Nursing School Student Orientation

1-4-2021

1 Henry Ford Health System

• Founded by Henry Ford and opened in 1915 • HFHS includes multiple hospitals, medical centers, and a wide range of other health services • Henry Ford Hospital • Henry Ford Allegiance Health • Henry Ford Macomb Hospital • Henry Ford West Bloomfield Hospital • Henry Ford Wyandotte Hospital • Henry Ford Kingswood Hospital Welcome to Henry Ford Hospital

Our Mission To improve human life through excellence in the science and art of health care and healing.

Our Values HFHS Guide to World Class Service I encourage INNOVATION & CURIOSITY I will COACH & INSPIRE Continuously learn, ask questions, offer creative ideas Encourage each other to grow and develop; practice and challenge the status quo productive feedback I act with COURAGE I own SAFETY & HIGH RELIABILITY Behave authentically and risk vulnerability; speaking Embrace high standards to ensure excellence in care and from both the head and heart service I demonstrate INTEGRITY & TRUSTWORTHINESS I communicate with EMPATHY & TRANSPARENCY Honor commitments and confidentiality; deliver on Understand the thoughts and feelings of others; be open and promises honest I champion DIVERSITY & INCLUSION I ensure OUTCOMES & ACCOUNTABILITY Support an environment where all people thrive and Commit to achieving results through collaboration and succeed data-based decisions Culture of Caring

5 Policies and Procedures Nursing students & Faculty will adhere to HFHS standards, policies & procedures. These can be accessed from OneHENRY. HFHS Dress Code ID Badge must be worn and visible at all times • Both School ID badge & HFHS badge • HFHS employees cannot use their employee ID badge during clinical If a student forgets, loses or damages a HFHS badge • Notify the instructor • There is no admittance to the clinical unit with out a badge If a student leaves the clinical rotation or school, faculty must contact HFH badge office to deactivate badge. • ALL badges EVERY time must be returned to where they where obtained with in a week of last clinical day noted on ACEMAPP. • Deposit is forfeited if badges are not returned Nurse Dress Code • No open-toed shoes or cut outs i.e. crocs • No artificial nails; nails no longer than ¼ inch • Natural hair color and back off the shoulder • Jewelry • No bracelets • No more than one necklace • Maximum of two rings • Earrings may not hang more than 1 inch below lobe • Tattoos should be covered if possible. No offensive, vulgar or obscene tattoos are to be visible

8 Use of Scents and Colognes Acceptable • Use of deodorant & light, mild perfume or after-shave, light scented mouth wash • All clothing worn during the shift must be free of the odor of tobacco. Breath, skin, and hair must also be free from any scent of tobacco Unacceptable • Excessive or heavy scent of any kind either from poor hygiene, strong perfume, or any other scented personal products HFHS ID Badges

Badge and Badge Buddy • Badge is needed to leave some of the parking areas • Return to the instructor on the last clinical day • Students are not to return badges individually Badge Deposit • If badge is not returned by the end of clinical date noted in ACEMAPP, deposit will be forfeited • Badges are returned every semester after every clinical both student and instructor. A new deposit is required every semester. Guidelines

• Students must be introduced to patients • Name and School are to be on the white board in room. • Patients have the right to refuse care from any student • Includes observation • Each patient assigned to a student must also have a staff RN assigned • Students can not print/make copies of any medical records • This is a breach of security and confidentiality and may result in the loss of school privileges at HFH. Reporting Responsibilities Report to the patient’s RN at the beginning of the shift Receive report from the patient’s RN • Identify student’s role in assigned patient care Report to patient’s nurse and instructor • All new abnormal findings • Changes in patient condition • One half hour before leaving the unit • Patient status update at least every 2 hours Always leave a contact number • Provide end of shift report with up to date patient status to the patient’s RN prior to leaving the unit Student Documentation

All Students must complete a one-time scheduled 4-hour EPIC training All student documentation must be co-sign by instructor Students can NOT • Witness consents • Print or make copies of any part of the electronic medical record or hard chart for any reason Nursing Care Students can perform the following tasks ONLY with Clinical Instructor Supervision • Change IV tubing • Maintain IV line • Change & flush central line with direct observation • Perform blood glucose test • Direct Clinical Instructor observation • Clinical instructor badge • Documentation Nursing Care (continued) Students CANNOT perform the following:

• Perform phlebotomy or start IV’s • Perform ECG’s • Administer IV push medications • Give Respiratory treatments • Administer Chemotherapy • Adjust or discontinue alarms • Administer and/or hang blood or • Remove PICC or central line catheters blood products • Provide care to a patient requiring an N95 • Titrate drips mask • Accept telephone orders • Witness Consents

15 Remember the Basic Rights

• Right patient • Right drug • Right dose • Right route • Right time • Right documentation

16 Medication Administration HFHS unit RN’s cannot substitute for the RN Clinical Instructor • ONLY RN Clinical Instructors are approved to access the Pyxis medication system and remove medication • RN Clinical Instructors MUST be present when administering medications. • EVERY medication & order must be double checked by faculty & co-signed by faculty at time of administration • The student must SCAN the patient armband and SCAN the medication barcode before administering medication • Exception: if the student is in a management/leadership course and partnered with a Staff RN, the Staff RN will double check and co-sign all medications in EPIC Medication Administration Record (MAR) • Document in Epic/Co-signed by RN Clinical Instructor • Patient Header: Note allergies highlighted in bright yellow • Review the “Start/Stop” Date & Time MAR • All medications must be scanned with the bar code scanner prior to administration. • The current time will be reflected in the “time filed” of the medication administration window. • Ensure all fields are correct then Click “accept” (your signature) box will appear for instructor to place his/her dual signature at that time. MAR • Discontinued meds will appear highlighted in yellow on the MAR in the Electronic Medical Record (EHR) • When a range medication is ordered (ex. 1-2 tablets), document how many were given • If more than one tablet/vial is given you must scan both packages to satisfy total dose SAFETY Safety • Plain Language Emergency Codes • Rapid Response Team • Patient Identification • Patient Hand Off • Infection Control • Restraints • Fall Risk Plain Language Emergency Alerts

The illustration on the right displays the new Plain Language Emergency Alerts that replaces the Color Codes. For additional details, please Click Here. Role in an Emergency Be familiar with the Plain Language Emergency Alerts and the responsibilities Student • Report to your Clinical Instructor • Follow instructions from Clinical Instructor & follow unit protocols • Know evacuation plan and where emergency equipment is kept on your unit • Return to your unit if not on unit Clinical Instructor • Report to the charge nurse for further instructions • Gather all students to provide guidance with role responsibilities Rapid Response Team (RRT)

• Always report patient changes to the patient nurse; no matter how small • Provides clinical support to the General Practice Unit nurse in caring for patients identified to be physically deteriorating • Purpose is to decrease morbidity and mortality through early and aggressive intervention • 24 hour coverage, 7 days a week RRT Criteria

• Respiratory Distress- increase in oxygen • Tachycardia with heart rate > 130 requirements to 50% Venturi mask, • Bradycardia with heart rate < 60 labored breathing, restlessness, lethargy, use of accessory muscles, respiratory rate • Seizures new, prolonged or repeated < 10 or > 30, decrease in pulse oximetry < • Acute mental status changes 90% or significant deviation from baseline • Acute stroke signs • Blood Pressure- SBP > than 180 or SBP < Any condition that warrants concern than 90, or any significant deviation from • and does not meet above criteria baseline • Chest pain Predictive Model: Deterioration Index

27 What is the Deterioration Index (DI)? • The Patient Deterioration Index (DI) predictive model is an auto calculation composed of 125 data elements that includes demographics, vital signs, lab results, and assessments and can identify with a high level of accuracy, patients at low, medium or high risk for an adverse event or mortality. • DI is not intended to replace clinical judgment • DOES NOT replace Stroke Alert, Sepsis Alerts, or Rapid Response Triggers

28 What is the Deterioration Index (DI)?

• Deterioration Index score automatically recalculates a score every 20 minutes based on documentation • Includes: Observation and General Practice Unit patients 18 years and older

29 What are the Deterioration Index Demographics (DI) components? • Age (in years) Vital Signs (most recent in last 72 hours) • Systolic Blood Pressure • If the values are outside of the • Temperature normal range, the components • Pulse • Respiration Rate are added as a percentage into • SpO2 the Deterioration Index algorithm Nursing Assessments (most recent in last 72 hours) to result in an overall score • Glasgow Coma Score • Abnormal Neurological Assessment • Abnormal Cardiac Rhythm • On Oxygen Lab Results (most recent in last 72 hours) • Hematocrit • WBC • Potassium • Sodium • Blood pH • Abnormal Platelet Count • Abnormal BUN

