How to Use This Syllabus Look Over the Table of Contents

Annual Mandatory Education—Professional Nurse

How to Use this Syllabus Look over the Table of Contents. Note that: o Lessons are organized alphabetically. o Mousing over a Lesson title allows you to left-click and go to that Lesson. o The bottom of each page displays the page number and Lesson title. Exam questions are presented in Lesson order. Hold down the ‘Ctrl’ key while pressing the ‘F’ key to view a ‘Find’ dialog box o Type in a key word or phrase to find it in the text. o Remember that ‘Find’ will find all instances of the word or phrase in the entire document. Before using ‘Find’, consider navigating to the proper Lesson first, in order to be as close as possible to the information you want to ‘Find’.

IMPORTANT NOTE on the limitations of this material: This content is not localized to a particular healthcare environment, system, or entity. Since local system and administrative processes are crucial to patient safety, it is imperative that the learner be familiar with local, facility/entity practices such as: policies and procedures, equipment, patient identification and validation procedures, communication and handoff practices, etc. Adhere to your organization’s policies and procedures.

How to Use this Syllabus ...... 1 Abuse ...... 2 Accident Prevention ...... 16 Advance Directives ...... 18 Age Specific Care ...... 20 Back Safety ...... 32 Bioterrorism ...... 39 Blood Products Administration ...... 47 CMS HACs and IHI Care Bundles ...... 55 Consent for Treatment ...... 60 Corporate Compliance ...... 62 Cultural Competence ...... 66 Documenting Patient Care ...... 69 Drugs in the Workplace...... 75 Electrical Safety ...... 82 Emergency Preparedness ...... 86 End of Life Care ...... 94

Annual Mandatory Education—Professional Nurse

Ethical Care ...... 96 Fall Prevention ...... 99 Fire Safety ...... 101 Harassment ...... 116 Hazardous Materials ...... 122 HCAHPS ...... 136 HIPAA, HITECH, Social Media, and Patient Privacy ...... 143 Infant Abduction ...... 147 Infection Control, Part 1: Basics ...... 154 Infection Control, Part 2: HAI, Ebola, MRSA, HAP, TB, HIV/AIDS ...... 165 Latex Allergy ...... 183 Management of Assaultive Behavior ...... 189 Medical Gas Safety ...... 199 Medication and Treatment Errors and Sentinel Events ...... 200 National Patient Safety Goals of The Joint Commission ...... 204 Organ and Tissue Donation ...... 210 Pain Management ...... 212 Patient Rights and Responsibilities ...... 222 Patient Transfers and Body Mechanics ...... 224 Population Served ...... 235 Procedural Sedation ...... 246 Quality Improvement ...... 253 Radiation Safety ...... 258 Restraints/Restrictive Practices ...... 263 Risk Management and Event Reporting ...... 272 Security ...... 278 Team Communication about Serious Events, the SBAR Model ...... 282

Abuse Types of Abuse

Annual Mandatory Education—Professional Nurse

The healthcare environment and abuse People can report abuse without identifying themselves. Any health care worker who determines abuse has occurred or suspects it is responsible for reporting the situation.

To abuse means ‘to damage, injure, or use wrongly’. It is not always easy to determine if someone seeking medical help is a victim of abuse. For example: An infant who has not learned to talk is unable to provide necessary information. A victim may deny abuse because of fear of exposing the caregiver or partner. A non-victim may claim abuse when it isn't true.

Workers are better able to recognize the signs and correctly identify abuse when they know the facts. The following facts are important to know: All types of abuse are found in all social and economic groups. Types of abuse include child abuse, domestic violence (sometimes known as "spouse abuse"), and elder abuse.

Reporting child abuse Child abuse is an act that results in death, physical or emotional injury, sexual abuse, or exploitation of a child. Child abuse occurs most often in children aged 0-3 years. The most common child abuse situations involve neglect or physical abuse by the female parent. The four types of child abuse are: Physical abuse Neglect Sexual abuse Emotional abuse

Some facts about child abuse: 9 of every 10 victims are abused by one parent. At least 1 of every 3 victims suffers from more than one type of child abuse. About 1% of all children have been abused or are at risk of being abused. The highest cause of death in child abuse cases is due to neglect.

Health care professionals are MANDATED REPORTERS of child abuse. This means that any health care professional who suspects child abuse must report the case to the state hotline number.

Reporting domestic violence Domestic violence is behavior that may include physical, sexual, economic, emotional and psychological abuse of one family member or partner by another. Because the abuse is often between intimate partners, it is also sometimes called "spouse abuse." Examples of domestic violence include stalking

Annual Mandatory Education—Professional Nurse

(surveillance or telephone harassment, for example) and battery (threatened or actual physical violence).

Some facts about domestic violence: There are about 4 million cases annually. 95% of reported cases involve a male batterer and female victim While intimate partners commit 22% of the violence against women, intimate partners commit only 3% of the violence against men. 50% of female victims of domestic violence report a physical injury. About 40% of these victims seek professional medical treatment. 30% of female murder victims are killed by their intimate partner.

Health care professionals are NOT mandated by law to report domestic violence to state agencies or to law enforcement unless the situation involves injury by a weapon. Victims of domestic violence are considered to be competent adults, capable of taking action for themselves. However, all injuries due to weapons must be reported to the law enforcement agency.

The role of the healthcare professional is to: Report the injury if it is caused by a weapon. Document all findings. Encourage the victim to seek help with his or her domestic situation. Educate the victim about abuse and options for help.

Reporting abuse of the elderly Each year elderly persons in domestic settings are abused, neglected, and exploited by family members and others. Many victims are people who are frail, vulnerable, cannot help themselves, and depend on others to meet their needs. Self-neglect is a form of abuse that occurs with the elderly.

Some facts about abuse of the elderly: The incidence of elder abuse in domestic settings increases annually. For every reported case, 5 cases go unreported. Females are more likely to be abused than males (after accounting for the larger proportion of females in an aging population). Elders over 80 are 2-3 times more likely to be abused than elders between 65 and 80. In 9 out of 10 cases in which the abuser is known to the abused elder, the abuser is a family member, such as an adult child or an adult child's spouse.

Health care professionals are MANDATED REPORTERS of abuse of the elderly in almost all states. Actual rules will vary from state to state.

Annual Mandatory Education—Professional Nurse

Child Abuse

What is child abuse? The federal Child Abuse and Prevention Treatment Act (CAPTA) defines child abuse and neglect as: at a minimum, any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act which presents an imminent risk of serious harm.

A child is someone who is less than 18 years old, or (except in the case of sexual abuse) the age defined by the Child Protection Act of the state in which the child resides.

Some recent national statistics on child abuse and neglect: More than 1% of all children (11.8 out of every 1000) were abused or were at risk of being abused. 3 out of 5 children who were abused suffered from neglect More than 1 out of 3 children who were abused suffered from more than one type of abuse. 9 out of 10 children who were abused were abused by one parent. Neglect or physical abuse was most commonly inflicted by the female parent. Sexual abuse was most commonly inflicted by the male parent. There were 1100 child deaths as a result of child abuse.

Potential abusers and high-risk children Parents and caregivers who are most likely to abuse a child are those who: Are single parents with very little outside help Have a problem with substance abuse Live in poverty Have high stress and limited resources to help in high stress times Have witnessed violence or were the victims of violence and abuse as children Have inadequate parenting skills and unrealistic expectations of a child.

Children who are at higher risk of abuse are: Mentally challenged children Premature infants Colicky babies/babies who cry a lot Children 0 - 3 years old Children with chronic medical problems Children with behavioral problems Children who live in a home where there is spouse abuse.

Annual Mandatory Education—Professional Nurse

Four types of child abuse Four types of child abuse are: 1. Physical abuse 2. Neglect 3. Sexual abuse 4. Emotional abuse.

Physical abuse Physical abuse is an action such as kicking, punching, hitting, biting, burning, shaking or other action that causes physical harm to a child, even if the harm is not intentional, as in over-punishment.

Neglect Neglect is the failure to provide for the child's basic physical, educational, or emotional needs. Allowances must be made for cultural values, poverty, and other factors that might be part of the reason for neglect. For example, people living in poverty may not be able to afford the medication the child needs.

Physical Neglect Physical neglect includes abandonment, the failure to provide food, not allowing a runaway to come home, inadequate supervision so that the child is endangered, and withholding medical treatment or other life-sustaining treatments including water and nutrition, when the treatment would most likely result in correction of a medical condition. NOTE: This does not include cases where there is no chance of recovery from illness, such as in a child with terminal cancer or a newborn with a condition that is incompatible with life.

Emotional Neglect Emotional neglect includes not responding to the emotional needs of a child, exposing a child to domestic violence, allowing a child to use drugs and/or alcohol, and the failure to provide the necessary psychological care.

Sexual abuse Sexual abuse is inappropriate sexual behavior with a child. It includes fondling a child's genitals, making the child fondle the adult's genitals, intercourse, incest, rape, and sexual exploitation. To be considered child abuse, these acts have to be committed by a person responsible for the care of a child (such as a parent, baby-sitter, or daycare provider) or related to the child. If a stranger commits these acts, it would be considered sexual assault and handled solely by the police and criminal courts.

Emotional/psychological abuse Emotional abuse is an act, by parents or caregivers, which could cause behavioral, cognitive (affecting the thinking process), emotional, or mental disorders. Examples of this type of abuse include bizarre forms of punishment such as locking a child in a dark closet, basement, or attic. Emotional abuse is generally present with most other forms of abuse and is often hard to prove. Copyright 2015, Cross Country University Page 6 of 284, Abuse

Annual Mandatory Education—Professional Nurse

Signs of child abuse Child abuse is often hard to recognize unless it is very obvious. Knowing the signs and symptoms of the different types of abuse will help you recognize possible cases.

Signs of physical abuse include: Injuries inconsistent with the explanation of the injury (examples include an infant who is not yet walking or crawling with a broken leg, or injuries on both sides of the body because of a fall - injuries due to a fall are usually found on one side only) Injuries in several stages of healing such as old bruises and new bruises Evidence of old fractures Injuries such as rope burns, scalding, and cigarette burns.

Signs of neglect include: Malnutrition Failure to keep medical appointments or prescribed treatment Child not dressed for the weather Child not taking medicine as prescribed. Socioeconomic factors such as poverty may appear as neglect.

Signs of sexual abuse include: Provocative behavior or knowledge of sexual matters inconsistent with child's age Suicidal gestures Behavior problems Diagnosis of sexually transmitted disease in a child.

Signs of emotional/psychological abuse include: Poor development of basic skills Anxiety or insecurity Withdrawal Destructive behavior Aggression or angry outbursts.

Reporting child abuse In all states, the health professional is a MANDATED REPORTER for suspected cases of child abuse. Individual facilities may have their own policies about who files the actual report.

Each state has its own statutes defining: The procedure for reporting suspected cases of child abuse Who must file the report

Annual Mandatory Education—Professional Nurse

Other factors such criminal punishment for abuse.

If abuse is suspected or if a child tells you he or she was abused: Notify the appropriate State agency (your facility will have a hotline number to call) and they will get the details from the child. DO NOT interview the child. Studies show that the testimony of children is less accurate when they are asked to repeat it. DO NOT allow the child to leave with the caregiver until the state agency is contacted and you have their permission to allow the child to leave with the parent/caregiver.

Elder Abuse

What is elder abuse? Elder abuse is the physical, emotional, or financial mistreatment, neglect or exploitation of a person 60 years of age or older by another person or the self-neglect of an individual in this age range.

There are three situations in which elder abuse occurs: 1. Domestic elder abuse 2. Institutional elder abuse 3. Self-neglect or self-abuse

Domestic elder abuse Domestic elder abuse is abuse of an older person by someone who has a special relationship with the elder such as a spouse, sibling, child, friend, or caregiver. The abuse occurs in the older person's home or in the home of the caregiver.

Institutional elder abuse Institutional elder abuse is abuse of an older person that occurs in a residential facility for older persons such as a nursing home, foster home, group home, or boarding house. In institutions, the persons who are the abusers have been hired to provide care and protection for elders.

Self-neglect Self-neglect (also known as self-abuse) is the behavior of an elderly person that threatens his or her own health or safety. It occurs when the older person refuses or fails to provide himself/herself with enough food or water, clothing, shelter, safety, personal hygiene and/or medication. Self-neglect usually occurs when an elder lives alone.

Statistics on elder abuse: In 2012, 1.5 million elder persons in domestic settings were abused or neglected (including self- neglect). It is estimated that for every case that is reported, 5 are unreported. Copyright 2015, Cross Country University Page 8 of 284, Abuse

Annual Mandatory Education—Professional Nurse

Even after accounting for the larger proportion of women in an aging population, females are abused more often than men. Those over 80 are abused at a rate 2-3 times higher than elders between the ages of 60 and 80. In over 90% of cases where the abused elder knows the abuser, the abuser is a family member. Two thirds of these abusers are the children of the elder or the children's spouses.

Commonalities in elder abuse More than two-thirds of the people who abuse elders are family members who are responsible for the care of the victims. There are many different reasons for elder abuse but no single major cause. Each case is different and has different contributing factors.

Common factors that lead to elder abuse include: Caretaker stress Impairment of dependent elder Personal problems of caretakers Cycle of violence.

Caretaker stress Caring for a frail, elderly person can be extremely stressful, especially if the patient is confused and/or has physical problems. If the caretaker does not have help, it can be very exhausting and frustrating.

Impairment of dependent elder Research shows the incidence of abuse is more frequent among elders with impairments. As impairments such as physical or mental disabilities get worse, the abuse tends to be more common.

Personal problems of abusers Adult children who abuse elderly parents often suffer from mental and emotional disorders, alcoholism, drug addiction, and/or financial problems. These children are dependent on their parents for support and are abusive when their parents become infirm and unable to provide the support they previously supplied.

Cycle of violence The cycle of violence is a pattern of abuse that has three phases: 1. Tension rises. 2. Abuse (often violence) occurs. 3. The abuser apologizes, promises to change, and volunteers to go for help.

The cycle repeats over and over becoming more severe each time. Children who grow up in this situation become abusers because this is the only way they know to respond to tension. The behavior can continue from one generation to another.

Annual Mandatory Education—Professional Nurse

Types of elder abuse The four types of elder abuse are: Physical abuse Psychological abuse Financial or material exploitation Neglect or abandonment

Physical abuse Physical abuse is intentional physical pain or injury inflicted on an elder by the person who is responsible for his or her care. Examples include slapping, bruising, sexual assault, use of unreasonable physical restraint, deprivation of food or water, and over- or under-medicating.

Psychological abuse Psychological abuse is the infliction of mental or emotional suffering by a person who is in a position of trust with an elder. Examples include verbal assault, humiliation, intimidation, threats, and isolation from the family and/or friends.

