b. Document findings and nursing actions in patient’s medical record. 4. For ICN infants who are at high risk for hypoglycemia and who are NPO or unable to feed for any reason within the first hours of life: a. Check glucose within 60 minutes of life b. Notify pediatrician of results c. Document findings and nursing actions in the patient’s medical record. 5. If the baby remains NPO and is not yet on IVF (intravenous fluids) a. The blood sugar should be rechecked hourly until three hours of age b. Notify the pediatrician of the results. c. Document findings and nursing actions in patient’s medical record.

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6. For ICN infant receiving intravenous fluids (IVF) a. Screen blood glucose one hour after i. IV dextrose bolus, ii. Initiation of IVF or hyperalimentation (HAL) or parental nutrition iii. Discontinuation of IVF or HAL iv. Infiltration of IV v. Change in IVF concentration, rate or tubing. b. If no changes to IVF, check blood glucose every six hours c. After the discontinuation of IVF, check blood glucose before each feeding times two feedings. 7. Notify pediatrician of blood glucose less than 45 mg/dl or greater than 150 mg/dl in any ICN baby.

REFERENCES 1. Adamkin, D.(2011). Postnatal glucose homeostasis in late-preterm and term infants committee on fetus and newborn. Pediatrics. 127(3). 575-579. 2. AAP News (2011). Algorithm is key resource on screening, Management of Neonatal Hypoglycemia in At-Risk Infants. Retrieved on November 5, 2012 from http://aapnewsde.aap.org/aapnews-open/201103_o?pg=20#pg20. 3. John Muir Health Blood Glucose Monitoring Policy and Procedure 4. Harris DL et al. Dextrose Gel for neonatal hypoglycemia (the Sugar Babies Study): a randomized, double-blind, placebo controlled trial. Lancet 2013; 382: 2077-83. 5. Consensus Clinical Guidelines for Screening & Management of Hypoglycemia in Late Preterm and Term Infants (≥ 34 weeks GA) UCSF NCNC (Northern California Consortium). 8/2018. https://www.ucsfbenioffchildrens.org/pdf/hypoglycemia_full_guideline.pdf 6. Clinical Practice Guideline: Neonatal Glucose Assessment and Clinical Management. Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital https://www.brighamandwomens.org/assets/BWH/pediatric-newborn-medicine/pdfs/dpnm- hypoglycemia-revised-12-19-16.pdf

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APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A N/A 03/2020 Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 03/2020 N/A N/A Council (CPC) Medical Executive Date: N/A N/A 04/2020 Committee Board of Trustees Date: N/A N/A

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Neonatal Blood Glucose Monitoring Algorithm For Asymptomatic, At-Risk Neonates

Birth to 4 hrs of life • First feed within one hour of life •Initial glucose check 30 min after first feed, no later than 90 minutes of life

<20 mg/dL 20 to 40 mg/dL >40 mg/dL •Notify MD •Breastfeeding and ≥ 35 wks •Feed on demand at •Transfer to ICN 0.5ml/kg of 40% oral glucose gel or least every 2-3 hours 5 mL/kg of formula or EBM •Check glucose before Repeat glucose in 45 to 60 minutes each feed •All others 5 mL/kg of formula or EBM Repeat glucose in 45 to 60 minutes

Repeat glucose <25 mg/dL: Repeat glucose 25 to 40 mg/dL Repeat glucose >40 mg/dL: •Notify MD •Breastfeeding and ≥ 35 wks •Feed on demand at least •Transfer to ICN 0.5ml/kg of 40% oral glucose gel or every 2-3 hours 5 mL/kg of formula or EBM •Check glucose before each Repeat glucose in 45 to 60 minutes feed •All others 5 mL/kg of formula or EBM Repeat glucose in 45 to 60 minutes

•Feed on demand at least every 2-3 hours 4 to 24 hrs of life •Check glucose before each feed

< 35 mg/dL 35 to 45 mg/dL >45 mg/dL •Notify MD •Feed 5 mL/kg of formula or EBM •Feed on demand at •Transfer to ICN •Repeat glucose in 45 to 60 minutes least every 2-3 hours •Check glucose before each feed

Repeat glucose <45 mg/dL •Notify MD •Transfer to ICN

• For Preterm Infants and SGA Infants: Discontinue glucose 40% Glucose Gel: 0.5ml/kg Wt Dose monitoring at 24 hours of age only if the last two AC •Only for breastfeeding glucoses are >45, otherwise continue until two infants ≥ 35 wks 2kg 1.0 mL consecutive AC glucoses are >45 •Only to be used until 4 hrs 3kg 1.5 mL • For Infants Of Diabetic Mothers and LGA Infants: of life Discontinue glucose monitoring at 12 hours of age only if •See protocol for admin 4kg 2.0 mL the last two AC glucoses are >45, otherwise continue until instructions two consecutive AC glucoses are >45 •Not to exceed 2 doses total 5kg 2.5 mL

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FAMILY BIRTHING CENTER VACUUM-ASSISTED VAGINAL DELIVERY

Department Labor and Delivery Effective Date 03/2020 Campus Highland Hospital Date Revised 03/2020 Category Labor and Delivery Next Scheduled 06/2023 Review Document Family Birthing Center, Executive Vice President, Patient Owner Director of Nursing; Responsible Care Services; Associate Chair, OB/GYN Chief Medical Officer; Chief Medical Officer Printed copies are for reference only. Please refer to electronic copy for the latest version.

PURPOSE To promote safe, standardized performance of vacuum-assisted vaginal deliveries in the Family Birthing Center at Highland Hospital.

POLICY There is an attending obstetrician-gynecologist available to the Family Birthing Center (FBC) at all times who is able and credentialed to perform vacuum-assisted vaginal delivery (VAVD) if indicated. 1. Background Operative vaginal delivery (OVD) can be used to achieve or expedite safe vaginal delivery for maternal or fetal indications in the second stage of labor. Often, OVD can be safely accomplished more quickly than cesarean delivery (ACOG, 2015). When criteria are met, OVD is preferable to delivery by cesarean section because it avoids the morbidities associated with cesarean delivery. OVD is accomplished either with the use of obstetric forceps or by applying traction to the fetal scalp with a vacuum extractor. Vacuum-assisted vaginal delivery (VAVD) accounts for approximately 2.6% of vaginal births in the US. VAVD is the method of OVD most commonly performed on the FBC.