30 Goals of the Deterioration Index

• Decrease • Unexpected deaths or significant safety events • Code blues

• Increase (metric/monitors) • Number of calls/consults to Rapid Response (Rescue Metric)

• Supports proactive interventions • Improves the quality of patient observation and monitoring • Improves communication within the multidisciplinary team

31 Difficult Airway Team Patient will have WHITE AIRWAY arm band and an Airway sign placed over head of bed • Instruct patient not to remove until arriving home • When a patient can not be intubated with direct laryngoscopy Patients at risk • Inability to visualize glottis opening • Angioedema, severe allergic reactions • Cervical mobility compromised • C-collar, cervical spinal surgery, ankylosing spondylitis • Tracheal abnormalities • Tracheal stents, radical neck surgery Patient Identification All patients must wear a HFH ID band at all times • MUST remain on for the duration of the hospital stay • Remove any non-HFH patient ID bands • ID band components • Last name & First name • MRN – medical record number • Gender • Date of Birth • Barcode for scanning Patient Identification All HFHS employees, students, and faculty are REQUIRED to check patient identification prior to any of the following: • Medications • Procedures • Specimen collection • Treatments Missing ID band Transport of tests/specimens • Notify Instructor • • Notify Staff RN • Discharge • Staff RN only able to replace Two patient identifiers are REQUIRED • First & last name • MRN Color Features of Patient Bands

IF color coded patient alert wrist bands are utilized, the following colors are to be used:

RED - Allergy YELLOW - Fall Risk PURPLE - Do-Not-Attempt-to- Resuscitate (DNAR) PINK - Limb alert WHITE - AIRWAY” in black print difficult to intubate patient Patient Identification

• Always use 2 identifiers • Match the ID band to the chart, order, label, • Match the last name and first name • Match the medical record number (MRN) • Ask the patient, • “May I see your identification band?” • “ Please tell me your name and date of birth.” • Compare the name and MRN to the document you have such as the lab tag or EKG request IPASS with SAFETY

A process to convey important information about a patient’s care when transferring care responsibility, from one caregiver to another, that includes an opportunity to ask and respond to questions.

This process is always completed at every change of shift. IPASS with SAFETY Nurse’s Benefit Patient’s Benefit • Increases accountability as nurses include • Patient meets/introduced to patient in his/her plan of care oncoming nurse • Increases accuracy of information between • Patients and families are part of shifts the Plan of Care (POC) • Increases positive feedback on HCAHPS • Reduces patient anxiety • Pain control • Promotes trust in the care team • Nurse to patient communication • Nurse communication IPASS with SAFETY Completed before entering Patient’s room Completed at the Patient’s bedside Illness Severity: Review Patient Status Stand at the bedside: Introduce the oncoming RN Patient summary: Admission & medical history Assess your patient: Pain, IV, meds, skin, O2 Action list: Tasks to finish during RN shift Fall risk: See Hester Davis Assessment Situational awareness: Therapy and treatments Notify your patient -not necessarily ‘orders’; family/patient Explain plan of care: Review schedule with patient preferences Try to involve your patient: Answer any patient Synthesis of receiver: Review/Repeat back to questions off-going RN Y Why: Ask patient if there are any questions Ticket to Ride

• Ticket to Ride is a communication tool • Used to transport the patient from unit to unit and back • Printed from Epic and placed in the chart • Requires signatures of the RN and transporter Infection Control • Standard Precautions are required for all patients • Before entering a room read the isolation precautions sign carefully and put on appropriate personal protective attire and equipment • Wash hands before and after entering room • Student may NOT provide care to patients in isolation that require a N95 Mask • Read all isolation signs for directions Medical Waste • Be aware of the Regulated Medical Waste Handling and Disposal Guidelines • Students and instructors should not handle chemotherapy agents, blood products or their waste • Any material that is soaked or saturated with, or contains blood or other potentially infectious material • Heavily Saturated Bandages, Gauze and Personal Protection Equipment • Suction Canisters after contents are solidified • Blood Filled Tubing • Blood Transfusion Bags Medical Waste – Red Bag Waste NO other trash should be in this bag • Don’t over fill red waste bags • Only Fill 50% to 75% full • Only 3 suction canisters to a bag • Lancets are to be placed in a sharps container not a bag • Always tie the bag • Place in red labeled bio tub, bio cart or bio hamper • Never put red bags or sharps down a trash chute • If any medical waste is noticed in a clear bag, that clear bag should be treated as medical waste and disposed of in a red bin in the soiled utility room Medical Waste Sharps