Financial or material exploitation Financial or material exploitation is the theft or improper use of the elder's money or property, without his or her consent, for someone else's benefit. Examples include forcing or tricking the elder into selling his or her home, forging a signature on pension checks or wills, misusing "power of attorney," and not allowing the older person to buy needed clothes.

Neglect or abandonment Neglect is the failure of a caretaker to provide adequate food, clothing, shelter, psychological care, physical care, medical care or supervision to avoid physical harm, mental anguish or mental illness to the elder. Examples include: failure to assist with personal hygiene or the provision of clothes, and failure to protect an elder from health and safety hazards.

Signs of elder abuse Signs of physical abuse include: Elder's report of being hurt Injury inconsistent with the story of how it was received Injuries in various stages of healing Observed actions of caretaker, such as hitting, slapping, or burning Caretaker's refusal to allow anyone to see an elder alone

Signs of sexual abuse (a type of physical abuse) include: Elder's report of being sexually abused Torn, stained or bloody underclothing Bruises or other injuries around breasts or genitals Copyright 2015, Cross Country University Page 10 of 284, Abuse

Annual Mandatory Education—Professional Nurse

Unexplained vaginal or rectal bleeding Unexplained sexually transmitted disease (STDs) such as gonorrhea or syphilis

Signs of psychological abuse include: Elder report of psychological abuse Elder being very agitated and upset Elder being withdrawn and uncommunicative Unusual behavior often attributed to dementia (hitting/biting)

Signs of financial or material exploitation include: Using the elder's ATM without permission Taking over a bank account without permission Forgery of an elder's signature on financial documents Making changes to the will without approval Providing substandard care despite an elder's ability to pay

Signs of abandonment, neglect, or self-neglect include: Malnutrition Untreated bedsores Untreated health problems Unsafe living conditions Unsanitary appearance such as dirty clothes Desertion in clinical facility, shopping mall or other public location

Reporting elder abuse As a health professional, in any state, you are a MANDATED REPORTER of suspected cases of elder abuse. Your facility may direct the procedure for reporting. All calls are confidential and must be made to the state hotline. The investigation will be carried out by the state Adult Protective Services.

If abuse is suspected or an elder tells you he or she was abused: Document all findings, including any statements the victim and caretaker make Do not allow the elder to leave without permission from the state Adult Protective Services

Your community should also have an Area Agency on Aging that provides services for the elderly. If a caretaker expresses any concerns or clearly needs help, you can call, or refer them to, this agency.

Spouse Abuse/Domestic Violence

What is spouse abuse? Spouse abuse, also known as domestic violence, is a pattern of threatening or violent behavior used to establish power and control over an intimate partner. It involves emotional, financial, physical, sexual, Copyright 2015, Cross Country University Page 11 of 284, Abuse

Annual Mandatory Education—Professional Nurse

and social abuse of a person. Spouse abuse happens in all types of intimate relationships: between married couples, between unmarried couples, between homosexual couples, and between couples living together or apart. People of different race, income, and education are potential abusers or victims of spouse abuse. In a relationship where spouse abuse prevails, one person is forced to change their behavior because of abuse or the perceived threat of abuse.

Facts about spouse abuse: There are about 4 million cases annually. 30 % of female murder victims are killed by intimate partners. 95% of reported cases of spouse abuse involve violence against women. 50% of female victims of spouse abuse report a physical injury. About 40% of those victims seek professional medical treatment. 75% of severe abuse occurs after the victim has left the abuser. 1 in 4 women will experience violence in their lifetime.

Power and control Spouse abuse or domestic violence is the result of one person's need for power and control over another and the belief that he or she has the right to gain the power and control in whatever way possible. Husband abuse does exist but represents only 5% of spouse abuse cases, so most examples and illustrations in this module will refer to wife abuse.

The abuser seeks to exert power or gain control over the victim in a variety of ways. Ways to exert power and gain control are through: Physical abuse Sexual abuse Social abuse Financial abuse Emotional abuse.

Physical abuse Physical abuse is the infliction of pain or physical injury by the victim's partner. A physical abuser may hit, push, kick, slap, hold down, or throw things at the victim, and may also harm a victim's children, pets, or property, or commit battery (a threat of violence accompanied by the ability to carry out the threat).

Sexual abuse Sexual abuse is violence by the victim's partner in which sex is used to hurt, degrade, dominate, humiliate, or gain power over the victim. It is an act of aggression. Victims of sexual abuse have a pronounced inability to trust, which leads to secrecy and non-disclosure. The abuse may involve force, coercion, bribes, threats, or corruption, and may include prostitution or money. A victim of sexual abuse may be treated as a sex object, called sexual names, or forced into sexual activities by the abuser, who Copyright 2015, Cross Country University Page 12 of 284, Abuse

Annual Mandatory Education—Professional Nurse

may brag or boast to the victim about sexual activities with another person, or compare the victim's sex actions to those of other persons.

Social Abuse Social abuse of a spouse is the isolation, restraint, or other behaviors that prevent or limit a partner from interacting with others. Social abuse is also about power and control and is aimed at limiting the victim's interactions with family, friends, coworkers, and others. A social abuser may make jokes and insults about the victim, may prevent the victim from working or from seeing friends, or may drive friends away, and may deny the victim's social values or isolate the victim by moving to another location.

Financial abuse Financial abuse of a spouse is the misuse or exertion of control over money, access to money, or possessions. It includes stealing and lying about money. A financial abuser may remove large sums of money from the victim's bank account, deny the victim the ability to pay bills or buy necessities, deprive the victim of money or access to money, or deny the victim job freedom.

Emotional abuse Emotional abuse is behavior that causes feelings of unworthiness. It can interfere with the positive development of another. Emotional abuse is almost always present in situations where other forms of spouse abuse occur. It is cruel and destructive. Victims of emotional abuse may be put down by their partner, told no-one else will want them if the partner leaves, and ignored or isolated. An emotional abuser may withhold affection from the victim, or use jealousy, passion, or anger to justify actions.

Spouse abusers and why their victims stay Individuals at risk of becoming abusers include: Victims of child abuse Adult children from a family with a history of domestic violence Those who have learned that physical force is the way to solve problems People with low self-esteem and low self-control Individuals who suffer from substance abuse, alcoholism, and drug addiction Individuals with a rigid stereotype of gender roles who feel the need to be "in control" Those who do not have the communication skills to handle emotions in non-violent ways People who live in a society that believes domestic violence is a private matter so that acts of violence go unpunished.

Victims stay in abusive relationships because of: Economic constraints Fear of severe abuse if they leave the abuser Feelings of guilt, shame, and failure

Annual Mandatory Education—Professional Nurse

Failure to recognize that the actions are actually abuse (the victim feels that she or he deserves the abuse) Social isolation and lack of support for victims and their children Promises of change from the abuser Prior lack of intervention or help Threats of violence.

The cycle of spouse abuse The cycle of abuse is common in many cases of spouse abuse. It results in the battered person living in a state of fear with the belief that there is no escape. The three phases of the cycle are: 1. Tension-building phase 2. Crisis phase 3. Honeymoon phase.

Phase 1: Tension-building phase The tension-building phase is characterized by stress. The abuser shows signs of increasing irritation with the victim, often finding fault with everything she does, and the victim becomes fearful and tries to find ways to appease the abuser.

Phase 2: Crisis phase The crisis phase is characterized by violence. The abuser's anger reaches a critical point and is released in the form of verbal or physical violence. The abuser may shout and scream at the victim, threaten her, and damage the victim's property. Physical assaults such as punching, kicking, or slapping hard enough to bruise, break bones, and draw blood may also occur. The police or neighbors may be called, or the violence may be unknown to people outside. The victim may be made to feel she provoked the escalation from phase 1 to phase 2.

Phase 3: Honeymoon phase The honeymoon phase is characterized by a return to calmer behavior. The abuser is sorry, promises to get help and never do this again, and may offer affection to the victim.

The healthcare worker and spouse abuse Victims of spouse abuse often have obvious physical injuries. Others may have vague complaints and deny abuse.

When a patient denies spouse abuse, the following signs may alert health care workers to suspect abuse: A pattern of missed appointments Delays in seeking treatment Frequent medical visits for vague complaints with lack of evidence of physical causes

Annual Mandatory Education—Professional Nurse

Injuries in several stages of healing such as old bruises and new bruises, and evidence of old fractures Injuries during pregnancy (because pregnancy is a high risk situation for abuse) Injuries inconsistent with the explanation of the injury.

Examples of situations in which the injuries are inconsistent with the explanation of the injuries: Someone states that the injuries are caused by a fall, and yet the bruises and cuts, on the hands and arms, are consistent with self-defense injuries. Someone states that the injuries are caused by a fall, and yet the injuries are found on both sides of the body (usually, in a fall, injuries are on one side only).

When abuse is suspected: Provide privacy and the opportunity for the patient to talk. Privacy also means privacy from partner, family members, or acquaintances. Assure the patient of confidentiality. Be non-judgmental and caring. Ask if the partner has ever harmed or threatened to harm the patient or his or her children. Let patient know that there are options. Reinforce the idea that victims do not cause nor deserve the abuse. DO NOT ask a patient why he or she does not leave the abuser. DO NOT change your course of action because a patient does not admit to abuse.

Healthcare workers' responsibilities include: Screening all patients for signs of abuse Documenting all findings including the victim's statements Ensuring domestic violence information is available in waiting areas and rest rooms Knowing the options and inform the patient of options. Making referrals, as indicated.

Options for victims include: Pressing charges to have the abuser arrested Obtaining an injunction or restraining order against abuser (the purpose of the restraining order is to prevent the abuser from communicating or associating with the victim) Going to a safe house or women's shelter for protection and accommodations Going back home. Getting help when ready.

BE CAUTIOUS about giving the victim a phone number to call for help. The abuser may find it and respond abusively. Instead, help the victim memorize the number, tell her how to find the numbers for help, or tell her the names of organizations she can look up in the phone book when it is safe. If the abuser seeks help, follow the hospital policy on spouse abuse and refer him or her to treatment centers for help. There is also help for substance abuse.

Annual Mandatory Education—Professional Nurse

End of Abuse Lesson

Accident Prevention

The worker's role in hospital safety Each worker has a personal responsibility in recognizing safety hazards and preventing accidents in the hospital.

Actions that help you to be a responsible worker include: Have your eyes checked regularly. Your sense of sight helps you to be aware of safety hazards. Come to work well rested. When you are tired, you are more likely to be careless or miss seeing a hazard. Don't be in too much of a hurry. Take smaller steps and watch for warning signs such as "WET FLOORS." If you have to walk on a wet floor, take it easy.

Keeping the hospital safe is everyone's job.

Causes of accidents When people come to a hospital, they expect to be safe. But accidents can happen.

Possible causes of accidents in the hospital are: Wet floors or puddles Standing on an unstable object (such as a rolling chair) to reach something on a high shelf Burned out lights in stairwells and hallways Cords stretched across the floor and boxes or carts cluttering walkways.

Accidents can be prevented if workers recognize hazards/causes and respond to them.

How to prevent accidents Most accidents can be prevented if you do one of two things: 1. REMOVE the problem 2. REPORT the problem

If you REMOVE a problem, it is eliminated or taken away so that it will not cause an accident for you or anyone else.

If you see a problem that you cannot remove, call or contact the appropriate department about the problem. Once you REPORT it, someone will remove the problem.

Some examples of how you can prevent accidents are:

Annual Mandatory Education—Professional Nurse

If you see a puddle and wipe it up before someone slips, you REMOVE the problem. If the puddle is too large to easily wipe up, you should REPORT it to your Housekeeping or Environmental Services Department. If you see a burned out light, REPORT it. Proper lighting is important in areas such as stairwells, loading docks and parking areas. REMOVE or REPORT extended cords and other objects such as boxes, books or equipment to keep walkways clear and safe. REPORT any hazard immediately. Do not assume that someone else has reported it.

Identify and correct safety hazards Slips, such as water on the floor, should be cleaned up. Trips, or obstacles, should be removed. Sharps, such as needles or glassware, should be properly disposed of.

Take care in using equipment To avoid injuries, equipment must be correctly used and cared for: Make sure equipment is working properly. Make sure equipment is in good working condition. Do not use equipment that you have not been taught how to use.

How to respond to accidents If an accident does happen, remain calm.

If you are injured tell your supervisor. If you need treatment, see your Employee Health Nurse or go to the Emergency Department. If you are seriously injured or think you might have broken bones, do not move - moving could make an injury worse. Call for help and/or wait for someone to come to help you. Be sure to tell them what caused your accident so they can remove or report the problem.

If another person is injured, wait for someone to assist you. While lifting or moving an injured person, you can hurt yourself. Use a wheelchair or a stretcher to take the person to the Emergency Department for treatment. If the person is seriously hurt or unconscious, wait with the injured person while someone calls for help. If there is any possibility of a back, neck, or head injury, the injured person should not be moved.

Once you have taken care of an injured person, report the accident. If you know the cause of the accident, report it so the problem can be removed.

All accidents do need to be reported.

End of Accident Prevention Lesson

Annual Mandatory Education—Professional Nurse

Advance Directives

What are "advance directives?" Recent advances in healthcare have resulted in extended life expectancies. However, some people DO NOT want an extended life if the quality of that life would be severely diminished. To enable people to indicate their wishes for future healthcare before they become incapacitated, an "advance directive" may be written.

The Patient Self-Determination Act of 1990 dictates that all patients entering the healthcare system (including home health, nursing homes, hospitals, etc.) must be given the opportunity to complete an advance directive document and have it on file. The document defines the patients' preferences in end- of-life decisions or at any time that they are unable to convey their own wishes regarding healthcare. Advance directives are voluntary and are supported by the Patient's Bill of Rights (item 4).

There are two types of advance directives: Living Wills Healthcare surrogates

Living Wills Living Wills give direction about medical care, or limitations to medical care, that patients desire when there is no hope of recovery and they are unable to make their needs known.

Healthcare surrogates Healthcare surrogates are persons who have the legal right to direct the care of patients who are unable to make informed decisions.

Each state has its own laws pertaining to advance directives, but they are similar in all states. An advance directive signed in one state will be honored in another.

Patients entering hospital should be told about advance directives and, if they do not have one, they should be provided with the opportunity to complete one. Patients should also be informed that advance directives may be changed (by the patient) at any time. If patients complete advance directives or have already prepared advance directives, copies must be placed in their charts and staff must be made aware of them. Patients must understand the importance of providing copies to families, doctors, healthcare surrogates and hospitals so their wishes are honored. Advance directives are NOT intended to be secret documents.

What is a “Living Will?” A "Living Will" is a document that gives direction about the medical care, and limitations of medical care, desired by the patient when he or she is either in a permanent vegetative state with no hope of recovery or has an imminently terminal condition AND is unable to make his or her needs known (for Copyright 2015, Cross Country University Page 18 of 284, Advance Directives

Annual Mandatory Education—Professional Nurse

example, if the patient is in a coma or otherwise unconscious or in a confused state). Living Wills have to be witnessed by two people or notarized, but they do not have to be drawn up by an attorney.