2. Indications for VAVD OVD is a reasonable alternative to cesarean delivery when operative intervention to complete labor is indicated and OVD can be safely and readily accomplished (UpToDate, 2019). The choice of instrument (forceps or vacuum extractor) is based on individual clinical circumstances and the operator’s experience and skill. The following are indications for VAVD in patients who are candidates for OVD; however, they are not absolute, and cesarean delivery remains an option: a. Prolonged second stage of labor with indication for prompt delivery b. Suspicion for immediate or potential fetal compromise with ongoing labor in the second stage c. Maternal factors such as exhaustion, ineffective pushing, or cardiac or neurological disease for which active maternal pushing efforts are contraindicated

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The upper limits of duration of second stage labor are not established. Therefore, a prolonged second stage of labor that continues progressing without fetal or maternal indications for prompt delivery requires individualized evaluation as to whether expectant management will likely result in spontaneous vaginal birth (SVB). Absent other indications, prolonged second stage is not in and of itself an absolute indication for OVD, especially when indicators suggest that SVB is likely to occur (e.g. progressive fetal descent, rotation from occiput posterior to occiput anterior position) or when other interventions to promote progress in second stage (e.g. oxytocin augmentation, position change, coached pushing, manual rotation from occiput posterior to anterior position) have not been exhausted.

3. Contraindications a. Any contraindication to vaginal birth b. Fetal head unengaged in maternal pelvis c. Position of vertex cannot be determined d. Suspected cephalopelvic disproportion e. Fetus known or suspected to have bleeding disorder or bone demineralization condition f. Gestational age below 34 weeks + 0 days

4. Caution a. History of shoulder dystocia during a prior birth b. Suspected fetal macrosomia c. Multiple attempts to place fetal scalp electrode

5. Risks a. Maternal i. Genital tract laceration ii. Obstetric hemorrhage iii. Anal sphincter injury iv. Bladder injury b. Fetal i. Subgaleal hemorrhage ii. Retinal hemorrhage iii. Intracranial hemorrhage iv. Cephalohematoma v. Scalp injury

6. Prerequisites a. Complete cervical dilation b. Fetal head is engaged and +2 station or lower c. Position of fetal head is known i. Ultrasound examination may be used to determine or confirm position d. Estimated fetal weight (EFW) is established and documented e. Pelvis assessed as adequate for vaginal delivery relative to EFW

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f. Maternal bladder has been emptied g. Anesthesia is adequate h. Mother has given informed consent after being advised of the risks, benefits, and alternatives to OVD i. There is an ability and willingness to move promptly to cesarean delivery in case of failure to deliver vaginally with operative assistance

PROCEDURE 1. Equipment The FBC utilizes the Kiwi Vacuum Delivery System with Omni Cup, or any equivalent product(s) with the following safety features a. Integral pump/handle for single-operator use b. Traction force indicator c. Universal cup suitable for all positions of the fetal vertex; or a variety of styles of cup appropriate for use with different fetal positions d. Manufacturer’s instructions for all vacuum extractors available on the FBC are attached to this document (Appendix A)

2. Facilities a. The FBC has two dedicated operative suites, one of which is immediately available in case of unsuccessful VAVD attempt. Every effort is made to avoid attempting a VAVD if both operative suites are in use simultaneously b. The FBC has a Level 2 Intensive Care Nursery (ICN) available to treat a compromised infant or stabilize for transport c. VAVD may be attempted in any of the FBC’s Labor-Delivery-Recovery rooms, triage beds, or operative suites, depending on the indication, urgency, and predicted likelihood of a successful VAVD

3. Provider responsibilities All VAVDs are performed by the attending obstetrician (OB). In the case of a patient who is being managed or co-managed by a certified nurse midwife (CNM), the following applies: a. The CNM is responsible for informing the attending OB of any maternal or fetal condition during the second stage of labor that might indicate the need for an operative delivery. The CNM documents this conversation in the medical record b. The OB makes a bedside evaluation of any CNM-managed patient for whom evaluation for operative delivery is requested or indicated c. The OB documents her or his evaluation in the medical record, including her/his discussion with the patient and receipt of informed consent for operative delivery, if applicable d. If the OB performs a VAVD for a CNM-managed patient, the CNM may resume primary responsibility for care and management of the patient, including completion of the delivery, once the fetal head has been successfully delivered by the OB and the vacuum removed

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e. In the above circumstances, the OB completes all documentation related to the VAVD as would be required for a VAVD of an OB-managed patient f. If the OB attempts a VAVD for a CNM-managed patient and the attempt is unsuccessful, that patient automatically and immediately becomes the primary responsibility of the attending OB, who proceeds towards cesarean delivery

4. Personnel The following are immediately available and in-house at all times a. Obstetrician (OB) experienced and credentialed in VAVD b. Provider credentialed to first-assist at cesarean delivery (e.g., second obstetrician, certified nurse midwife, resident physician, general surgeon) c. Registered nurses experienced in care of the spontaneously laboring or surgical obstetric patient d. OB surgical technician e. Anesthesia team (anesthesiologist, certified registered nurse anesthetist) f. Pediatrician(s) experienced and certified in neonatal resuscitation g. Registered nurses experienced and certified in neonatal resuscitation and care of infants in the ICN