Dispose of materials in an approved sharps container • Syringes & needleless syringes • Lancets & scalpels • IV Needles & IV spike chambers • Broken glass or glass vials • Surgical blades • Disposable scissor • DO NOT RE-CAP used needles Exposures If you experience a needle stick or Blood/Body Fluid Exposure • Obtain first-aid first • Notify Clinical Instructor • Clinical Instructor must report exposures to the manager • Complete exposure report form (Radiologic-online form) • Follow up in employee/occupational health Reusable Items All linen • Doesn’t matter if it is soiled or bloody (double bag) • Place in linen chute or collection area • NEVER place in trash or red bag Pillows & bed liners • Regularly cleaned and disinfected • Never throw them away Restraint Policy for Management of Non Violent-Non Self Destructive and Violent-Self Destructive Patients Restraint Alternatives Only use restraints when alternative methods are unsuccessful

• Environmental modification • Behavioral modification • Lighting • Frequent re-orientation • Bedside commode • De-escalation techniques • Call light within reach • Diversional Activities • Therapy modification • TV, Radio, someone to talk with, • Investigate reason for confusion reading to the patient • Evaluate alternative forms of • Social Diversion-Family members may patient behavior management be invited to stay with patients or patient safety assistants Restraint Types

Non-violent/Non-Self-Destructive Violent/Self-Destructive • Use to support medical healing • Used if the patient’s mental, emotional or • RN assessment every 2 hours behavioral condition places them at • Must have a physician order with a face imminent risk of endangering the life or well to face assessment within 24 hours being of themselves or others • Restraint orders must be renewed • Continuous monitoring at bedside every calendar day • Document patient checks every 15 minutes • Every other order must be a face- • RN assessment every 1 hour to-face physician order • Face-to-Face Assessment required within 1 hour of application • New order required every 4 hours Nursing Assessment

Prior to applying restraints, nurse assessment will involve: • Neurological • Respiratory • Circulatory • Integumentary • Position • Pain Re-Assessment

• Evaluate whether the need for restraint is still present • Are less restrictive methods appropriate? • Discuss with patient’s RN and instructor Restraint Monitoring Evaluate • The physical and emotional well being of the patient and the continued protection of his/her rights and dignity Rounding every hour Document every 2 hours • Offer fluids and food • Check comfort of room - too warm/cold • Offer bathroom • Reposition (TAPS) • Check circulation • Perform range of motion on limbs Restraint Monitoring

Physical Restraints Adaptive/Supportive Devices

Lap/waist belts-that patient Lap belts-patient can remove cannot remove

Mittens of all types-whether Geri chairs-that patient can they are tied down or not release Types of Restraints Securing the Restraint Patients can be quickly released from the limb restraints in 2 ways

1. Can detach the Quick Release Buckles and Velcro on limb holder

2. Can detach the Quick Release Buckles on webbing loop attached to bed frame Hester Davis Fall Prevention Tool

56 Types of Falls Anticipated Physiologic Behavioral • Predictable and Preventable • Not predictable, not Preventable

Unanticipated Physiologic Developmental (learning to walk) • Not predictable, not Preventable • Not predictable, not Preventable • Only children and younger Accidental • Not predictable, Preventable

57 Hester Davis Fall Prevention Tool Asks for assessment on the following:

• Age • Toileting needs • Last known fall • Volume, electrolytes status • Mobility • Communication/ sensory • Medications • Behavioral • Mental status/ LOC/ Awareness

58 Fall Prevention

Hourly Rounding Assessment • 4 P’s (Pain, Personal Needs, Position, • On admission Possessions) • Transfers • Communication white board in each • Every 8 hours patient room • Change in patient’s condition • Engage patient and family in care plan • Provide Education to patient and family

Please review the Fall Risk Assessment located in the 2018 HD Tool Kit on OneHENRY. Fall Risk

Applies to all inpatients identified as high fall risk based on fall risk assessment tool. For Fall Risk Assessment Score greater than or equal to 4: • Place Fall Risk signage • Apply a Yellow Armband and Yellow Socks to the patient • Communicate high fall risk status during handoffs & Patient Care Rounds • Discuss and initiate a plan of care that addresses the identified fall risk factors Falls - What To Do • Notify Instructor and patient’s • Post-fall debrief with Nursing Unit nurse immediately Leadership • RN will assess the patient for • Review how/why fall happened injury • What could have prevented it? • After RN assessment, assist to the safest position • How to prevent another fall • Bed • Chair • On floor with blanket if further assessment is necessary Documentation Electronic Health Record