Patients must understand that they will be treated, will receive palliative care, and will be kept comfortable even when a Living Will is activated. Each state has its own requirements as to the type of care that can be designated. Some states allow the patient to say exactly what he or she does or does not want; others have limitations. A Living Will may include specifics such as whether to allow or withhold: Mechanical ventilation Cardio-pulmonary resuscitation (CPR) Nutrition, fluids, or feeding tubes Medication Other treatments.

Each state has its own requirements as to when a Living Will is applicable. As a rule, two physicians must certify that the patient meets the criteria before a Living Will can be enacted.

Important note: A Living Will is NOT the same as a "Do Not Resuscitate" order.

A "Do Not Resuscitate" order (also known as a "no-code" order) is written expressly to indicate the patient's request not to perform CPR if he or she stops breathing or has no pulse. Patients sometimes think that because they have a Living Will, they will automatically have a "Do Not Resuscitate" order (no- code). However, even with a Living Will, the law requires that a no-code order be written by a doctor. The doctor is the person who decides when to activate the Living Will, NOT the patient. The information in the Living Will is considered a guide for the doctor to use when faced with making the decision to write a no-code order. Some doctors are reluctant to do so. Patients must understand that a Living Will must be discussed thoroughly with both the family and the doctor so the patients' wishes are clearly understood and the desired no-code order will be written at the appropriate time.

What is a "healthcare surrogate?" A "healthcare surrogate" (sometimes called a "healthcare representative" or "healthcare proxy") is the person or persons who can legally direct the care of a patient when he or she is unable to make informed decisions because of confusion, unconsciousness, etc. The "durable power of attorney for healthcare" form identifies this person or persons.

A healthcare surrogate's responsibilities include: Making decisions the patient would normally make concerning healthcare if he or she were able Carrying out the wishes of the patient (even though he or she may not agree with them).

Patients must be able to trust healthcare surrogates to carry out their wishes. A healthcare surrogate is responsible for making sure the contents of a Living Will are carried out according to the directions of Copyright 2015, Cross Country University Page 19 of 284, Advance Directives

Annual Mandatory Education—Professional Nurse

the patient. However, the role of surrogates also includes representing patients at any time that they are unable to speak for themselves, not only when there is no hope of recovery.

Patients must be made aware of the importance of choosing the right healthcare surrogate. They must share with their surrogates all information regarding their wishes for future healthcare AND the contents of their Living Wills.

End of Advance Directives Lesson

Age Specific Care

Summary of Physical Development Principles

Newborns (0-1 month) display reflex movements and respond to stimulation. One example of a reflex is the newborn grasping a finger when it touches the palm of his/her hand. Infants (1-12 months) experience pronounced physical changes and growth. During this time they triple their birth weight, develop gross motor skills that enable them to walk (with or without help), and begin to develop fine motor skills such as picking up things using their forefinger and thumb (pincer grasp). Toddlers' gross motor skills develop as they become more balanced on their feet. Children at this age (1-3 years) can walk, jump, catch, and roll a ball. Their fine motor skills increase as they attempt to balance blocks and draw circles. The changes in gross and fine motor development experienced by preschoolers (3-6 years) improve their ability to walk, run, jump, and hop. Their control of a pencil or crayon improves. In school-age children (6-12 years) athletic abilities and eye-hand coordination are well developed. They can participate in and enjoy team sports. The adolescent (12-20 years) experiences greater physical growth than at any other time apart from infancy. Muscle development increases in both sexes, and puberty begins with the development of hormones. Young adults (20-45 years) are generally as fit and healthy as they will ever be. During the middle adulthood (45-65 years), many people become aware of the gradual changes occurring in their bodies - signs of the aging process. Seniors (65 years and older) experience a continuation and acceleration of the body changes that began during the middle adulthood stage. Thinning and graying of hair, appearance of wrinkles, and a general decline in the efficiency of some body systems are more pronounced in seniors. All of the development stages described in this module refer to typical individuals of each group. There may be substantial variation between individuals within the "normal" range.

Annual Mandatory Education—Professional Nurse

Summary of Intellectual Development Principles Intellectual development of the newborn depends a great deal on stimulation such as exposure to patterns (especially black and white), voices, and facial expressions such as smiling. Infants progress from being able to follow objects with their eyes to looking for objects. By 12 months, many infants speak their first understandable words. Toddlers begin to think about what they do before they do it, and they show the ability to think by imitating a model. As language develops, toddlers increase their vocabulary, improve articulation, sentence structure, and listening skills. Preschool children are busy developing skills, using language, and gaining control. They can express their needs because they have greater command of language. School-age children develop an increased ability to remember and pay attention. They enjoy activities such as games with rules and collecting things. Adolescents are in a transition period from concrete to abstract thinking and become increasingly more independent. The capacity to hold and use knowledge is at a peak in adults. Their experience, opinions, and potential for problem-solving and creative thinking are important in developing a sense of identity and purpose, both of which are critical throughout adulthood. There is a general slowing down of mental processes in seniors, but general knowledge, long- term memories, and verbal comprehension are sustained. All of the development stages described in this module refers to typical individuals of each group. There may be substantial variation between individuals within the "normal" range.

Summary of Psychosocial Development Principles Each stage of psychosocial development in the human development life cycle is characterized by a different psychological need or goal, which must be resolved by the individual. The psychosocial development stages are as follows: The psychosocial goal of the newborn and infant (0-1 year) is to attain TRUST as opposed to mistrust. The psychosocial goal of the toddler (1-3 years) is to attain AUTONOMY or INDEPENDENCE as opposed to doubt or shame. The psychosocial goal of the preschooler (3-6 years) is to attain INITIATIVE as opposed to guilt. The psychosocial goal of the school-age child (6-12 years) is to attain COMPETENCE as opposed to inferiority. The psychosocial goal of the adolescent (12-20 years) is to attain ROLE IDENTITY as opposed to role confusion. The psychosocial goal of the young adult (20-45 years) is to attain INTIMACY as opposed to isolation. The psychosocial goal of the middle adult (45-65 years) is to attain GENERATIVITY as opposed to stagnation. The psychosocial goal of the senior (65+ years) is to attain INTEGRITY as opposed to despair.

Annual Mandatory Education—Professional Nurse

All of the development stages described in this module refers to typical individuals of each group. There may be substantial variation between individuals within the "normal" range.

Safety Concerns Safety concerns for newborns, infants, and toddlers Safety needs are based on physical abilities, judgment and intellectual skills. Parents, or other adults, are responsible for the safety of newborns, infants, and toddlers.

Safety concerns for newborns, infants, and toddlers fall into the four main areas: 1. Falls 2. Car safety 3. Choking or suffocation 4. Burns and scalds

The newborn (0-1 month) Falls: Hold newborn babies firmly and support their heads. Keep one hand on the baby when on a table, scale, or bed. Ensure crib rails are up and secured whenever baby is left in crib.

Car safety: Use a rear-facing car seat designed for newborn babies. Place the car seat in the middle of the back seat, when possible. Never place a baby's car seat in a seat fitted with an airbag.

Burns and scalds: Do NOT use a microwave to heat formula. Always test bottle temperature on the inside of your wrist. Always test bath temperature with the inside of your wrist. Protect babies from sunburn by using shade, suitable hats and clothing, and approved sun protection.

Choking or suffocating: Lay babies on their backs or sides to sleep (not stomachs) to reduce the risk of Sudden Infant Death Syndrome (SIDS). Hold the bottle when feeding a baby; do not "prop" a bottle. Keep plastic bags away from babies. Never tie anything around a baby's neck (pacifiers, etc.). Avoid clothing with strings or other objects that may get into the mouth. Do not allow baby to lie on a beanbag seat or cushion. Do not place stuffed animals or other toys in the baby's crib. Copyright 2015, Cross Country University Page 22 of 284, Age Specific Care

Annual Mandatory Education—Professional Nurse

The infant (1-12 months) Falls: Hold an infant firmly and support the head until head control is established. Be prepared for an infant to lunge backwards. Keep one hand on the infant when on a table, scale or bed. Ensure crib rails are up and secured, especially when an infant is able to stand. Use gates to block stairs at top AND bottom.

Car safety: Use a rear-facing car seat. Place the car seat in the middle of the back seat, when possible. Never place a baby's car seat in a seat fitted with an airbag.

Burns and scalds: Do NOT use a microwave to heat bottles or formula. Always test bottle temperature on the inside of your wrist. Always test bath temperature with the inside of your wrist. Protect infants from sunburn by using shade, suitable hats and clothing, and approved sun protection. Use sunscreen (after six months of age) if babies will be exposed to sunlight.

Choking or suffocating: Lay infants on their backs or sides to sleep (not stomachs) to reduce the risk of Sudden Infant Death Syndrome (SIDS). Hold the bottle when feeding an infant; do not prop the bottle. Stay with an infant in the bath; never leave an infant unsupervised in the bath. Keep all small objects out of reach. Keep plastic bags away from infants. Never tie anything around an infant's neck (pacifiers, etc.). Avoid clothing with strings or other objects that may be put in the mouth. Do not allow infant to lie on a beanbag seat or cushion. Do not place stuffed animals or other toys in the crib. Keep mini-blind cords and other cords out of reach.

The toddler (1-3 years) Falls: Remove objects that can be climbed. Prevent the toddler from running too fast, especially on slippery floors or if wearing slippers or in bare feet.

Annual Mandatory Education—Professional Nurse

Ensure crib rails are up and secured, or transfer the toddler to a low bed. Use gates to block stairs at top AND bottom. Secure outside doors with locks that are out of reach. Ensure playground supervision.

Car safety: Use a forward-facing child's car seat. Place the car seat in the middle of the back seat, when possible. Never place a toddler seat in a seat fitted with an airbag.

Burns, scalds, and electrical hazards: Keep matches, lighters, candles and oil lamps out of reach. Always test bath temperature with the inside of your wrist. Keep electrical cords and appliances out of reach. Install covers on electrical outlets. Use sunscreen if toddlers will be exposed to sunlight.

Choking, suffocating, and poisoning: Stay with a toddler in the bath; never leave a toddler unsupervised in the bath. Keep all small objects out of reach. Keep plastic bags away from toddlers. Avoid foods that could cause choking, such as hard candy, nuts and grapes, whole wieners or hot dogs (cut wieners into small pieces lengthwise), lollipops, etc. Keep all medicines in a locked cupboard. Keep all cleaning supplies and other poisonous materials locked up or well out of reach.

Remember, adults are responsible for the safety of newborns, infants and toddlers.

Safety concerns for preschoolers, school-age children, and adolescents Parents or other responsible adults must still supervise all activities of preschoolers. However, preschoolers (and older children) are old enough to understand simple instructions, so children must be taught about safety concerns.

The preschool child (3-6 years) The preschooler should learn about the following safety concerns: Road and car safety (crossing the road, using a child car seat and seat belts) Bicycle safety (wearing a helmet, etc.) Fire safety (lessons such as "Stop, Drop, and Roll") Safety with hazardous materials (poisons and medicines) Safe handling of scissors or other sharp implements Prevention of sexual abuse Copyright 2015, Cross Country University Page 24 of 284, Age Specific Care

Annual Mandatory Education—Professional Nurse

Stranger awareness

The school-age child (6-12 years) The school-age child should: Learn to apply road safety rules at all times Wear a helmet whenever riding a bicycle and walk a bicycle across an intersection Continue to wear a seatbelt in a motor vehicle Learn how to swim and how to apply rules of water safety Practice safety in all projects or activities Learn about stranger awareness and the dangers of sexual abuse Learn about the dangers of drugs, alcohol, and cigarettes.

The Adolescent (12-20 years) Safety concerns for adolescents include: Motor vehicle safety Drug and alcohol abuse Sexually transmitted diseases Unplanned pregnancy Risks of violence (gangs, abuse, accidents, etc.) Suicide (the third most common cause of death among teenagers).

Remember, adults are responsible for the safety of preschoolers, schoolchildren and adolescents.

Safety concerns for adults and seniors Adults are responsible not only for their own safety, but also for the safety of people in all other age groups. Declining abilities, and the increase of elder abuse, may affect the safety of seniors.

The Adult (20-65 years) Safety concerns for adults include: Environmental safety at home and at work Electrical safety at home and at work Fire safety at home and at work Motor vehicle safety Personal safety in the community Proper use and disposal of hazardous materials.

The Senior (65+ years) Safety concerns for seniors include those listed above for adults and: Performing home safety assessments Reducing the risk of falls (good lighting, hand rails on stairs, placement of furniture, electrical appliances, loose rugs, etc.) Copyright 2015, Cross Country University Page 25 of 284, Age Specific Care

Annual Mandatory Education—Professional Nurse

Avoiding adverse drug reactions (common when a person has more than one physician and/or uses over-the-counter medications) Preventing elder abuse (reporting suspicious situations and providing relief when caregivers become overwhelmed or frustrated). Remember, adults are responsible not only for their own safety, but also for the safety of seniors.

Patient care concerns for newborns, infants, and toddlers The newborn (0-1 month) Patient care concerns with newborns include: Encouraging bonding between parents and the newborn Encouraging the mother (or primary caregiver) to stay with the newborn as much as possible Encouraging physical contact between the mother (or caregiver) and baby Involving parents or other primary caregivers in health care decisions Reminding parents about hygiene when handling newborns or preparing their food.

The infant (1-12 months) Patient care concerns with infants include: Encouraging the mother (or primary caregiver) to stay with the infant as much as possible Encouraging physical contact by allowing the infant to sit on mother's lap, etc. Involving parents or other primary caregivers in health care decisions Trying to meet the infant's needs promptly to develop trust Reminding parents about hygiene when handling or preparing food for the infant Educating parents about maintaining immunization records Allowing infants to change positions frequently and using a high chair some of the time Placing infants on their backs or sides to sleep Holding infants for bottle feedings and not propping their bottles Recognizing signs of separation anxiety in older infants and being supportive of parents Nurturing development in a sick infant by providing stimulating toys and games - young infants like bright colors, musical toys, mobiles, and rattles; as they grow, they need space to explore and objects to grasp, such as stacking blocks; and at later stages they enjoy looking at pictures, playing peek-a-boo, being read to, and naming and pointing to body parts.