5. Practice a. Selection of candidates Attending OB reviews medical record, maternal status, fetal status, and labor course prior to making recommendation for VAVD b. Assessment of mother includes parity, contraction pattern, body habitus, pelvic anatomy, cervical exam, adequacy of analgesia/anesthesia, degree of fatigue, quality of pushing efforts, bladder status, and ability to actively participate in VAVD attempt c. Assessment of fetus includes gestational age, estimated fetal weight, presenting part, station, and position, presence and degree of asynclitism, molding, or caput, fetal heart rate characteristics, presence of high-risk conditions that may influence ability to tolerate vaginal delivery d. Informed consent is obtained from the mother and fully documented, including risks, benefits, and alternatives to VAVD, and need for cesarean delivery if VAVD cannot be successfully achieved e. If delivery is not urgently indicated, second stage management is reviewed to ascertain that all reasonable efforts to support spontaneous vaginal birth have been considered or attempted (refer to AHS policy “MCH – Physiologic Management of Second Stage Labor;” refer to attached second stage labor algorithms [Appendix B]) f. Communication of intent to attempt VAVD is made to all persons listed above in “Personnel” section of this policy. In addition, the charge nurse and unit clerk for Labor and Delivery are notified, as are any ancillary staff who may be asked to attend the delivery (e.g. respiratory therapist) g. Availability of operative suite, pediatric team, anesthesia team, and surgical assist are verified prior to beginning procedure

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h. Patient is placed in dorsal lithotomy position with labor bed broken down to facilitate downward traction during VAVD i. Patient’s bladder is emptied j. A second labor nurse is present to perform real-time documentation in the patient’s medical record k. Rotational maneuvers are not attempted during VAVD l. Sequential application of vacuum extractor and obstetric forceps is associated with increased rates of maternal and fetal injury and should be avoided m. In the event that a VAVD attempt is not progressing normally towards vaginal delivery, the attempt is abandoned and the patient is delivered by cesarean section

6. Parameters for VAVD a. Suction pressure does not exceed 600 mmHg b. Suction pressure may be fully maintained between contractions or reduced to less than 200 mmHg, per provider preference c. Episiotomy is not routinely performed to facilitate VAVD i. Midline episiotomy is associated with greater likelihood of anal sphincter injuries compared with mediolateral episiotomy ii. Mediolateral episiotomy is associated with greater perineal pain and disrupted healing in the postpartum period compared with midline episiotomy d. Strong evidence-based recommendations regarding maximum number of spontaneous cup detachments (pop-offs), pulls, and maximum time of vacuum application permissible during a VAVD attempt are not available. However, best practice recommendations based on expert opinion and lesser-quality evidence suggest that a VAVD attempt not exceed three pop-offs, three sets of pulls (over three contractions), or a maximum application time of 15 minutes. It may be appropriate to continue beyond these maximums of duration or number of pulls if delivery appears clearly imminent

7. Documentation Thorough documentation of all VAVD attempts is required of nursing and delivery providers. a. Elements of documentation that must appear in the medical record include, but are not limited to: i. Indication for procedure ii. Estimated fetal weight iii. Gestational age iv. Assessment of fetal heart rate at time of decision to attempt VAVD v. Cervical exam at time of decision to attempt VAVD vi. Presence and type of anesthesia or analgesia vii. Procedural details, including: 1. Type of vacuum extractor used 2. Time of vacuum application(s) 3. Maximum suction pressure 4. Number of pulls

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5. Number of pop-offs 6. Total time of application b. Elements of documentation that must appear in the delivering provider’s procedure note (or in a progress note completed immediately prior to attempted VAVD) include, but are not limited to: i. Discussion with patient including risks, benefits, and alternatives to VAVD ii. Receipt of patient’s informed consent to VAVD and to cesarean section should VAVD fail (verbal) iii. Fetal station and position at time of vacuum application iv. Whether and what kind of episiotomy was performed v. Occurrence of obstetric laceration(s) vi. Complications of procedure vii. Rationale for departure from established guidelines (e.g. continuing VAVD attempt after third pop-off) viii. Outcome of VAVD attempt, including route of delivery and maternal or fetal injuries sustained, if any

8. Systems Reporting and Learning a. All failed or complicated VAVDs are debriefed with all available members of the delivery team as soon as possible after the birth b. The OB Clinical Practice and Quality Improvement workgroup reviews a sample of attempted VAVDs quarterly to ensure appropriate selection of candidates and complete documentation c. Unit statistics regarding VAVD are compiled and reported at least annually to the OBGYN and Quality departments

REFERENCES 1. ACOG Committee Opinion No. 687: Approaches to limit intervention during labor and birth. Obstet Gynecol (2017); 129:e20-8. 2. ACOG Obstetric Care Consensus No. 1: Safe prevention of the primary cesarean delivery. Obstet Gynecol (2014); 123:693-711. 3. ACOG Practice Bulletin #154: Operative vaginal delivery (2015; reaffirmed 2019). Retrieved Jan 31, 2020 from https://www.acog.org/-/media/Practice- Bulletins/Committee-on-Practice-Bulletins---- Obstetrics/pb154.pdf?dmc=1&ts=20200131T1813004432 4. Elsevier Skills: Vacuum extraction delivery (Maternal-newborn) (2019). Retrieved Feb 6, 2020 from https://point-of-care.elsevierperformancemanager.com/skills/1123/extended- text?skillId=MN_024 5. UpToDate: Operative vaginal delivery (2019). Retrieved Jan 31, 2020 from https://www.uptodate.com/contents/operative-vaginal- delivery?search=vacuum%20assisted%20delivery&source=search_result&selectedTitle= 2~63&usage_type=default&display_rank=2

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6. UpToDate: Procedure for vacuum-assisted operative vaginal delivery (2019). Retrieved Jan 31, 2020 from https://www.uptodate.com/contents/procedure-for-vacuum-assisted- operative-vaginal- delivery?search=vacuum%20assisted%20delivery&topicRef=4474&source=see_link

APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A N/A 3/2020 Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 4/2020 N/A N/A Council (CPC) Medical Executive Date: N/A N/A 04/2020 Committee Board of Trustees Date: N/A N/A

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FEMA OAKLAND URBAN SEARCH AND RESCUE TASK FORCE

Department Pharmacy Effective Date 05/1995 Campus Highland Hospital Date Revised 01/2020 Category Clinical Next Scheduled 06/2023 Review Document Director of Pharmacy Executive Chief Administrative Officer/ Owner Responsible Chief Nurse Executive Printed copies are for reference only. Please refer to electronic copy for the latest version.