• Documentation will take place in EPIC • ALL documentation will be co-signed by Clinical Instructors • If the instructor has not completed EPIC, instructors can not cosign • The students CANNOT document if the instructor can not cosign. • ALL documentation should take place in REAL-TIME • Document when the task is done • Take a WOW into the room if possible and document Documentation Admission Process The entire admission process must be completed within 24 hours of patient’s arrival. If this is not possible, the RN must document “unable to complete” and indicate reason. • Admission vital signs within the first hour of arrival in REAL-TIME • Hester Davis Falls assessment : Identify the fall risk ASAP • Head-to-toe assessment with a height & actual weight within 8 hours of arrival • Documented under Patient Care Summary • Admission database • Documented under Admission Navigator • Plan of care Documentation Admission Navigator

Patient Profile “patients story” • Is a conversation with the patient. What language do they prefer? What specific needs do they have? What fears do they have about this hospitalization or their overall health? How can we individualize our care of this patient so it meets their needs? • Includes risk screenings. Review of Systems (ROS) • Is how we record the patient’s subjective information about the signs/symptoms they are experiencing now at the time of admission? Documentation Admission Navigator (continued)

Patient Care Summary • Is the 24 hour flowsheet where every discipline documents their assessments and interventions? Discipline Specific Flowsheets • Are specific to a particular discipline (such as dieticians or respiratory therapists) Documentation Head-to-Toe Assessment • Neurological • Cardiovascular • Peripheral Neurovascular • Respiratory • Gastrointestinal • Genitourinary • Skin • MUST BE COSIGNED BY THE INSTRUCTOR Documentation Head-to-Toe Assessment (continued)

Epic Documentation - Charting “WDL” • “WDL”- Within Defined Limits • Charting “WDL” means that you have determined that the patient’s physical findings match the WDL definition • If findings match the WDL, then there is no need to further document findings Documentation Head-to-Toe Assessment (continued) Epic Documentation - Charting “WDL- Except” • “WDL-Except”- within defined limits except • Charting exceptions to the definition WDL • Physical findings that do not fit within the WDL criteria require further documentation & explanation Documentation - Vital Signs Below are the normal adult findings. Document and Report ALL abnormal or significant findings significant to the patient’s RN immediately. • Oral Temperature 36.0 – 37.5 C • Urine Output at least 240 ml in 8 hours • Pulse range 60 – 100 beats per • Blood glucose 70 – 140 mg/dL minute • Pulse Oximetry >92%; pregnancy >95% • Respiratory Rate 12 – 20 breaths • Pain- whatever the patient says it is; identify per minute pain goal and preferred scale • Blood Pressure • Systolic 100 – 140 • Diastolic 60 – 90 Documentation - Interdisciplinary Plan of Care

• Regulatory agencies require us to have & use a plan of care to direct the care of our patients • The patient’s care plan is used by all disciplines to document and revise Documentation - Patient Education • Document all education and response of patient & family • Topics could include - medications, plan of care, upcoming tests, discharge planning • Sonifi • Direct Link between epic and educational Videos • 30 educational videos • Assigned by the nurse for the patient to view for education Protocols Nurse-Driven

Intervention orders the scope of RN Practice • Case management / social work • Wound/skin/ostomy nurse consult • Pressure injury treatment • Dietitian consult • Speech pathology • Pastoral care • Lactation specialist consult • Progress patient activity level unless otherwise contraindicated • Ethics consult Nurse-Sensitive Indicators Directly affected by nursing practice Reflect three aspects of nursing care: 1. Structure-supply of nursing staff, skill level of staff, and education of staff 2. Process-assessment, intervention, and job satisfaction 3. Outcomes-patient outcomes that improve if there is greater quantity and quality of nursing care

• Prevention of bloodstream infections (CLBSI), catheter associated urinary tract infections (CAUTI), prevention of falls and hospital acquired pressure injuries. Other Policies to review

• Tier 1: Social Distancing • Tier 1: Universal Mandatory Mask • Tier 1: Eye Protection During COVID 19 • Tier 1: PPE Guidelines for All Staff • Tier 1: Temporary Visitor Restrictions During COVID 19 Pandemic Thank you and welcome to Henry Ford Health System!