The toddler (1-3 years) Patient care concerns with toddlers include: Arranging for the same staff to care for the toddler whenever possible (consistency is important) Approaching the toddler slowly and calmly Allowing parents or primary caregivers to remain with the toddler as much as possible (separation anxiety may continue) Learning the toddler's words for describing pain, illness, eating, toileting, etc. and use these same words Being aware of any rituals and food likes and dislikes Copyright 2015, Cross Country University Page 26 of 284, Age Specific Care

Annual Mandatory Education—Professional Nurse

Beginning care by performing tasks the toddler will object to the least (for example, examine fingers or toes before the chest or head) Allowing the toddler to handle the equipment (such as a stethoscope) whenever possible Being honest with both the toddler and parents when explaining what is about to happen Providing the toddler with very simple explanations about what is going to happen, just before the event Providing the toddler with choices when possible (for example, showing two pairs of pajamas and asking which pair the child wants to wear) Educating the parents that it is normal for a sick child to suffer some developmental regressions, but that he or she will catch up Providing stimulating toys and games, such as dolls, musical toys, hide and seek, stacking toys, balls, push toys and being read to for up to 15 months old; rocking horse, shape sorting, crayons and paper, running and chasing games for up to 18 months old; modeling clay, finger and brush paints, tapes and follow along story books, songs and puppets for up to 24 months old; and, play with other children, building toys, drawing, painting, nurse and doctor kits and imitation household objects for up to 36 months old.

Patient care concerns for preschoolers, school-age children, and adolescents As children get older, patient care concerns change. The preschool child (3-6 years) Patient care concerns with preschoolers include: Arranging for the same staff to care for the preschooler whenever possible (consistency is important) Encouraging parents or caregivers to stay with preschoolers and participate in their health care Ensuring that immunizations are up-to-date Encouraging pretend play by using a doll and/or medical supplies to help the preschooler overcome fear Allowing the preschooler to play with real equipment, when possible Getting the preschooler to point to where it hurts (descriptions from this age group are not reliable) Setting limits, but allowing the preschooler to have some control by offering choices Relating clinical procedures to things the preschooler is familiar with, such as comparing an injection to a pinch or an ant bite Reassuring the preschooler that being sick is not punishment for something he or she did and that nobody can be blamed for it Providing stimulating toys and games, such as toy trucks, cars, dolls, story and song tapes, playing simple games, imitating adult roles such as playing house or dress-up, reading books, drawing, coloring, painting, working with modeling clay, and simple puzzles.

Annual Mandatory Education—Professional Nurse

Allowing schoolchildren to express their fears Being aware schoolchildren may deny pain they are having Explaining procedures so they are able to understand what will be happening Giving honest information about discomfort and other issues that may be involved in procedures Assuring schoolchildren that neither they nor their parents are to blame for the illness Involving a schoolchild in his or her care and allowing choices when possible (for example, about whether to take a bath in the morning or evening) Providing privacy whenever possible Being aware schoolchildren may be concerned about the loss of newly mastered shills Being aware they may be concerned about separation from school, schoolmates and school activities Coordinating patient care and visits from a home tutor, if provided Allowing friends or classmates from school to visit, if possible Providing books, art supplies, puzzles, board games, card games, music and other stimulating activities.

The Adolescent (12-20 years) Patient care concerns with adolescents include: Respecting the adolescent's need for privacy and concerns about modesty Understanding adolescents may fear their loss of independence Involving the adolescent in healthcare decisions as much as possible Explaining procedures, routines, and restrictions imposed by the illness Answering all questions honestly Recognizing both positive and negative coping behaviors as attempts to adjust to a threatening situation Attempting to deal not only with behavior, but also with the feelings that cause the behavior Accepting levels of performance and allowing for temporary regression Being a good listener Maintaining a sense of humor Encouraging breast self-examination with females and testicular self-examination with males Interpreting adolescents' reactions to hospital stays to parents, and emphasizing their need to be respected as individuals who are separate from their parents Encouraging adolescents to wear their own clothes and use personal items (as long as it does not interfere with their care or hospital regulations) Allowing the adolescent access to a telephone for keeping in contact with friends and encouraging parents to allow the same contact at home.

Patient care concerns for adults and seniors Patient care concerns with adults include:

Annual Mandatory Education—Professional Nurse

Being sensitive to concerns about the implications of hospitalization on their jobs and families Allowing adults to verbalize their fears and worries Being aware of emerging vision or hearing deficits Involving adults in their care as much as possible Providing adults with choices whenever possible Remembering that competent adults have the right to choose or refuse treatment Involving family members as much as possible Including adult patients and their families in instruction and teaching activities Providing information about healthy nutrition and the importance of regular exercise Recognizing that physical impairment may be due to various factors including age, illness, or inappropriate medication Providing information about risk factors related to chronic diseases, such as preventing complications of chronic diseases and reducing the risks Providing information on advance directives.

The Senior (65+ years) Patient care concerns with seniors include: Setting realistic goals for seniors' care Assessing for risk of falls Assessing and adjusting the environment to suit the needs of the senior Determining current medications, including dosage and frequency, and being alert to adverse reactions Encouraging good nutrition (in spite of decline in sense of taste) Encouraging senior's participation in care Remembering that competent adults, including seniors, have the right to choose or refuse treatment Helping seniors to remain oriented to their surroundings Allowing seniors to talk about their lives and accomplishments Making sure seniors understand advance directives and how to make their wishes for end-of-life decisions known.

Communication Techniques

Communication techniques with newborns, infants, and toddlers The newborn (0-1 month) and infant (1-12 months) Communication with newborns and infants must take place through the parent or primary caregiver. Caregivers must feel comfortable enough to ask questions and should have their questions answered at a level they can understand. Procedures should be demonstrated, and repeated if necessary, so they are able to do what is required.

Annual Mandatory Education—Professional Nurse

Although he or she will not be speaking, it is still important to speak to the newborn or infant while caring for him or her. Babies will turn to the sound of a voice and, as they grow, they will begin to imitate the sounds they hear.

Newborns and infants communicate by crying. A cry means the baby is not comfortable and needs something, such as food, changing, company, relief from pain, etc. They do NOT cry because they are spoiled. No cry should be ignored.

The toddler (1-3 years) Toddlers are able to communicate on their own. However, communication will often have to be at the toddler's level using his or her particular terms.

Communication techniques for toddlers: Avoid baby talk and speak in short, but complete, sentences using simple words (one or two syllables). Get down to the child's level when speaking to him or her. Learn words the toddler uses for eating, toileting etc. and use them. Ask closed questions (yes or no answers), questions that require simple responses, or questions that enable indicating through selection (for example, ask whether the toddler wants to wear blue or yellow pajamas while showing both pairs of pajamas). Provide simple explanations to the toddler just before any procedure is performed. Try to avoid using the word NO, and distract the toddler by providing an alternate activity. (The word NO, very common to this age group, is also very powerful.) Reinforce the behavior you want by using positive expressions rather than negative ones (for example, saying WALK instead of DON'T RUN). Discourage tantrums by ignoring the inappropriate behavior (as long as the toddler is safe) and not encouraging the behavior by providing attention to it. Parents are still the primary communicators for toddlers.

Communication techniques with preschoolers, school-age children, and adolescents

The preschool child (3-6 years) Communication techniques for preschoolers: Be honest about what the preschooler will experience, including discomfort. Relate all procedures to things that are familiar to the preschooler, such as relating an injection to an insect bite or a pinch. Avoid medical terms and explain in terms the preschooler will understand. Speak in full simple sentences and avoid baby talk. Get down to the preschooler's level when speaking to him or her. Provide simple explanations of procedures just before the procedure is performed. Reassure the preschooler that he or she is not being punished for something. Copyright 2015, Cross Country University Page 30 of 284, Age Specific Care

Annual Mandatory Education—Professional Nurse

Assure the preschooler that the illness is not anyone's fault. Allow the preschooler to participate in care, when possible. Provide choices when possible. Allow the preschooler to ask questions and answer them honestly (this age group may have a lot of "WHY?" questions).

The school-age child (6-12 years) Communication techniques for schoolchildren: Include the schoolchild in conversations. Include the schoolchild in instructions and teaching activities with the parents. Prepare the schoolchild for procedures in advance. Make sure medical terms are not misunderstood. Provide appropriate written material that will help explain procedures. Continue to offer the schoolchild choices. Explain procedures and being honest about discomfort associated with them. Allow the schoolchild to express fears and anxieties. Use words the schoolchild understands. Encourage schoolchildren to participate in care. Never shame the schoolchild (for example, do not say things such as "A big boy like you shouldn't cry").

The Adolescent (12-20 years) Communication techniques for adolescents: Include both the adolescent and parents in patient teaching activities. Be aware the adolescent can understand more advanced concepts. Explain procedures, routines, expectations, and restrictions imposed by the illness. Explain the use of medical terms. Answer all questions honestly. Provide reading material to help explain procedures. Allow the adolescent to express fears, anxieties, or other emotions. Allow the adolescent access to a telephone. Treat adolescents with respect and do not talk down to them or make critical remarks. Be non-judgmental, and do not express disapproval or shock at anything the adolescent shares with you.

Communication techniques with adults and seniors

The Adult (20-65 years) Communication techniques for adults: Explain all procedures. Provide instructions or teaching.

Annual Mandatory Education—Professional Nurse

Explain medical terms. Be honest. Avoid talking down to adults. Allow adults to express fears and concerns. Determine how adults prefer to be addressed (DO NOT assume you can use their first names).

The Senior (65+ years) Communication techniques for seniors: Explain all procedures and make sure the senior clearly understands. Include family members in explanations, especially if senior does not appear to understand. Allow the senior to talk about his or her life and accomplishments. Treat seniors as adults (DO NOT talk down to them). Determine how seniors prefer to be addressed (DO NOT assume you can use their first names) Be patient during teaching activities, and take all the time necessary to instruct or explain.

End of Age Specific Care Lesson

Back Safety

Anatomy of the back Your back or spinal column is the main support structure for your body. It carries most of the body's weight and is the main pathway of the nervous system. The back is composed of 24 moveable bones called vertebrae. Each vertebra is separated from the next by a cushion-like pad called a disc that absorbs shock. The vertebrae and discs are supported by ligaments and muscles that keep the back aligned in three balanced curves. These three natural curves form an S-shape when your posture is correct.

Annual Mandatory Education—Professional Nurse

Your back has three natural curves that form an S shape when your posture is correct.

A healthy back is a balanced back - your neck, chest and lower back curves are all properly aligned. You know your back is aligned properly when your ears, shoulders, and hips are in a straight line. Anything that forces the back out of its natural S-shape can strain the muscles and damage the discs. When any part of the back becomes diseased or injured, back problems and pain are almost certain to follow.

Causes of back injury Back injuries are one of the most common types of injuries in the workplace and also one of the most common reasons that people miss work. One study showed that 50-70% of all workers will have some kind of lower back pain at least once. A single back injury can affect you for the rest of your life. Besides the pain it causes, the injury can also keep you from doing many of the things you like to do.

Back injuries happen when you: Lift things that are too heavy - INSTEAD, you should get someone to help or use a cart or dolly to move heavy objects Twist back muscles - INSTEAD, you should always turn your body to face the object you want to lift even if it isn't heavy Bend at the waist to lift - INSTEAD, you should bend at the knees letting the stronger muscles of your legs do the lifting Use back muscles instead of leg muscles to lift - INSTEAD, you should get close to the object you want to lift using your leg muscles to do the lifting Pull heavy objects - INSTEAD, you should push objects such as rolling beds or stretchers, using your leg muscles.

Techniques to protect your back Many back injuries happen when people lift things incorrectly. Here are some pointers about lifting safely.

DO: Get help, if you need to move something that is too heavy Use carts or dollies, when possible, to carry heavy objects Get directly in front of anything you need to lift so you can use your leg muscles. Reaching forward takes your body out of alignment Hold things close to your body, when lifting and carrying Face your load. If you need to turn, move your feet and never twist your back Use two hands to lift. If you only use one hand, you will be off-balance and your back muscles will not be set properly Take frequent stretch breaks, if you are doing a lot of lifting.

Annual Mandatory Education—Professional Nurse

Try to lift something that is too heavy Twist or turn your back while lifting Try to lift something over your head. This will make you use your back muscles instead of your leg muscles.

Follow these steps when lifting: Stand with your legs apart (about the width of your shoulders) and keep your back straight. Bend your knees and squat, keeping your heels off the floor. Tighten your stomach muscles and keep your chin tucked in. Pick up the object in a smooth motion and hold it close to your body, hugging the load. Straighten your knees. Once you are standing, change direction by pointing your feet in the direction you want to go and turning your whole body. Avoid twisting at the waist while carrying the load. Remember to keep your ears, shoulders, and hips in a straight line maintaining the three natural curves of your back. When you put the object down, follow the same steps in reverse.

Good health habits also protect your back. Get enough rest so that you are able to think clearly. People make mistakes more frequently when they are tired or under stress. Don't smoke. Nicotine robs the body of oxygen that the muscle cells need to work well. It also decreases blood flow to the muscles. Eat healthy. Being overweight puts extra stress on back muscles. Exercise to strengthen back, stomach, hip, and leg muscles.

Your facility may require that you wear a back belt if your job involves routine lifting. If you use a back belt, remember to tighten it before you lift anything. That is the only time it should be tightened.

Exercises for your back Most people do not exercise on a daily basis and when they do, it is often without the proper preparation.

Check with your doctor before you begin any exercise program. Try to exercise every other day. Inhale deeply before each repetition and exhale when performing the repetition.

The following exercises are from the American Academy of Orthopedic Surgery:

Wall slides to strengthen back, hip, and leg muscles Stand with your back against a wall and feet shoulder-width apart. Slide down into a crouch with knees bent to about 90 degrees. Count to five and slide back up the wall. Repeat five times.

Annual Mandatory Education—Professional Nurse

Leg raises to strengthen back and hip muscles Lie on your stomach. Tighten the muscles in one leg and raise it from the floor. Hold your leg up for a count of ten and return it to the floor. Do the same with the other leg. Repeat five times with each leg.

Leg raises to strengthen stomach and hip muscles Lie on your back with your arms at your sides. Lift one leg off the floor. Hold your leg up for a count of ten and return it to the floor. Do the same with the other leg. If that is too difficult, keep one knee bent and the foot flat on the floor while raising the other leg. Repeat five times with each leg.

Alternative leg raises You can also sit upright in a chair with legs straight and extended at an angle to the floor. Lift one leg waist high. Slowly return your leg to the floor. Do the same with the other leg. Repeat five times with each leg. Partial sit-up to strengthen stomach muscles Lie on your back with knees bent and feet flat on the floor. Slowly raise your head and shoulders off the floor and reach with both hands toward your knees. Count to ten. Repeat five times.

Back leg swing to strengthen hip and back muscles Stand behind a chair with your hands on the back of the chair. Lift one leg back and up while keeping the knee straight. Return slowly. Raise the other leg and return. Repeat five times with each leg.

Office Ergonomics

What does ergonomics mean? Ergonomics is about the design and arrangement of things so people and things interact safely and efficiently. The study of ergonomics is used to design things like chairs or work areas, so that the job gets done well and the worker is safe from injury.

Workers should know about ergonomics so they can: Avoid repetitive motions that cause repetitive stress injuries (RSI) Maintain proper body alignment Set up their work area to prevent personal injury.

When workers do not know those three things, injuries can occur.