POLICY Alameda Health System (AHS), Highland Campus pharmacy will supply pharmaceuticals to the Federal Emergency Management Agency (FEMA), California Emergency Management Agency (Cal EMA), and Oakland California Task Force-4

PROCEDURE 1. The FEMA Oakland Urban Search and Rescue CATF-4 will provide to the Director of Pharmacy or designee a list of emergency medications to be immediately available for deployment by the Oakland CATF-4 when mobilized by FEMA or when conducting training except as follows: a. Any medications or central supply items listed which could not be returned to AHS for re-issue due to refrigeration or sterility will not be issued for training exercises. b. Narcotics will not be issued for training exercises. 2. CATF-4 “Medical Specialist” will immediately call Highland pharmacy, (510) 437-4222, and request that the attached list of medications and central supplies be made available when the CATF-4 is being mobilized by FEMA or conducting training that will require the use of the medical cache. 3. Upon receiving a call from FEMA Oakland US&R Task Force for activation, the AHS pharmacy staff will order the FEMA cache from the wholesaler. The wholesaler will fill all the medications on the FEMA list EXCEPT for CIIs. CII medications on the list will be provided by Highland pharmacy. 4. Pharmacy staff will provide highest priority to CATF-4. 5. The Wholesaler will deliver the medications within 4-5 hours from when the order is placed.. 6. CATF-4 “Medical Specialist” will pick up the medications. Pharmacy will obtain the IV fluids from central supply if necessary.

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7. CATF-4 Medical Specialist below receiving the supplies must show a pictured Task Force ID (either MD or EMT-P) and sign for all items received.

NAME POSITION TEAM McPartland, David Team Manager RED Ho, Jeff Medical Specialist RED Garcia, Salvador Medical Specialist RED Gray, Geoff Medical Specialist RED Buell, Linda Lead Paramedic Team WHITE Manager Oftedal, Brian Medical Specialist WHITE Meineke, Ryan Medical Specialist WHITE McCarthy, Joe Medical Specialist WHITE Chase, Loren Medical Specialist WHITE Gray, Geoff Paramedic Team Manager BLUE Mahar, Paul Medical Specialist BLUE Bartlow, Todd Medical Specialist BLUE Gonzales, Bruno Medical Specialist BLUE

8. A pre-written narcotic order signed by CATF-4 physician below will be on file in the pharmacy to be filled when the CATF-4 is mobilized by FEMA or Cal EMA. Pre-signed DEA-222 by the CATF-4 physicians (minimum of two DEA 222 forms) will be kept in the outpatient CII safe. The pharmacist filling narcotics will complete the DEA-222 form. The narcotic order will be dated on the date of mobilization. NAME DEA CA LICENCE PHONE NUMBER NUMBER Chilcott, Marisha BL7442356 A88901 925-370-5973 Jayasekera, Neil BJ4639689 A054573 510-290-8306 Peterson, Bill BP0364428 G56798 707-480-6113 Pramanik, Rajiv FP0645107 A83452 415-533-7497 Reilly, Brenda BR7697711 A7051897 925-408-2652

9. At the conclusion of any CATF-4 drill or deployment, AHS will accept the return of all emergency medications and central supply items that both parties (AHS and CATF-4) agree are reusable. 10. CATF-4 will pay for all used and non-returnable items received from AHS. Pharmacy buyer will create an invoice within three weeks and follow up on the status with Paramedic Team Manager at (510) 615-5872

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APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A N/A 01/2020 Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 03/2020 N/A N/A Council (CPC) Medical Executive Date: N/A N/A 04/2020 Committee Board of Trustees Date: N/A N/A

Page 3 of 3 Alameda Hospital

WOUND VAC (VACUUM ASSISTED CLOSURE) HEALING SYSTEM PROTOCOL

Department Nursing Administration Effective Date 10/2006 Campus Alameda Hospital Date Revised 08/2016, 03/2020 Category Clinical Next Scheduled 08/2019, 06/2023 Review Document Director of Nursing Executive Vice President, Patient Care Owner Responsible Services Printed copies are for reference only. Please refer to electronic copy for the latest version.

PURPOSE To outline nursing management of the patient using a VAC System

POLICY To promote safe and effective wound VAC therapy.

PROCEDURE Content: Equipment and Supplies: 1. From Central Services. a. VAC Machine with drain canister. b. Obtain special bed if ordered. c. Appropriate size sponge (black) small, medium, large, extra large. d. Tubing (T.R.A.C.™ pad) has tubing with drape attached. e. 3-way connector if needed. f. Extra drape material. g. Extra drain canister.

2. From Unit. a. Scissors. b. Pad protector (towels, chux, linen). c. Gloves, non-sterile. d. Measuring devices, cotton tipped applicators. e. Plain paper to draw initial shape of wound. f. 35 ml syringe. g. NS to irrigate. h. 4 x 4 dressings. i. Skin prep.

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Initial Procedure: 1. Measure wound length, width, depth. a. 12 o'clock head. b. 3 p.m. right side. c. 6 p.m. foot. d. 9 p.m. left side.

2. Check for tunneling, undermining. a. Use cotton applicator to measure depth, tunneling and/or undermining.

3. Draw initial picture of wound shape, including tunneled or undermined areas. a. Make extra copies of wound picture without measurements. These are for staff following you. b. Make copy of wound picture with measurements as a guide. c. Each dressing change staff measure wound again and indicate new measurements on wound picture as wound heals.

4. Put initial wound pattern on clipboard.

Dressing Procedure: 1. Dressing change frequency to be every 48 hours, or Monday/Wednesday/Friday.

2. Medicate patient for pain ½ hour prior to start of dressing change.

3. Instill 35 ml normal saline (NS) to loosen old sponge.

4. Turn VAC machine off, clamp canister and dressing tubes.

5. Remove occlusive drape by holding patient's skin with one hand and gently peeling off dressing with other hand.

6. Gently loosen all sponge(s) and remove - make sure all foam is out of tunneled and undermined areas.

7. Remove used tubing.

8. Cleanse wound - use NS or other as per MD order.

9. Measure wound and use new clean picture guide for labeling.

10. Cut sponge to size of wound. a. Make sure to cut sponge away from wound to keep smaller pieces from falling into wound.

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11. Placing sponge(s) in wound(s). a. For larger wounds use more than 1 sponge, or sponge pieces. b. May need to cut lengthwise sponge pieces to fit undermined areas c. Place sponge(s) in wound. d. Apply skin prep to intact skin to protect against skin tears. e. Cut occlusive drape appropriate size to cover foam dressing and to cover 3 – 5 cm of intact skin. Trim drape as needed. i. Remove white backing line (labeled 1) and place drape on foam. ii. Remove top support layer (labeled 2). iii. Pat around drape to ensure an occlusive seal. Seal is more important than dressing appearance. f. To secure tube: i. Choose a location to apply the tubing. ii. Cut a hole through the drape, approximately 2 cm in diameter, leaving the foam intact. g. An alternate way is to cut a 2 cm diameter hole into the drape before you lay it on the foam.

NOTE: Very important to cut a complete hole, not a slit, in the drape, as a slit may not allow fluid to pass through the drape, which results in a blockage alarm.

h. Remove backing liner (labeled 1) from T.R.A.C Pad. Place the pad on the drape with the hole in the center of the pad elbow, directly over the hole in the drape. i. Gently pat around the T.R.A.C Pad to ensure complete adhesion j. Remove support layer (labeled 2). k. Remove blue handles from the drape and the T.R.A.C Pad where applicable.

Before Starting VAC Machine: 1. Connect canister tubing to dressing tubing.

2. Unclamp both dressing and canister tubes if clamped.

3. Turn machine on and check for seal as follows: a. Black foam sponge flattens in wound. b. No air leaks around dressing or tubing. c. No hissing sound. d. Press lightly on foam edges and tubing drape with fingers. e. If necessary use draping material to seal up edges and tubing leaks.

4. For more than one wound: a. Same procedure as for one. b. Connect both tubing's to 3-way connector. c. Then connect canister tubing to 3-way connector.

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5. Fill the deficit. a. Protect the periwound/tissue. b. Maintain a seal.

Using the Machine: 1. Place therapy unit on footboard of bed. a. The unit can also be hung from an IV pole using the integrated IV pole clamp located on the back of the unit. Always operate the unit in upright position.

2. Attach power cord to the VAC ATS unit and connect to power supply.

3. Turn unit on by pressing the green power on switch above the power cord.

4. Alarms if and what to do about them: See Attachment V.A.C. ATS Alarm Types.

5. Canister installation: a. Slide canister into the canister port (A) until an audible click is heard ensuring that the canister is fully inserted. b. Connect the 2 halves of the TRAC connector (C) together by twisting until it locks in place. c. Verify that both clamps are open. d. Turn therapy on.

NOTE: If unit tips over and continues to alarm, the drainage may have covered the inside filter and unit will register as having full canister even if not full. Change canister even if not full. Change canister as above and turn therapy on.

6. Canister removal: a. Turn therapy off. b. Close clamps on canister and dressing tubing. c. Twist T.R.A.C connector to disconnect canister tubing from dressing tubing. d. Press canister release button (on front of machine), then pull out canister. e. Dispose of canister according to hospital policy regarding biohazard waste.

7. Transportation of the unit or disconnecting from the unit for greater than 15 minute periods: a. Turn Therapy OFF. b. Turn Power OFF (green button). c. Clamp tubing. d. Disconnect. e. To start unit again, repeat steps A through E.

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8. Selecting wound suction therapies: a. Press therapy buttons to select therapy screen. b. Select level of negative pressure. i. Use arrow keys to increase or decrease therapy levels between 50 and 200mm Hg as per physician order. The unit is set at a default negative pressure of 125mm Hg. c. Select continuous or intermittent. i. Selecting intermittent shows you the intermittent screen. • The default setting is set for 5 minutes on and 2 minutes off. • Use the arrow keys to increase or decrease interval times between 1 and 10 minutes in accordance with MD orders. • Press exit to confirm selection and return to therapy screen. d. Select intensity level: The intensity level is the rate of negative pressure at the wound site in mm Hg per second. i. The lower the intensity level, the more gradual the negative pressure increases to the desired setting. ii. This option is especially useful for patient’s who may experience pain during initial pull down and release of foam, especially during intermittent therapy. iii. The intensity option ranges from 10 -50 mmHg in increments of 5. The default setting is 10. It is recommended that new patients start at default (10) setting and increase gradually to patient tolerance and needs. iv. The intensity can also remain at the minimum setting throughout the entire length of treatment to enhance patient comfort. v. Use the arrow keys to increase or decrease pressure at the wound site. This should be adjusted in accordance with varying wound conditions, patient tolerance and at the discretion of the physician. vi. Press exit to return to therapy screen.

Documentation: 1. In nurses' notes under "Skin Integrity Protocol". a. Appearance of wound including surrounding skin area. b. Size of wound. c. Amount of wound suction drainage. d. Response of patient to dressing change.

2. Pictures taken: a. Every week on Wednesday if that is day of dressing change, otherwise once per week. b. Label with area, date of picture, medical record number. c. Put picture in skin section taped to blank "Doctors Progress Notes"

3. Individualized Plan of Care on Kardex. a. Size of sponge dressing: small, medium, large, extra large. b. Draw appropriate shape of wound for cutting of sponge. c. Whether 3-way connector is needed for 2 or more wounds. d. Which day dressing is to be changed.