Repetitive stress injuries at work include: Carpal tunnel syndrome Tendonitis Back injury

Annual Mandatory Education—Professional Nurse

Carpal tunnel syndrome Carpal tunnel syndrome is an RSI to the wrists. It can be caused by typing for long periods of time while using poor hand and wrist positions. It causes pain, weakness, and changes in sensations such as coldness, tingling, or numbness.

Tendonitis Tendonitis is inflammation of the "tendon" - the cord that connects a muscle to bone. Repetitive motions on a single body part can cause tendonitis, resulting in pain, tenderness, limited movement and swelling. Repeated overuse of the wrist (in typing), the arms (lifting heavy objects), the legs (carrying a lot of weight), and other body parts can cause tendonitis.

Back injury Many back injuries are caused by not lifting properly, lifting things overhead, pulling instead of pushing heavy objects, twisting or turning the back while lifting, being off balance by lifting with one hand, and being overweight.

Protect yourself from RSIs that usually cause pain, result in loss of time at work, and keep you from doing things you like to do.

Good posture for good health Back injuries are one of the most common workplace injuries. Back injuries are caused by poor posture, poor lifting habits, and poor health.

Prevent back injury by keeping good posture when sitting and standing, using good lifting techniques, and maintaining good general health.

Good posture Your back has three natural curves that form an S-shape. To keep your spine well aligned and moving smoothly, you must maintain the balance of these three curves. This alignment reduces stress on the spine and helps prevent back injury. Your back is aligned in good posture when your ears, shoulders, and hips are in a straight line.

Along with good posture, you should: Change positions frequently Alternately relax and stretch your muscles Move around to improve circulation, comfort, and flexibility.

Lifting techniques: Stand with your legs shoulder width apart. Keep the back straight while bending the knees and squatting. Pull the object close to your body. Copyright 2015, Cross Country University Page 36 of 284, Back Safety

Annual Mandatory Education—Professional Nurse

Tighten your stomach and lift your head. Rise using your leg muscles. Keep your ears, shoulders, and hips in a straight line.

Good health for good posture: Maintain a healthy weight. Condition your back. Exercise regularly. Get plenty of rest.

Good posture when standing, sitting, and lifting, and good general health help to prevent back injuries.

Your computer workstation and your health When your job involves sitting at a desk and using a computer for much of the time, you are at risk for injuries. If you set up your workstation to meet your needs and keep good body posture while at the computer, you can avoid injury.

Annual Mandatory Education—Professional Nurse

Set up your workstation as follows:

Monitor Place the monitor directly in front of you. Position the top of the monitor screen at or below eye level and an arm’s length or about 22 inches away. Tilt or swivel the monitor screen to avoid glare. Chair Choose a chair that is adjustable in height. The seat should be about 2 inches away from the back of your knees. Use the backrest of the chair for full support of the lower back. Sit up straight maintaining the natural curves of your neck and back.

Keyboard Sit in front of the "J" on the keyboard. Relax your shoulders. Allow clearance for knees under the keyboard. Bend arms and forearms at a 90° angle and keep your hand aligned with your forearm. Copyright 2015, Cross Country University Page 38 of 284, Back Safety

Annual Mandatory Education—Professional Nurse

Mouse Place the mouse at the same height as the keyboard and close to the keyboard to avoid reaching and shoulder stress. Use the keyboard rather than the mouse when possible. Keyboard shortcuts are available to replace many mouse actions and thereby reduce the stress on arms and shoulders.

Support for work tasks There are tools to help prevent injuries in the office and to help you do your job well.

Several support tools are available: A document holder is used to place documents close to the computer screen and at the same height and distance as the screen. A holder decreases stretching and reaching. A wrist rest can be used to rest the palms of your hands when you are not typing. A cradle that holds the phone and supports it on your shoulder should be used if you often tuck the phone between your ear and shoulder. The cradle keeps your ear and shoulder in alignment. Use carts or dollies to carry heavy objects when possible.

End of Back Safety Lesson

Bioterrorism

What is bioterrorism? Bioterrorism is the intentional use of biological agents to harm or kill civilian populations and cause fear.

Biological agents are bacteria and viruses that produce disease. These diseases are spread through person to person contact or through other mediums, such as: Powders Sprays Water or food.

Another type of terrorism you should be aware of is chemical warfare. Chemical warfare uses chemical agents, instead of biological agents, to harm or kill.

There is a real risk of terrorism Although at least 11 different nations have experimented with biological and chemical weapons, we have traditionally thought that they would never be used. The reasons for this thinking were: Countries have seldom used such weapons before Use of such weapons is morally distasteful Sophisticated labs are needed to produce and deliver such weapons The destructive potential is too great.

Annual Mandatory Education—Professional Nurse

It seems obvious in our post-9/11 world that this traditional thinking is false. Although most countries may hesitate to use biological or chemical agents, extremist terrorist groups of today may have an interest in obtaining such weapons. These groups may be willing to sacrifice themselves and any moral consideration for their cause.

Another problem is a lack of security at some labs, which could enable biological agents to be stolen. In 1997, for example, it was found that one lab in Russia was only loosely guarded. This lab contained a number of deadly viruses. Some of the Russian weapons stockpile, nuclear, biological, and conventional, is unaccounted for since the breakup of the Soviet Union.

Mechanisms of bioterrorist activity What are the chances of a bioterrorist attack? At this time, there is no clear answer. Although the threat is real, the risk of a large-scale attack is thought to be low. This is because of the difficulty of handling and spreading biological and chemical agents in large amounts.

There are three main mechanisms by which biological agents could be spread: 1. Through contact with skin, as in a powder or liquid 2. Through inhalation, if sprayed in a ventilation system or other manner so that the agents are suspended in the air and breathed in 3. Through ingestion of contaminated food or water supply.

If people are injured or become sick as a result of a bioterrorist attack, they will come to a medical facility for treatment. In many cases, the symptoms will not obviously be caused by terrorist activity. Hospital personnel must be very diligent in detecting the cause of a patient's symptoms. This will enable the correct treatment to be given and help to prevent further spread.

Agents of Bioterrorism

Biological agents The agents of bioterrorism are disease-producing bacteria and viruses. The bacteria and viruses that are most likely to be used by terrorist groups can be divided into two categories, based on the way they are spread: Only by direct contact with the biological agent By contact with the agent or person-to-person contact.

Agents that can only be spread through direct contact with the biological agent and not through contact with the infected person include: Anthrax Botulism Tularemia.

Annual Mandatory Education—Professional Nurse

Other agents can also be spread by person-to-person contact. These include: Smallpox The Plague (pneumonic form).

Anthrax Anthrax is caused by bacteria called Bacillus anthracis. It is usually found in hoofed animals and can be spread to humans who are exposed to infected animals.

There are three types of Anthrax: Cutaneous Inhalation Intestinal.

For purposes of bioterrorism, intestinal anthrax is very rare. This would be more difficult than spreading by other means.

Cutaneous This is the most common form of anthrax. Bacteria might be carried on a powder or on an infected animal. The bacteria are spread through contact with broken skin, such as a cut.

After an incubation period of 2 to 5 days, a papular (raised) lesion appears. After 2 to 2.5 days, this lesion becomes vesicular (filled with fluid). Eventually it becomes blackened and hard. Cutaneous anthrax is curable with antibiotics. If not treated, it can cause death in 5-20% of cases.

Inhalation This form is caused by breathing in the anthrax bacteria. In bioterrorism, the bacteria might be carried on a powder or spray. The incubation period can be 60 days or more.

Inhalation anthrax begins with flu-like symptoms. This makes it difficult to diagnose in the early stages. One suspicious sign to watch for is an elevated white cell blood count, which is not seen in a viral illness like the flu.

After the initial symptoms, the infected person improves, and then becomes very ill with severe respiratory symptoms. Death usually occurs within 24-36 hours.

The inhalation form of anthrax can be treated, but requires early detection and treatment to be effective. This is difficult because of the flu-like nature of the early symptoms.

New screening tests for anthrax are being developed. A vaccine has also been developed, but is not on the market yet.

Annual Mandatory Education—Professional Nurse

Botulism and Tularemia Two other biological agents that are spread only by contact with the agent are botulism and tularemia.

Botulism Botulism is caused by bacteria called clostridium botulinum. It is generally spread through food. The incubation period is 1 to 5 days. Symptoms include: Nausea Vomiting Weakness Dizziness.

Patients have no fever and remain alert and oriented. The illness progresses to affect the nerves and eventually paralyzes the respiratory muscles. Patients need to be on ventilators during recovery, which could be a problem if many people were affected at one time. After weeks to months of supportive care, most patients do recover. Tularemia Tularemia is caused by the bacteria francisella tularensis. It is primarily found in the Pacific U.S. and Midwest in rabbits, deer, birds, and other wildlife. It can be spread to humans through: Contact with infected animals Contaminated food or water Breathing in the bacteria.

Symptoms of tularemia include: Fever Chills Weakness Fatigue.

Other symptoms depend on the mode of infection and can include: Ulcer at infection site plus enlarged lymph nodes Enlarged lymph nodes with no ulcer Respiratory symptoms.

The respiratory mode of tularemia (known as Typhoidal) is the most serious and can be fatal 30-60% of the time if untreated. This is the type most likely to be used by terrorists.

Treatment of tularemia is symptomatic and includes antibiotics, such as streptomycin and tetracycline. People who have been exposed can be treated preventatively.

Annual Mandatory Education—Professional Nurse

Person-to-person contact Some disease-producing agents that may be used in bioterrorism cause illnesses that can also be spread from person to person. These include: The Plague Smallpox.

The Plague The Plague, also known as Black Death, is caused by the bacteria Yersina pestis. It is most commonly spread through bites from fleas carried on infected rodents. It can also be spread from person to person.

Pneumonic (respiratory) Plague is the most likely form to be used by bioterrorists. The incubation period is 1 to 4 days. Symptoms include: Severe weakness Myalgia (muscle pain) Fever Cough Bloody sputum Bruising Headache.

These symptoms are followed by septicemia and pneumonia. Treatment can be given using antibiotics. The patient will die quickly without treatment.

Pneumonic Plague is very contagious. It requires both standard precautions and droplet precautions. Antibiotic treatment should be given to anyone who has potentially been exposed.

Smallpox Smallpox is caused by the virus variola major. It is highly contagious. There is no treatment although research is being done on the effectiveness of new antivirals. It is fatal in 20-40% of cases and will likely leave scars, possibly very disfiguring scars.

Although smallpox only exists now in 2 labs, the possibility exists that it may have fallen into the wrong hands. Early symptoms are flu-like and include: High fever Headache Weakness Backache.

Symptoms may also include vomiting and abdominal pain. The fever disappears after 2 to 4 days.

Annual Mandatory Education—Professional Nurse

The incubation period is 7-19 days. After the initial symptoms, a rash develops. The rash progresses from macules (small red area) to papules (raised rash) to vesicles (fluid filled) to pustules (open) to scabs in about 5 days. Diagnosis is made from scrapings of the vesicles.

For those who have been exposed to smallpox, the vaccine may help to prevent or lessen the severity of the illness. This is especially true if the vaccine is given within 3 or 4 days of exposure.

Once a person has contracted smallpox, there is no treatment. Only supportive care can be given. Strict isolation and airborne precautions are required. Waste and laundry must be burned. Precautions must also be maintained during post-mortem care and cremation is necessary.

The smallpox rash moves from the face and extremities inwards to the trunk.

The smallpox rash is different from the typical chickenpox rash. The chickenpox rash begins on the face, upper trunk, and shoulders and spreads to the extremities. There may also be different stages in one area at the same time. For example, an extremity may have some new lesions and some scabbed over.

The smallpox rash starts on the face and extremities and moves inward to the trunk. All lesions in one area will be at the same stage.

Responding to the Threat of Bioterrorism

Recognizing potential terrorist activity People who are injured or who become sick as a result of biological or chemical terrorism will come to a medical facility for treatment. Initially, it might be that no one will know that a terrorist attack has occurred--even the victim.

The hospital, especially the emergency department, may be the first place to identify that an attack has occurred.

Annual Mandatory Education—Professional Nurse

Hospital and emergency department staff should be alert to possible signs of terrorist activity. These include: Increase in the incidence of a particular disease Disease with unusual geographic or seasonal distribution Large number of cases of unexplained diseases or deaths Large numbers of persons with similar disease or symptoms.

If you suspect a problem Healthcare workers in emergency departments and hospitals need to know what to do when faced with a potential bioterrorist situation. If you suspect a problem, you should tell: Your supervisor Physicians involved Infection control practitioner.

Law enforcement and your local public health department must also be informed of any potential or suspicious situations. The CDC (Centers for Disease Control and Prevention) has asked state health departments to have officials available 24 hours a day to investigate possible situations. Remember, time is very important in isolating the event and the persons involved.

If you suspect that a patient's symptoms could result from a bioterrorist attack, you should also take a careful history. Find out where the patient has been recently as well as complete details about the onset of the problem itself.

If people arrive at the emergency department who are obviously covered with an unknown substance or a known harmful substance, they must be decontaminated before entering. Allowing anyone to enter who is covered with a harmful chemical could contaminate the building and other people. Hospitals should have an outside decontamination area with proper showering equipment. You should know your hospital plan for dealing with this kind of situation.

Be sure that you know and use correct personal protective equipment, especially when dealing with an unknown situation. You should also know and implement your hospital plan for dealing with a terrorist incident. If your facility has a drill to practice this situation, treat it seriously. Treat it as though it were an actual event.

Suspicious packages One known example of bioterrorism has been the sending of anthrax through the mail. Because of this situation, the CDC has given guidelines for recognizing and handling suspicious packages and envelopes. These include: Inappropriate or unusual labeling Suspicious appearance Other signs. Copyright 2015, Cross Country University Page 45 of 284, Bioterrorism

Annual Mandatory Education—Professional Nurse

Inappropriate or unusual labeling might include such signs as: Too much postage Handwritten or poorly typed address Common words misspelled Strange or no return address Incorrect titles or titles with no names Not addressed to a specific person Marked with restrictions, such as "Personal," "Confidential," or "Do not x-ray" Threatening language Postmark that does not match the return address.

Suspicious appearance of a package or envelope includes such signs as: Powdery substance felt through or seen on a package or envelope Oily stain, discolorations, or odor Lopsided or uneven envelope Excessive packaging, such as tape, string, etc.

Other signs of a suspicious package or envelope include: Heavy weight Ticking sound Protruding wires or aluminum foil.

If you do discover a package or envelope that is suspicious, do not open it. The CDC recommends the following steps: Do not shake or empty contents. Do not carry, show to others, or allow others to look at it. Do not sniff, touch, taste, or look closely at it or at anything that spills out. Tell others in the area. Leave area, close the door, and prevent others from entering. Turn off ventilation system if possible. Wash hands with soap and water. Get help if you or others have been exposed. At work, contact supervisor and security officer. At home, contact law enforcement.