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APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 08/2020 N/A Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 03/2020 N/A N/A Council (CPC) Medical Executive Date: N/A 04/2020 N/A Committee Board of Trustees Date: N/A N/A

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ADVANCED PRACTICE: CERTIFIED REGISTERED NURSE ANESTHETIST STANDARDIZED PROCEDURES/PRACTICE PREROGATIVES: DEPARTMENT OF ANESTHESIA

Department Anesthesia Effective Date 06/2020 Campus AHS System Date Revised 06/2020 Category Clinical Next Scheduled 06/2023 Review Document CRNA Executive Associate Chief Medical Owner Responsible Officer; Chief Medical Officer Printed copies are for reference only. Please refer to electronic copy for the latest version.

I. INTRODUCTION The following are the policies and guidelines for the care provided to the patients by Certified Registered Nurse Anesthetists (CRNAs) in the AHS Department of Anesthesiology. This establishes the legal authority for CRNAs to perform certain functions and procedures within the Department.

These standardized procedures were developed collaboratively and approved by the Interdisciplinary Practice Committees whose membership includes physicians, advanced practice providers, nurse anesthetists, nurses, and administrators, and are in accordance with the Nurse Practice Act in the California Business and Professions Code: Chapter 6, Article 2; The Nurse Anesthetist Act in The California Business and Professions Code: Chapter 6, Article 7, Section 2825-2833.6; The California Administrative Code: Title 16, Division 14, Article 7; and California Code of Regulations Title 22, Section 51240 (Medi-Cal).

Copies of the signed standardized procedures will be kept in an operational manual in the offices of the Department of Anesthesiology, and on file in the Medical staff office. Standardized procedures will be reviewed every 3 years.

II. DEFINITIONS 1. “Certified Registered Nurse Anesthetist” by definition shall be: a. Currently licensed as a Registered Nurse by the California Board of Nursing, and: b. In compliance with the following certification requirement: i. Current certification as a Certified Nurse Anesthetist by the National Board of Certification and Recertification of Nurse Anesthetists (NBCRNA). 2. “Graduate Registered Nurse Anesthetist” by definition shall be: a. Currently licensed as a Registered Nurse by the California Board of Nursing, and: b. In compliance with the following certification requirements:

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i. Successful completion of the training requirements for certification; and has applied for the certification examination, and is not more than one year from the date of graduation from their CRNA training program. ii. Failure to obtain certification within the twelve (12) month following graduation from their CRNA training program will be deemed an automatic resignation from the AHS Staff. iii. A Masters of Nurse Anesthesia may, or may not, be required as a prerequisite as per current AHS bylaws and date of hire. However, the CRNA will continue to qualify for Re-Certification during every renewal period.

3. “Supervising Physician” shall be a physician-anesthesiologist, or anesthesiologist-in- charge, who is a current member in good standing of the Medical Staff, and assigned to a particular patient or operating room, along with a CRNA, by the Departmental Anesthesiologist-in-Charge (AIC).

4. “Anesthesiologist-in-Charge (AIC)” shall be the physician-anesthesiologist within the Department whom is responsible for all clinical and operational issues within the department when the Chair and Vice-Chair are unavailable. They are also responsible for clinical assignments of all staff members for the current and following day. Supervising physician anesthesiologists, and CRNAs, report up to the AIC within the departmental chain of command. Refer to Departmental Job Description for AIC/Trauma anesthesiologist for more information.

5. “Sponsoring Physician” In accordance with the Hospital Bylaws, the Chair of the Department of Anesthesiology is ultimately responsible for adherence to this protocol and for the quality of care provided by departmental clinicians.

6. “Department of Anesthesiology” refers to all anesthetic services operating at AHS including inpatient surgery, outpatient surgery, endoscopy, labor and delivery, obstetric surgery, , critical care medicine, preoperative anesthesia clinic, neonatal and adult resuscitation, and emergency airway management.

III. APPLICATION 1. In addition to the general requirements set forth in Section 12 of the Hospital Bylaws and under Rules and Regulations, the following criteria shall specifically apply to any CRNA applying for privileges in the Department of Anesthesiology: a. Current licensure in good standing as a Registered Nurse and Nurse Anesthetist in the state of California. b. Current Certification by the NB-CRNA as a Certified Registered Nurse Anesthetist. c. Current Advanced Cardiac Life Support certification (ACLS) which includes Basic Life Support (BLS) by the American Heart Association. d. The Chair of the Department will review applicant qualifications. 2. Credentialing materials must be reviewed and approved by the Credentials Committee, Medical Executive Committee, and the Board of Trustees before the CRNA can provide care under a protocol. Credentials will be reviewed and renewed every two years.

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3. Before beginning practice, the CRNA will sign this procedure agreement with the Chair of the Department.

IV. CONDITIONS AND STANDARDS OF PRACTICE General Conditions 1. The CRNA shall render all care within the standards provided in this document.

2. The CRNA shall provide all care in accordance with the laws and regulations of the State of California, and with the Bylaws and Regulations of the Medical Staff (specifically Article VIII of the Rules and Regulations regarding dependent allied health practitioners), and the Department of Anesthesiology.

3. At no time shall the care rendered by the CRNA exceed the scope of licensure.

4. The CRNA agrees to work cooperatively and collaboratively with the supervising physician, AIC, nursing staff and other health professionals.

5. The CRNA shall immediately notify the Chair of the Department of Anesthesiology in the event that the practitioner’s professional license is revoked, limited, or otherwise affected by the action of the Federal or State Health Care Agency, or in the event that he/she receives any notification of investigation of his/her professional license.

V. FOCUS PROFESSIONAL PRACTICE EVALUATION (FPPE), PROCTORING, & REPORTING STRUCTURE 1. Focused Professional Practice Evaluation (FPPE) / Proctoring is a process which is intended to optimize patient safety and quality care. Routine evaluation: Each CRNA is directly observed providing patient care by the supervising anesthesiologist until the level of performance is determined to be satisfactory. The routing FPPE/Proctoring plan is outlined on the CRNA privilege form. Once all elements of the FPPE/Proctoring is complete, the outcome of the FPPE will be recorded in the confidential Quality section of your credentials file (maintained by the Medical Staff Office).

2. Once the basic competency of the CRNA has been established, advanced skills proctoring may be initiated. In the advanced skills proctoring, CRNAs will be directly supervised and signed off for each skill.

3. Each patient cared for by the CRNA will be presented to the supervising anesthesiologist, and final anesthesia charts and procedures signed / attested per EPIC.

4. The Chair of the Department of Anesthesiology or his/her designee will follow standard new hire probationary guidelines.

5. CRNA performance oversight is connected with Nursing Leadership, as well as to the Chair of the Department of Anesthesiology. When anesthesia is administered by a CRNA, it is

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recognized as the practice of nursing. Performance evaluation criteria for CRNAs are reviewed annually by Nursing Leadership, in collaboration with the Chair of the Department of Anesthesiology, to assure practice standards remain current, and performance concerns are addressed jointly.

VI. SCOPE OF PRACTICE Authorized Duties and Practice The CRNA is a clinical member of the Department of Anesthesiology, and is authorized to perform the following patient-related activities within the scope of practice defined by Title 16 of the California Administrative Code. However, Per AHS Article VIII of the Allied Health Professionals Rules and Regs, CRNAs’ licensure or certification does not permit, and/or the Medical Staff and Board of Trustees does not authorize, the independent exercise of clinical privileges. Rather such privileges are to occur only under anesthesiologist supervision, through delegation, and/or through the use of protocols or standardized procedures. The supervising anesthesiologist is overall responsible for the perioperative care of each patient. 1. Take the patient’s medical history and perform a focused physical examination.

2. Order specific laboratory, radiographic, and cardiac studies as appropriate for the patient.

3. Collect specimens, perform and interpret pertinent point of care tests as indicated.

4. Perform any anesthetic/nursing procedure for which he/she has been granted privileges.

5. Counsel and educate patients and their families on health promotion and anesthetic management options.

6. Manage perioperative and anesthetic conditions as needs arise, in collaboration with the supervising anesthesiologist.

7. Timely communicate important anesthetic and surgical events to the supervising anesthesiologist, including, but not limited to, induction of anesthesia, airway management, neuraxial blockade, peripheral nerve blocks, placement of invasive monitors, shock states (e.g.- hemorrhagic shock, anaphylactic shock, etc.), OR fire, malignant hyperthermia, emergence events (e.g.- laryngospasm, severe delirium, etc.). If the supervising anesthesiologist cannot be located or is unavailable, the AIC shall be contacted.

8. Have anesthesia records and procedure notes document, and attested/co-signed, by the supervising anesthesiologist, per EPIC.

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Per The American Association of Nurse Anesthetists (AANA) and American Association of Anesthesiologists (ASA): 1. Perform and document a thorough pre-anesthesia assessment and evaluation.

2. Obtain and document informed consent for the planned anesthetic intervention from the patient or legal guardian, or verify that informed consent has been obtained and documented by a qualified professional.

3. In collaboration with the supervising anesthesiologist, formulate a patient-specific plan for anesthesia care.

4. Implement and adjust the anesthesia care plan based on the patient’s physiologic status. Continuously assess the patient’s response to the anesthetic, surgical intervention, or procedure. Intervene as required to maintain the patient in optimal physiologic condition.

5. Monitor, evaluate, and document the patient’s physiologic condition as appropriate, as per the ASA monitoring, NPO status, and ASA related guidelines, for the type of anesthesia and specific patient needs. When any physiological monitoring device is used, variable pitch and threshold alarms shall be turned on and audible. The CRNA should attend to the patient continuously until the responsibility of care has been accepted by another anesthesia clinician within the Department. a. Oxygenation: Continuously monitor oxygenation by clinical observation, pulse oximetry and fraction of inspired oxygen (FiO2). If indicated, monitor oxygenation by arterial blood gas analysis. b. Ventilation: Continuously monitor EtCO2 ventilation. Verify intubation of the trachea or placement of other airway devices by auscultation, chest excursion, and confirmation of EtCO2. Use ventilatory pressure monitors as indicated. Continuously monitor EtCO2 during controlled or assisted ventilation and any anesthesia or sedation technique requiring airway support. c. Cardiovascular: Continuously monitor cardiovascular status via electrocardiogram. Perform auscultation of heart sounds as needed. Evaluate and document blood pressure and heart rate at least every five minutes. d. Thermoregulation: The CRNA will have readily available, within the anesthetizing location, devices to monitor perioperative temperature. e. Neuromuscular: When neuromuscular blocking agents are administered, monitor neuromuscular response to assess depth of blockade and degree of recovery and reversal. f. Positioning: Monitor and assess patient positioning and protective measures, except for those aspects that are performed exclusively by one or more other providers (eg- attending surgeon). g. Adequacy of Anesthesia and Analgesia: Monitor level of consciousness, hypnosis, and pain control for patient comfort and safety appropriate for the related procedure.

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h. Global Anesthetic Assessment: Continuous clinical observation and vigilance are the basis of safe anesthesia care. Consistent with the CRNA’s clinical judgment, additional means of monitoring the patient’s status may be used depending on the needs of the patient, the anesthetic being administered, and/or the procedure being performed.

6. Document pertinent anesthesia-related information on the patient’s medical record in an accurate, complete, legible, and timely manner.

7. Evaluate the patient’s status and determine when it is safe to transfer the responsibility of care. Accurately report the patient’s condition, including all essential information, and transfer the responsibility of care to another qualified clinician in a manner that assures continuity of care and patient safety.

8. Adhere to appropriate safety precautions as established within the practice setting to minimize the risks of fire, explosion, electrical shock and equipment malfunction. Based on the patient’s overall health status, surgical intervention or procedure, ensure that the equipment reasonably expected to be necessary for the administration of anesthesia has been checked for proper functionality and document compliance. When the patient is ventilated by an automatic mechanical ventilator, monitor the integrity of the breathing system with a device capable of detecting a disconnection by emitting an audible alarm. When the breathing system of an anesthesia machine is being used to deliver oxygen, the CRNA should monitor inspired oxygen concentration continuously with an oxygen analyzer with a low concentration audible alarm turned on and in use. Should any anesthesia related equipment be deemed inoperable or compromised by the CRNA, the CRNA shall have such equipment replaced to allow for safe delivery of patient care.