You should also create a list of everyone who was in the room or area when the package was received. Also, list any others who may have been exposed. Give the list to public health officials and law enforcement.

Annual Mandatory Education—Professional Nurse

End of Bioterrorism Lesson

Blood Products Administration

Blood products requiring ABO and Rh group and crossmatch prior to administering

Whole blood is blood with all blood components intact is used to quickly increase blood volume and oxygen (O2) carrying capacity.

Packed red blood cells (RBCs or PRBCs) is whole blood with about 80% of plasma removed; total volume usually 250 milliliters (mL). It is used to sustain or increase O2 carrying capacity, often as an intervention for blood loss or RBC destruction.

Each unit of whole blood or RBCs can raise adult hemoglobin level one gram per deciliter (1 g/dL), equivalent to an increase of 3%

Leukocyte-poor RBCs is the same as packed RBCs with about 95% of the leukocytes removed; total volume about 200 mL, This product is generally administered to patients who have had a febrile, nonhemolytic transfusion reaction (See Transfusion Reactions) caused by the WBC antigens in a transfused blood component reacting with the patient's WBC antibodies or platelets.

White blood cells (WBCs or leukocytes) is whole blood with both RBCs and 80% of plasma removed; total volume about 150 mL. WBCs are used to treat sepsis unresponsive to antibiotics (especially if the patient has positive blood cultures or a persistent fever exceeding 101° F [38.3° C] and granulocytopenia [granulocyte count usually less than 500/microliters (µl)]).

White blood cell transfusions cause febrile transfusion reaction. Due to limited evidence that WBC transfusions are effective, and to the risk of transmission of infectious diseases such as cytomegalovirus (CMV), WBCs are not commonly in use.

Platelets is platelet sediment from RBCs or plasma; total volume 35 to 50 mL/ unit; 1 unit of platelets is expected to increase adult platelet count by 20-40 x 109/Liter (L). Platelets are indicated in thrombocytopenia, high volume transfusion of stored blood, leukemia, and preoperatively in low platelet count.

Blood products that do not require type and crossmatch

Annual Mandatory Education—Professional Nurse

Fresh frozen plasma (FFP) is uncoagulated plasma separated from RBCs and provides coagulation factors V, VIII, and IX; total volume is 200 to 250 mL. FFP can replace a missing or deficient blood factors. Note: It is no longer used for volume expansion, as prophylaxis after cardiac surgery, or with high volume blood transfusions.

Albumin 5% (buffered saline) and albumin 25% (salt-poor saline) is small plasma protein prepared by fractionating pooled plasma; total volume of 5% product is 12.5 g/250 mL; total volume of 25% product is 12.5 g/50 mL. Albumin is indicated as a volume expander in shock, burns, trauma, and infections; and to treat hypoproteinemia (with or without edema).

Factor VIII is the insoluble portion of plasma recovered from FFP; total volume about 30 ml (freeze- dried). Most recognizable as a treatment for hemophilia A, it is used to control bleeding associated with factor VIII deficiency, and to replace fibrinogen or deficient factor VIII.

Factors II, VII, IX, and X complex (prothrombin complex) is lyophilized (freeze-dried), commercially prepared solutions drawn from pooled plasma. Factors II, VII, IX, and X are indicated for various factor deficiencies that cause bleeding disorders. Note: These products are contraindicated in patients with fibrinolysis secondary to hepatic disease or in patients with disseminated intravascular coagulation and are not receiving heparin therapy.

Alternatives volume expanders include normal saline or lactated Ringer's solution, albumin or purified protein fractions, hydroxyethyl starch or dextrans

Pretreatment Care 1. Explain the procedure and ensure that the patient understands the procedure.

2. Ensure that informed consent has been given according to your organization’s policies.

3. Monitor baseline and ongoing vital signs according to policy.

4. Within 30 minutes of the procedure, get the blood product from the lab. Never store blood products at the point of care. Return the blood to the lab for storage if the procedure will be delayed by 30 minutes or more.

5. The Joint Commission’s National Patient Safety Goals require that one of the two following verification systems be used:

a. 2-person process in which one person is qualified to administer the blood product and the other person is qualified to participate in the verification process, as determined by organization standards.

Annual Mandatory Education—Professional Nurse

b. 1-person process in which the verifier is qualified to administer the blood product and verification includes an automated technology such as bar coding.

6. Before initiating a blood or blood component transfusion: a. Match the blood or blood component to the order b. Match the patient to the blood or blood component c. Use a two-person verification process or a one-person verification process accompanied by automated identification technology, such as bar coding d. Check the expiration date e. Examine for anomalous appearance (color, foreign objects, bubbles) f. Match the patient’s name and medical record number on the ID band with those on the on the blood product bag label. g. Ensure the appropriate blood product, and if applicable, the ABO blood group, and Rh compatibility. h. Match the patient's blood bank identification number with that on the blood bag.

Procedure

Setup, verification, and administration 1) Don appropriate personal protective equipment (PPE).

2) Verify patient identity.

3) Confirm IV patency or start an IV, 20 Gauge (G) or larger and in children or older patients, no larger than 20G.

4) Flush IV line with saline before (and after) transfusion, and keep the vein open between transfusions. Note: Only isotonic saline is suitable for an IV that will be used to transfuse blood products. Ensure that no additives are present. For example, calcium can cause clotting in the IV tubing, and glucose can hemolyse blood cells.

5) An infusion pump and blood warmer may be ordered.

6) Verify the appropriate blood or blood component with the doctor's order and verify the patient to the blood component. One verifier must be the appropriately qualified person who will administer the blood component. The second verifier must be appropriately qualified to conduct the verification.

7) Generally, verification of the blood product includes these steps: a) Match the patient wristband name and identification number to the blood bag label. b) Confirm the blood bag identification number, ABO blood group, and Rh compatibility.

Annual Mandatory Education—Professional Nurse

c) Match the patient's blood bank identification number with the number on the blood bag.

8) The Joint Commission’s National Patient Safety Goals require that one of the two following verification systems be used:

a) 2-person process in which one person is qualified to administer the blood product and the other person is qualified to participate in the verification process, as determined by organization standards. b) 1-person process in which the verifier is qualified to administer the blood product and verification includes an automated technology such as bar coding.

9) Monitor the patient closely and adjust the flow rate to no greater than 2 mL/minute for the first 15 minutes of the transfusion to observe for a possible transfusion reaction.

10) Remain with the patient and reassess his vital signs and blood pressure, facial color, and any complaints frequently for the first 15 minutes, according to facility policy.

11) If signs of a reaction develop, stop the transfusion and record the patient's vital signs. Infuse normal saline solution through a new I.V. line at a keep-vein-open-rate, and notify the physician. Save the blood product bag for return to the blood bank. Obtain a urine and blood sample and send them to the laboratory.

12) If no signs of a reaction appear within 15 minutes, adjust the flow to the ordered infusion rate, which should be as rapid as the circulatory system can tolerate.

13) After completion, flush the administration set and I.V. catheter with normal saline. Remove and discard the infusion equipment and reconnect the original I.V. fluid if necessary or discontinue the I.V. access.

14) Discard the blood bag, tubing, and filter in the appropriate hazardous waste container.

15) Monitor and assess the patient for 1 hour after the transfusion for signs and symptoms of delayed transfusion reaction.

Procedural variations for specific blood products

Whole blood and PRBCs Use a Y-type I.V. set with a 170-micron filter. Alternatively, a 20-40-micron filter is sometimes ordered.

Leukocyte-poor RBCs

Annual Mandatory Education—Professional Nurse

Use a straight-line or Y-type I.V. set. Infuse blood over 1½ to 4 hours. Use a 40-micron filter suitable for hard-spun, leukocyte-poor RBCs.

WBCs (not commonly in use) Use a straight-line I.V. set with a standard in-line blood filter. Provide 1 unit daily for 5 days or until the infection resolves.

Because a WBC infusion induces fever and chills, administer an antipyretic if fever occurs. Don't discontinue the transfusion; instead, reduce the flow rate, as ordered, for patient comfort.

Agitate the WBC container to prevent settling, thus preventing the delivery of a bolus infusion of WBCs.

Diphenhydramine (Benadryl) will likely be administered prior to transfusion of WBCs.

Platelets Use component drip administration set to infuse 100 mL over 15 minutes. As prescribed, premedicate with an antipyretic and an antihistamine if the patient's history includes a platelet transfusion reaction. If the patient has a fever before administration, notify the practitioner for probable delay of the transfusion.

FFP Use a straight-line I.V. set, and administer the infusion rapidly.

Albumin Use a straight-line I.V. set with rate and volume dictated by the patient's condition and response. Albumin is contraindicated in severe anemia. Keep in mind that albumin is contraindicated in patients with severe anemia. Use caution when administering to patients with cardiac or pulmonary disease due to potential circulatory overload.

Factor VIII Use the administration set supplied by the manufacturer. Administer with a filter; the standard dose recommended for the treatment of acute bleeding episodes in patients with hemophilia is 15 to 20 units/kg.

Factors II, VII, IX, and X complex Use a straight-line I.V. set, basing the dose on the desired factor level and the patient's weight. Coagulation assays are drawn prior to administration and at intervals throughout treatment.

Post-treatment Care

Annual Mandatory Education—Professional Nurse

Change the blood or blood administration set and filter after each unit or as needed to ensure sterility and/or system integrity.

If evidence of bleeding or reactivity develops at the I.V. site, discontinue the transfusion and the IV and notify the prescriber. Follow your facility's policy for treatment of the reaction site.

Monitor I&O, and signs of fluid overload such as lung status and edema.

After completing the transfusion, adhere to standard precautions and remove and discard the used infusion equipment in the biohazard material receptacle. Reconnect the original I.V. fluid, if necessary, or discontinue the I.V. infusion.

Return the empty component bag to the blood bank, if facility policy dictates.

Record the patient's vital signs.

Prepare to draw blood for a platelet count, as ordered, 1 hour after platelet administration to determine platelet transfusion increments.

Keep in mind that large-volume transfusions of FFP may require correction for hypocalcemia because citric acid in FFP binds calcium.

The half-life of factor VII is 8 to10 hours, which necessitates repeated transfusions at specified intervals to maintain normal levels.

Patient Teaching

Teach the patient to immediately report the following complaints to the nurse: o Flushing, feverish feeling, chills, nausea, headache (transfusion reaction) o Palpitations (with hypotension, arrhythmia, and shaking chills; may be sign of hypothermia) o Difficulty swallowing or breathing (possible anaphylaxis) o Tingling in the fingers, muscle cramps, nausea and vomiting, faintness (with hypotension, arrhythmia, and seizures; may signal hypocalcemia from citrate toxicity or liver impairment) o Intestinal colic, diarrhea, muscle weakness (with irritability, oliguria, T-wave changes on the electrocardiogram, and bradycardia; may signal hyperkalemia from large-volume transfusions).

Explain to the patient that additional transfusions may be needed.

Annual Mandatory Education—Professional Nurse

Inform the patient that specimens may be drawn to evaluate the effectiveness of therapy.

Blood transfusion reaction

Stop the transfusion in the event of a reaction Organization standards differ, but generally, when any evidence of a transfusion reaction occurs, stop the transfusion, and maintain a patent IV access with saline solution. Follow your organization standards for specific practices regarding IV flushing and admin set replacement practices, lab tests, and vital signs.

Overview Transfusion reactions occur with a variety of symptoms and severity. Transfusion reactions are grouped as follows: Transfusion-related acute lung injury (TRALI) Circulatory overload Bacterial contamination Acute hemolytic transfusion reaction (immune or nonimmune related) Nonhemolytic febrile transfusion reaction Allergic reactions

Transfusion-related acute lung injury (TRALI) Though relatively rare, less than 1 in 5,000, TRALI is the number one cause of death from transfusion reaction. Antibodies in the donor’s plasma cause a reaction that impairs breathing. Male-donated blood reduces the risk of TRALI to some extent.

Patients whose reactions are mild to moderate are treated with O2 and ventilator support as needed while the lungs recover.

Symptoms Shortness of breath of rapid onset Hypoxemia Rales Absence of signs of acute pulmonary edema No fever

Circulatory overload Many patients, especially those with compromised cardiac function have difficulty tolerating the additional fluid of a transfusion. Reactions are similar to those of heart failure, such as edema and/or dyspnea. Cardiac patients are generally transfused more slowly. Patients with evidence of fluid overload reaction are often treated with diuretics.

Annual Mandatory Education—Professional Nurse

Hypoxemia Rales Orthopnea Tachycardia Jugular venous distention Crackles at lung bases Dependent edema

Bacterial contamination Though blood products are tested carefully, infections cannot always be detected, especially where the donor was infected shortly before giving blood. Treatment is as for any sepsis.

Symptoms High fever Chills Vomiting Diarrhea Marked hypotension Weak pulse

Hemolytic reaction Subtle mismatches between host and donor blood (as well as occasional treatment errors) can result in the destruction of the donor’s red blood cells during or after the transfusion. Along with TRALI, this type of reaction has the highest death rate.

The patient may experience vague anxiety or discomfort, dyspnea, flushing, back pain, or chest pressure. Usually, this reaction starts as general discomfort or anxiety during or immediately after the transfusion. Severe shock can result, and this reaction can be fatal. As soon as this reaction is detected, the transfusion is stopped and the patient is supported according to the symptoms. A delayed hemolytic reaction can occur up to a month after transfusion, though these are usually mild.

Symptoms Fever Hypotension Flushing Wheezing Anxiety Red-colored urine Disseminated intravascular coagulation (late)

Annual Mandatory Education—Professional Nurse

Nonhemolytic febrile transfusion reaction Fever is the most common transfusion reaction, and is likely a response to transfused WBCs or their metabolic products. Chills, headache, back pain sometimes accompany fever. Generally acetaminophen is the only treatment needed. For purposes of whether or not stop a transfusion when a patient’s temperature elevated, standards vary. Generally, when no other symptoms are present, a transfusion should be stopped when temperature elevates more than 1 degree C or 2 degrees F.

Allergic reactions Allergic reactions are almost as common as febrile reactions. Some patients react to donor blood with classic allergic reaction symptoms such as itching, swelling, urticaria and other skin rashes, dizziness, and headache. Allergic reactions may be severe as well and cause breathing problems, hypotension and shock. In the event of an allergic reaction, the transfusion is stopped and the patient is treated accordingly.

Washed red blood cells can be given to patients who have a history of allergic reaction to transfusion. Washed RBCs have reduced amounts of WBCs and platelets.

Symptoms Urticaria Itching, maculopapular rash Flushing Asthmatic wheezing Anaphylaxis

Just for fun This lesson is concerned with transfusion and transfusion reactions. Blood group content was not addressed; however it is an important background to this content and deserves further study. Click the link below to play a game that will provide a good grounding on the technique and importance of typing and cross-matching. http://www.nobelprize.org/educational/medicine/bloodtypinggame/game/index.html

References Blood and blood product transfusion, Lippincott’s Nursing Procedure and Skills, Revised October 6, 2012.