9. The CRNA shall freely and openly “stop the line” during patient care delivery when an unsafe issue is observed, to protect patients and staff members from harm.

10. Adhere to infection control policies and procedures as established within the practice setting to minimize the risk of infection to the patient, the CRNA, other healthcare providers, and contamination of anesthesia equipment.

11. Participate in Departmental ongoing review and discussion of anesthesia care delivery to assess quality and appropriateness.

12. Respect and maintain the basic rights of patients and their families.

VII. EMERGENCY CARE The CRNA may perform life-sustaining measures whenever necessary. This includes, but is not limited to, emergency airway management and related interventions found in the American Heart Association’s (AHA) Advanced Cardiac Life Support (ACLS). The CRNA must timely communicate with the supervising anesthesiologist in all emergency situations after initial care

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has been started. If the supervising anesthesiologist cannot be located or is unavailable, the AIC shall be contacted.

VIII. DRUG DISPENSING AND ORDERING The State of California does not grant DEA prescriptive authority to CRNAs. Anesthetic agents administered in the perioperative period are dispensed, not prescribed. This is part of CRNA scope of practice and serves as the basis for CRNA practice with or without prescriptive privileges. CRNAs at AHS will select, dispense, administer, and order medications associated with the administration of anesthesia. This includes Post Anesthesia Care Unit orders and Pain Management orders beyond the initial procedure and recovery phase. The CRNA will timely and accurately document all dispensed narcotics on the anesthesia record, and follow pharmacy protocol and procedure for narcotic wastage.

IX. CLINICAL PROCEDURES FOR CRNA PRACTICE CRNAs at AHS will be granted the following privileges in accordance with their training, scope of practice, and individual proctoring assessment. Proctoring assessment is based on evaluation of the provider’s skills, abilities, and current competence to perform the requested privilege(s). Proctors are anesthesiologists assigned by the Chair of the Department.

Per Alameda Health System (AHS) Advance Practice Professionals (APP) Policy and Procedure Manual, CRNAs’ licensure or certification does not permit, and/or the Medical Staff and Board of Trustees does not authorize the independent exercise of clinical privileges.

Refer to the CRNA privileging and credentialing forms for a comprehensive list: 1. Moderate Conscious Sedation/Analgesia – Adult 2. Deep Conscious Sedation/Analgesia – Adult 3. Inhalation Anesthesia 4. Intravenous Anesthesia 5. IV Regional Anesthesia 6. Epidural Anesthesia 7. Subarachnoid Blockade 8. Peripheral Nerve Blocks +/- Ultrasound Guidance with interpretation 9. Double Lumen Tube Insertion / One lung ventilation 10. Endotracheal Intubation 11. Fiberoptic Endotracheal Intubation 12. Arterial Lines – peripheral 13. Central Venous Lines 14. Fluid / Electrolyte Management 15. Laryngeal Mask Airway Insertion 16. Fast Track LMA Insertion 17. Perioperative Monitoring

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Performance of procedures not included on this list to enhance safe patient care is at the clinical discretion of both the CRNA, and supervising anesthesiologist, after collaborative discussion of risks and benefits to the patient, for any procedure which the supervising anesthesiologist is privileged. For emergency / life-sustaining care, please refer to Section VII above.

X. STANDARD OF CARE Standards for adequacy of anesthesia related diagnosis, management, and treatment, shall be in accordance with AHS Policy and Procedure protocols, current evidence-based anesthesia practice standards of care (e.g.- as published by the ASA), Department protocols, or current texts/articles on the practice of anesthesiology.

XI. CONSULTATION AND REFERRAL CRNA will timely inform the supervising anesthesiologist, or AIC, for the following situations: • All conditions which have failed to respond to appropriate management • All conditions which do not follow classic diagnostic patterns • All conditions which do not follow clinical protocols or standardized procedures • Any significant unexplained physical or historical findings • All emergency situations after initial care • In situations where the patient expresses a desire to see a physician

XII. CRNA EDUCATION OF TRAINEES The CRNA shall engage in the education, both technical and non-technical, of trainees within the Department of Anesthesiology, via the structure set-forth within this document.

XIII. CRNA-PATIENT AND FAMILY COMMUNICATION Should the patient or family request an Anesthesiologist to provide full anesthesia care, notify the Anesthesiologist on the case and AIC so staffing arrangements can be amended.

XIV. SUPERVISING ANESTHESIOLOGIST RESPONSIBILITIES The supervising anesthesiologist agrees to: 1. Provide the CRNA with professional and collaborative supervision and support in accordance with the rules and regulations set forth by the Alameda Health System, to ensure a safe work environment for high quality patient care.

2. Provide timely consultation and/or assume management, when appropriately needed or requested. Will also communicate timely, and directly, to the CRNA, changes in clinical case assignments and staffing.

3. CRNAs, supervising physician anesthesiologists, and AIC will carry wireless communication devices (eg- pagers, cellular phones, etc) as a tool for timely, bi-directional, communication.

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4. Collaborate with the CRNA for cases or events undergoing QRC, IPPC, or other review or investigation, to facilitate fact-finding and an objective review process.

5. Cosign all anesthetic documentation according to AHS policy and EPIC co- signature/attestation requests.

6. Be physically and timely available according to the delegation of services agreement and authorization of services agreement.

7. Will adhere to the SEIU-Local 1021 (RN Unit) MOU agreement with regards to breaks either by themselves or via a delegated clinician within the Department.

XIV. AGREEMENT REVIEW The signature below acknowledges agreement to practice within the limits of the foregoing standardized procedures. Upon a two-year review, if changes are made, new signatures will be necessary.

Signed

______Certified Registered Nurse Anesthetist Date

APPROVALS

System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 06/2020 06/2020 Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 06/2020 N/A N/A Council (CPC) Medical Executive Date: N/A Committee Board of Trustees Date: N/A N/A

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