Blood Facts and Statistics, American Red Cross, http://www.redcrossblood.org/learn-about-blood/blood-facts-and- statistics, Last visited June 20, 2013.

End of Blood Products Administration

CMS HACs and IHI Care Bundles

Annual Mandatory Education—Professional Nurse

CMS Hospital Acquired Conditions Federal legislation has mandated that the Centers for Medicare & Medicaid Services (CMS) work to reduce the cost of care. An effective strategy has been to identify the most common and costly hospital- acquired conditions, and financially incentivize facilities to provide safer and speedier care that reduces the incidence and severity of these conditions.

Each healthcare facility will have local standards and procedures to address these conditions. Know your facility standards.

If acquired during the hospital stay, CMS may not reimburse the hospital for the care of the following conditions.

Foreign Object Retained After Surgery Air Embolism Blood Incompatibility Stage III and IV Pressure Ulcers Falls and Trauma o Fractures o Dislocations o Intracranial Injuries o Crushing Injuries o Burn o Other Injuries Manifestations of Poor Glycemic Control o Diabetic Ketoacidosis o Nonketotic Hyperosmolar Coma o Hypoglycemic Coma o Secondary Diabetes with Ketoacidosis o Secondary Diabetes with Hyperosmolarity Catheter-Associated Urinary Tract Infection (UTI) Vascular Catheter-Associated Infection Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG): Surgical Site Infection Following Bariatric Surgery for Obesity o Laparoscopic Gastric Bypass o Gastroenterostomy o Laparoscopic Gastric Restrictive Surgery Surgical Site Infection Following Certain Orthopedic Procedures o Spine o Neck o Shoulder o Elbow

Annual Mandatory Education—Professional Nurse

Surgical Site Infection Following Cardiac Implantable Electronic Device (CIED) Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Following Certain Orthopedic Procedures: o Total Knee Replacement o Hip Replacement Iatrogenic Pneumothorax with Venous Catheterization

HACs of special interest

Multi-drug Resistant Organisms (MDRO) From the CDC: Preventing infections will reduce the burden of MDROs in healthcare settings. Prevention of antimicrobial resistance depends on appropriate clinical practices that should be incorporated into all routine patient care. These include optimal management of vascular and urinary catheters, prevention of lower respiratory tract infection in intubated patients, accurate diagnosis of infectious etiologies, and judicious antimicrobial selection and utilization. Guidance for these preventive practices include the Campaign to Reduce Antimicrobial Resistance in Healthcare Settings (www.cdc.gov/getsmart/healthcare/), a multifaceted, evidence-based approach with four parallel strategies: infection prevention; accurate and prompt diagnosis and treatment; prudent use of antimicrobials; and prevention of transmission.

Two basic elements of an effective MDRO reduction program include: Administrative support Examples include Active Surveillance, a regimen of admission testing and isolation and treatment of patients with MDROs; prompt and effective communications; provision of adequate and accessible hand washing sinks and alcohol-containing hand rub dispensers; staffing levels appropriate to the intensity of care required; and enforcing adherence to recommended infection control practices.

Education The focus of the interventions was to encourage a behavior change through improved understanding of the problem MDRO that the facility was trying to control. Whether the desired change involved hand hygiene, antimicrobial prescribing patterns, or other outcomes, enhancing understanding and creating a culture that supported and promoted the desired behavior, were viewed as essential to the success of the intervention.

Central Line-associated bloodstream infections (CLABSI) Strategies such as implementation of IHI Care Bundles have reduced Central line-associated bloodstream infections (CLABSI) more than 50% in critical care patients in the last decade. But outside critical care areas, CLABSIs have increased.

The CDC guidelines are available at http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf.

Annual Mandatory Education—Professional Nurse

Surgical Complications and SCIP Measures Surgical site infections comprise 15% of all HAIs, and patients who develop a surgical site infection are at twice the risk of death compared to other surgery patients.

The Surgical Care Improvement Project (SCIP) is a partnership of several organizations including The Joint Commission and CDC intended to monitor and reduce surgical morbidity and mortality through the systematic reduction of surgical complications.

Hospitals track and report SCIP quality measures including: 1. Prophylactic Antibiotic Start within 1 Hour Patients receiving antibiotics within one hour prior to surgery have reduced rates of infection.

2. Prophylactic Antibiotic Selection for Surgical Patients The rate of patients appropriately receiving prophylactic antibiotics is a useful quality measure.

3. Prophylactic Antibiotics End within 24 Hours There is typically no reason for patients to continue taking antibiotics after 24 hours, and those who do are at risk for side effects.

4. Cardiac Surgery Patients with Controlled Postoperative Glucose Coronary artery bypass graft (CABG)/cardiac surgery patients are at higher risk for complications when their glucose is not kept in good control in the days after surgery.

5. Surgery Patients with Appropriate Hair Removal Electric clippers and/or hair removal cream is considered to have a lower infection risk than razors for hair removal.

6. Patients Receiving VTE Prophylaxis within 24 Hours Prior to or After Surgery Prophylaxis for blood clots can reduce infection risk.

7. Patients on Beta Blockers PTA (Prior to Arrival) Who Received Beta Blockers Perioperatively Studies have suggested that beta-blocker administration before surgery tends to enhance survival rates.

IHI Care Bundles The Institute for Health Improvement (IHI) is a research and education non-profit dedicated to the improvement of care. The organization has delineated several care bundles based on evidence-based best practices that improve care for certain conditions.

The following information is quoted from the IHI webpage linked here: IHI Q&A, What is a bundle?

Annual Mandatory Education—Professional Nurse

What is a care bundle? A bundle is a structured way of improving the processes of care and patient outcomes: a small, straightforward set of evidence-based practices — generally three to five — that, when performed collectively and reliably, have been proven to improve patient outcomes.[1]

A bundle is a specific tool with clear parameters. It has a small number of elements that are all scientifically robust, that when taken together create much improved outcomes. Don’t feel compelled to convert helpful checklists into overloaded bundles. If the concept of a bundle becomes so broad and loose in meaning, its power will start to diminish. We don’t want that to happen.

The elements are all necessary and all sufficient, so if you’ve got four changes in the bundle and you remove any one of them, you wouldn’t get the same results — meaning: the patient won’t have as high a chance of getting better. It’s a cohesive unit of steps that must all be completed to succeed.

The elements are all based on randomized controlled trials, what we call Level 1 evidence. They’ve been proven in scientific tests and are accepted, well-established.

The elements in a bundle involve all-or-nothing measurement. Successfully completing each step is a simple and straightforward process. It’s a “yes” or “no” answer: “Yes, I did this step and that one; no, I did not yet do this last one.” Successfully implementing a bundle is clear-cut: “Yes, I completed the ENTIRE bundle, or no, I did not complete the ENTIRE bundle.” There is no in between; no partial “credit” for doing some of the steps some of the time.

Bundle changes also occur in the same time and space continuum: at a specific time and in a specific place, no matter what. This might be during morning rounds every day or every six hours at the patient’s bedside, for instance.

Example 1: Central Line Bundle: This is a set of five steps to help prevent “catheter-related blood stream infections,” deadly bacterial infections that can be introduced through an IV in a patient’s vein supplying food, medications, blood or fluid. The steps are simple, common sense tasks: using proper hygiene and sterile contact barriers; properly cleaning the patient’s skin; finding the best vein possible for the IV; checking every day for infection; and removing or changing the line only when needed.

Example 2, Ventilator Bundle: Ventilator-associated pneumonia (VAP) is a serious lung infection that can happen to patients on a ventilator. The Ventilator Bundle has four care steps: raising the head of the patient’s bed between 30 and 40 degrees; giving the patient medication to prevent stomach ulcers; preventing blood clots when patients are inactive; and seeing if patients can breathe on their own without a ventilator.

What’s the difference between a bundle and a checklist?

Annual Mandatory Education—Professional Nurse

A checklist can be very helpful and an important vehicle for ensuring safe and reliable care. The elements in a checklist are often a mixture of nice-to-do tasks or processes (useful and important but not evidence-based changes) and have-to-do processes (proven by randomized control trials). A checklist may also have many, many elements.

A bundle is a small but critical set of processes all determined by Level 1 evidence. And it needs to meet all the criteria I described previously. Because some elements of a checklist are nice to do but not required, when they are not completed, there may be no effect on the patient. When a bundle element is missed, the patient is at much greater risk for serious complications.

There’s also a level of accountability tied to a bundle that you don’t always have with a checklist. An identified person or team owns it. A checklist might be owned by everybody on a floor or on a team, but we know that, in reality, when it’s owned by everyone — nobody owns it! Things don’t always get done. So maybe the pharmacist does one thing in a checklist, a nurse another, the doctor something else, but really it’s no one person’s job at the end of the day. A bundle is a person or a team’s responsibility — period. And it’s their job at a certain point and time — during rounds every single day, possibly. So it isn’t the kind of thing where people say: “You check that, I’ll check this.” No. It’s very clear who has to do what and when, within a specific time frame. The accountability and focus give a bundle a lot of its power.

End of CMS HAC and IHI Lesson

Consent for Treatment

What does "informed" consent mean? Informed consent is a process in which consent is obtained for a treatment or healthcare service when the patient knows about and understands the treatment, including its implications, benefits and risks, and the alternatives. The patient must know they have the right to accept or refuse the treatment or service.

Before undergoing treatment, patients must give consent. Some patients may not be capable of giving consent because of their age, mental competence, or other possible factors. In a situation in which the patient cannot give consent, a guardian represents that patient. The designated guardian may be a parent, other relative, friend, or caregiver. Healthcare workers must ensure that the consent is "informed" and signed by either the patient or the guardian.

The Patient's Bill of Rights supports the right of patients to have information that they can understand all treatment options, and to participate in the decision-making process.

Annual Mandatory Education—Professional Nurse

Consent is a legal process and it is usually represented as a written document. It is illegal to proceed with treatment or surgery without informed consent. If a patient refuses treatment, the physician should be informed.

Process for obtaining consent The process for obtaining consent involves knowing about: When consent must be obtained When consent does not need to be obtained What must be written on the consent form Who must sign the consent form.

When consent must be obtained Consent is obtained when a patient is admitted. This consent gives permission for your organization to treat the patient represented on the consent form. Invasive treatments, such as surgery, require an additional consent form.

When consent does not need to be obtained In an emergency, where life or limb is threatened, informed consent may not be necessary, unless the practitioner has reasonable knowledge that the patient would ordinarily refuse the treatment or procedure. If the practitioner knows that a patient needs a blood transfusion, but belongs to a religious group that does not condone blood transfusions, the physician cannot give the blood transfusion without informed consent.

What must be written on the consent form The consent form is a legal document that states the procedure to be performed, alternatives, and any risks involved. The form must be written in language the patient understands. Medical terms must be clarified. For example, 'appendectomy' might be written as 'operation to remove appendix'.

Who must sign the consent form The patient signs the consent form. If incapable of signing, the patient may be represented by a guardian. At the time of signing, the person signing must be mentally competent and able to understand the form. Patients should not sign a consent form if they are sedated or not fully awake and aware. Awareness can be assessed using the 'oriented x3' tool. Oriented x 3 means determination of orientation to time, person, and place. Questions are asked to determine if the patient knows who and where they are, and knowledge of day of week and time of day. The witness signs the form to witness the patient's or the guardian's signature. The witness is someone who is not directly involved in the procedure or treatment. The witness may be a nurse on the nursing unit, or admitting personnel in the Outpatient/Admitting area.

Rights and responsibilities in informed consent There are two aspects to rights and responsibilities in informed consent:

Annual Mandatory Education—Professional Nurse

Patient's right to information and choices Healthcare workers' responsibilities in the consent process

The physician, nurse practitioner, physician assistant, or other designated person must explain the procedure, expected benefits, alternatives to the procedure and the risks. The treatment or procedure is fully discussed, and the patient is given the opportunity to ask questions and make decisions.

Signing a consent form must be a voluntary process. After signing the consent, patients still have the right to refuse a treatment or procedure.

Health care workers must know their responsibilities in the consent process and must support the Patients' Bill of Rights and the ethical principles in healthcare. Their responsibilities in the consent process are crucial to the patient's treatment, procedures, and healthcare services.

The physician, nurse practitioner, physician assistant, or designated person is responsible for explaining the procedure, its implications, expected benefits and risks, and alternatives to the procedure. The treatment or procedure must be discussed fully to satisfy the patient's or guardian's needs. The patient must be given the opportunity to ask questions and make decisions.

The witness should ask questions to verify that the patient or guardian understands the procedure. The witness is NOT responsible for explaining the procedure or treatment. If the witness determines that the person signing the consent does not understand the form or the procedure, the witness MUST NOT allow the form to be signed and must notify the person who will be doing the procedure. If the patient or guardian signs the form with an "x", the witness must document the reason why the signature is an "x".

End of Consent for Treatment Lesson

Corporate Compliance

Ethical Business Practice

What is corporate compliance? Corporate compliance refers to comprehensive programs of internal control designed to prevent and detect fraud and abuse within healthcare facilities. The goal of compliance programs is to create an atmosphere within the facility that promotes ethical conduct according to State and Federal laws and operational standards required by insurance companies. Fraud and abuse are prosecuted under the False Claims Act with heavy fines attached to each offense.

The Department of Justice has made healthcare fraud a high priority, second only to violent crime. Increased resources have been allotted and efforts are ongoing to detect fraud and abuse within

Annual Mandatory Education—Professional Nurse

healthcare facilities. Fraud and abuse are being prosecuted under the False Claims Act with fines ranging from $5,000.00 to $10,000.00 per episode, plus triple the amount of the false claims. (For example: if 2 procedures were performed, but were billed as 8 performed, the cost of the 6 claimed procedures that were not performed would be tripled in the fine.) As a result, the best defense for a facility is to develop a compliance program. Such a program will not guarantee immunity from prosecution, but if a commitment to compliance is evident within the facility, it will be taken into account should an investigation take place.

Fraudulent and ethical business practices Fraud is the act of deceiving. It is the intentional distortion of truth in order to induce another person to part with something of value.

Examples of fraudulent practices are: Billing for services or goods not rendered Coding diagnoses falsely to obtain higher reimbursement (Medicare reimburses according to the code corresponding to the diagnosis, known as the Diagnosis Related Group or DRG) Receiving kickbacks (percentage of the fee charged) for diagnostic tests when referring patients Filing false claims Misquoting prices

Ethics is a set of moral principles and values. It is the discipline of dealing with right and wrong. Ethical business practices include: Accurate billing procedures Accurate filing of claims Accurate coding or assigning proper DRG Honest referrals Reporting abuses of the system

Strong compliance programs show patients, employees, and the community that the facility has made a commitment to conducting business ethically and legally. It also serves to ensure a high quality of care for patients and their families.

Elements of compliance A compliance program must contain seven basic elements for a facility to be deemed effective at compliance. The elements are: Standards of conduct Responsibility Internal reporting mechanism Education and training Internal policing Discipline Copyright 2015, Cross Country University Page 63 of 284, Corporate Compliance

Annual Mandatory Education—Professional Nurse

Evaluation and modification

Standards of conduct A facility should have comprehensive written standards of conduct and other policies that promote the group's commitment to compliance.

Responsibility It is essential that a facility designates a compliance officer or have a particular person responsible for implementing and monitoring the compliance process.

Internal reporting mechanism A facility should have an internal reporting system for receiving complaints and suspected problems. Employees should feel comfortable about making a report when necessary and not fear retaliation for doing so.

Education and training A facility must provide education and training for all staff that is tailored to the demands of the compliance process and meets current federal requirements. Priority should be given to risk areas that have been identified. Training materials should be continuously updated as federal requirements change. Internal policing A facility must have auditing systems to monitor the effectiveness of the compliance process. The auditing system should include employee interviews, chart reviews, and prospective billing audits.

Discipline A facility must have mechanisms for enforcing compliance programs and disciplining employees. Finding problems does not indicate ineffectiveness, but failing to correct problems and failing to take action to prevent further occurrences will severely weaken a compliance program.

Evaluation and modification A facility should implement a program of modifications to prevent future offenses. Self-evaluation is necessary to determine weaknesses and correct processes. Each element of a compliance program should be documented. Written reports are important and should include all policies, minutes of compliance committee meetings, meeting attendance sheets, training sessions, copies of training materials, employee screening reports, disciplinary reports, enforcement measures, and evaluation and modification of procedures.

Discovery of Fraud

What is fraud? Fraud is an intentional deceptive act done for unfair or unlawful gain. Examples of healthcare fraud include: Copyright 2015, Cross Country University Page 64 of 284, Corporate Compliance

Annual Mandatory Education—Professional Nurse

Deliberate overcharging Unnecessary home health visits to obtain reimbursement Unnecessary procedures done for financial gain.

Giving false information for gain is also fraud. Examples of false information for gain include: Duplicate billing False codes on healthcare visits or procedures to obtain a higher reimbursement Claims for reimbursement of home health visits that were not made False reports.

Fraud does not include acts that are honest mistakes. Mistakes can occur in billing and there can be reimbursement discrepancies but neither is fraud.

What to do if you suspect fraud The federal Child Abuse and Prevention Treatment Act (CAPTA) defines child abuse and all employees have a duty to report cases of fraud. It is also important that you alert your organization to cases that could look like fraud. After being alerted, the organization can solve the problems, and avoid legal accusations of fraud.

To be able to report fraud, you should know that: Your organization has a policy and procedure for reporting suspected fraud You may need to contact a specific person, and/or dial a hotline number You cannot be penalized by your organization for reporting suspected fraud.

How to prevent fraud and suspicions of fraud Mistakes such as simple billing errors and reimbursement discrepancies occur and, although not fraud, must be investigated to prevent future errors and to ensure that fraud is not intended. Prevent all errors that could possibly appear as fraud or raise the suspicion of fraud.

If your job involves billing, charging, or coding: Learn the policies and procedures, and then follow them Document your work accurately Seek training if you do not understand how to do tasks Take advantage of training opportunities that will help you do your job better Be thorough and ask for help if needed Treat all customers and patients courteously Always give customers and patients accurate information Cooperate in internal audits - they are in place to discover and then correct problems.

End of Corporate Compliance Lesson

Annual Mandatory Education—Professional Nurse

Cultural Competence

What is cultural competence Cultural competence is the ability to effectively communicate with people of different cultures, and to embrace cultural diversity among those with whom you interact. Understanding the terms ‘culture’ and ‘diversity’ are key to an understanding of cultural competence.

Culture Culture is a way of life. It is the knowledge, beliefs, and values of an ethnic or religious group, nationality group, or social group. Culture guides the groups' thoughts, decisions, and actions. The customs of each culture are learned and passed from one generation to another.

Diversity Diversity is variety. It is the human qualities that are different from our own and the groups to which we belong but are present in other individuals and groups. Diversity can be divided into two sub-categories: The primary category includes things that we cannot change such as age, ethnicity, physical abilities, race, and sexual orientation. The secondary category includes things that can be changed such as educational background, geographic location, income, marital status, military experience, parental status, religious beliefs, and work experiences.

Cultural diversity Cultural diversity refers to the differences between cultural groups and within cultural groups. For example, diversity within the Asian-American culture includes Korean Americans and Japanese Americans.

Cultural differences can be found throughout our country. For example: the popular sandwich made from a small bread roll and filled with a variety of meat, cheeses, and vegetables might be called a sub, submarine, poor boy, hoagie, grinder or foot-long depending on which area of the country you are in.

The influence of culture on behavior All cultural groups have certain customs, normal behaviors, beliefs, superstitions, and language that guide how they: Live Make decisions Face a crisis Communicate Structure their society Prepare food and eat Celebrate holidays Dress. Copyright 2015, Cross Country University Page 66 of 284, Cultural Competence

Annual Mandatory Education—Professional Nurse

The extent to which someone's cultural background influences their behavior is dependent on factors such as: Gender Sexual orientation Class Education Status within the family Immigrant status.

Examples of how culture influences behavior are: A Russian woman who has only been in the United States for a month and does not yet understand English will behave differently than a Russian woman who was born and raised in the United States even if she were raised learning Russian customs and language. People of all cultures have a "comfort zone" that determines how close they allow someone they don't know well to stand next to them. If someone gets too close, they feel uncomfortable. Cultures such as those in South American countries have a "small" comfort zone. If someone whose culture has a "wide" comfort zone meets with someone from South America who stands too close, the behavior of the South American may be incorrectly interpreted as being aggressive.

Prejudice and stereotyping The United States is a country of very diverse cultures. Its citizens come from 120 different countries with many different languages, religions, and customs. Not understanding how culture affects the way people act often results in prejudice and stereotyping.

Prejudice is a premature judgment; a positive or negative attitude or opinion about a person or group that is not based on facts. Prejudices may also result from an emotional experience with a person from a similar culture or group. A person who thinks or says, "I don't want Hispanics living in my neighborhood," is expressing a prejudice.

Prejudices are usually based on stereotypes which are over-simplified and over-generalized views about individuals or groups of people who belong to a different religion, race, nationality, or other group. They involve strong feelings that are difficult to change. Stereotypes also provide us with role expectations such as how we expect the other person or group to relate to us and other people. It is important NOT to over-generalize the characteristics of a culture and use them to label an individual within that cultural group.

Annual Mandatory Education—Professional Nurse

"Teenagers are music-crazed, car fanatics" "Very smart people are weird."

Cultural diversity in health care

Culturally diverse patient behaviors In health care, it is important to understand the impact that cultural background may have on a patient.

Patient behaviors that indicate cultural diversity include: How a patient or family member views healthcare The patient's health beliefs such as old wives tales, herbal remedies, or healers Eating behaviors such as what a patient will eat or what is taboo Treatment decisions (for example, some religious groups do not allow blood transfusions) Interactions with those in authority (for example, a patient who accepts everything he or she is told by someone perceived as an authority figure, without asking questions) Family roles (for example, a husband who does all the communicating for his wife) Beliefs and rituals related to life events including illness, birth, or death Display of emotions, which may vary from very demonstrative to very reserved Language.

Cultural diversity among healthcare workers Cultural diversity is evident in co-workers as well as patients. When you don't know or understand the cultural background of a patient or co-worker, you may misunderstand and misinterpret his or her body language or behavior.

Examples of cultural beliefs that may be related to the work of health care professionals are listed below: Many Asian cultures believe it is disrespectful to look someone in the eyes while speaking. However, in African cultures, failing to look a person in the eye is considered a sign of not being honest. The Arab culture prefers to buffer bad news to boost the spirits of the ill person. In some religions, it is important to include the elders of the church in any decisions that need to be made. Some cultures and religions oppose routine vaccinations and immunization or other kinds of treatment. Family involvement is very important in some cultures. African-Americans, Amish, Arabs, Asians, and Mormons tend to have large, close-knit families. Make allowances for families to spend the night and to be with the patient as much as possible. Those of the Islamic faith may wish to have privacy to pray five times per day. If this is important for your patient, try to incorporate these times into his or her care so that privacy can be arranged. Copyright 2015, Cross Country University Page 68 of 284, Cultural Competence

Annual Mandatory Education—Professional Nurse

There may be some articles of clothing, religious medals, holy pictures, icons or other objects that are important to a patient. Whenever possible, allow him or her to keep these at the bedside.

Responding to cultural diversity The actions of your patients, their families or your co-workers that you do not understand may be related to cultural beliefs or practice. It is important to be aware of the different cultural groups that may be represented at your facility among both staff and patients.

You will be better able to respond to culturally diverse patients and staff if you do the following: Learn about basic cultural beliefs, the patterns related to them, and how they impact health care. Learning about them will help you understand the behavior and support both the patient and his or her family but does NOT mean that you have to endorse the beliefs. Include questions about culture and religion into initial assessments. Remember to be sensitive to cultural needs and try to incorporate them into the patient's care. Learn a few important words or phrases from the languages of co-workers and patients you care for frequently. Use resources such as interpreters that are available in your facility to overcome language barriers. Remember that patients have the right to refuse treatment. Your job is to ensure that they are informed and that they understand potential risks involved.

End of Cultural Competence Lesson

Documenting Patient Care

Introduction A major responsibility of all healthcare providers is that they keep accurate and complete medical records. Much of what is recorded remains sensitive information. Understanding the need for clear and concise records and knowing portions of the record may be discovered and introduced during trials should enable the nurse to be a proficient recorder of patient care. The newest area of confidentiality is with computer documents, email, the internet, and the advent of HIPAA.

This lesson will therefore address one of our professions greatest concerns, documentation. Most nurses will say they dislike documentation because, generally, documentation is not closely tied to performance evaluation unless the quality is really poor.

So why is documentation necessary? It serves as a summary of a patient's care, no matter the setting. It is a communication tool between shifts and disciplines. If you are working the night shift and wonder how far the patient walked in PT, you can go to the chart and find out. Copyright 2015, Cross Country University Page 69 of 284, Documenting Patient Care

Annual Mandatory Education—Professional Nurse

Reimbursement. If a procedure, medication, etc., is not documented, then an insurance company is not likely to reimburse for such. As the saying goes, "If it isn't charted, it wasn't done," and isn't reimbursed. Similarly, it is a crime if a record is altered falsely to obtain additional reimbursement. Determining if standards of care are met. This is an important aspect of continuous quality improvement programs. The intent is to decrease unexpected events, improve outcomes, and improve patient satisfaction.

If litigation is brought about, it is the patient's chart that is used to "tell the story." Therefore, it must reflect accurately the patient situation. A patient's record is generally admissible as evidence. And again, "If it isn't charted, it wasn't done."

State hospital licensing laws and regulations and The Joint Commission standards specify required documentation. Other accrediting bodies may have documentation guidelines for other settings, such as long term care, home health, clinics, etc. Most of the guidelines are applicable to all settings.

Documentation should be as quantitative, i.e., measurable, and as factual as possible. Don't chart, "Pt. fell out of bed," unless you actually witnessed the event. Instead describe what you observed when you arrived on the scene.

Avoid stating personal feelings about the patient. Don't say, "Mr. Jones is bullheaded, obnoxious, and a pain in the rear end. Instead describe Mr. Jones' behaviors as factually as possible.

Documentation should be as timely as possible. Facts are less likely to be omitted when charting is done throughout the shift. This is of particular importance when recording changes in condition, medications, calls to physicians, procedures, etc.

Your documentation should be legible and accurate. Handwriting that is difficult to read creates a negative impression. It is necessary that the author be able to read what she has written years later. Reflect on what you really mean. Be sure that you use abbreviations that are approved by your institution.

Ultimately, rigorous documentation is for the benefit and protection of your patient, you, and your employer.

Documentation Guidelines The 5 C's of documentation are to be Correct, Complete, Concise, Consistent, and Cautious. Here are some specific guidelines to follow: Use military time. This eliminates guesswork - is it 7:00 p.m. or a.m.? Write legibly. Use black permanent ink for entries. Copyright 2015, Cross Country University Page 70 of 284, Documenting Patient Care

Annual Mandatory Education—Professional Nurse

Date and time all entries. Don’t document a symptom such as shortness of breath without charting what action you took Be as quantitative as possible, e.g., write “400 cc’s” instead of “large amount.” Allow no blank spaces - draw a line through the space to the end of the page. Make no erasures, obliterations, or 'whiting out', on any portion of the medical record. Use factual entries only. The medical record is no place for opinions, assumptions, or meaningless words or statement ('had a good day'). Use correct spelling, punctuation marks, and grammar. Ensure that the correct name and other identifying information should appear on each page of the medical record. Confine abbreviations to those adopted by healthcare delivery system. Document as soon as possible after the care is given. Document persons in contact with the patient, i.e., physicians, family - what was discussed, response, any new orders etc. Never countersign anything unless you can attest to the accuracy of the information, e.g., narcotic count. Document any unusual incident that occurs, e.g., fall. Document whenever a patient leaves the nurses care, e.g., for diagnostic work. Document patient transfer. Document consent for, or refusal of treatment. Document patient and/or family teaching/discharge planning Document the existence/disposition of any personal belongings of the patient (dentures, glasses, jewelry, money). Document patient responses to medication, treatments, and procedures. Adhere to agency/institution policies regarding documentation. Use 'late-entry' or 'addition to nursing note' when it is necessary to add omitted information to an existing entry. Use no colloquialisms please (e.g. GOMER - which apparently means 'Get Out of My Emergency Room' - as used in the book, House of God)

Though this is an amazingly large list of guidelines, you can remember them easily with the following mnemonic: DOCUMENT CORRECT COMPLETE CONCISE CONSISTENT AND CAUTIOUS. (Just kidding. Even Shakespeare couldn’t come up with a mnemonic for that mess. There are no shortcuts to good documentation. It takes practice and fastidious attention to detail.)

Flow sheets are designed to streamline the documentation process. However, flow sheets are only as good as the information that is listed on the flow sheet. Flow sheets should be developed with the staff's involvement and be periodically reviewed to assure that they represent the needs of the unit.

Annual Mandatory Education—Professional Nurse

Other documentation systems such as SOAP notes, PIE charting, or charting by exception can be effective. But again it is only as good as the information provided. Assuring competency of such systems is so important, as implementation of these systems varies widely by institution and by individual staff nurses. Therefore, a huge responsibility is placed on staff development and management for education and assuring that procedures are followed. When using one of these systems, ensure that you know the parameters of what should be documented. And always, as a rule of thumb, ask yourself, “Does this document accurately reflect my patient’s story?”

Documentation Weaknesses An outside reader should be able to review a patient's record and reconstruct the patient situation, no matter the setting. The following are some common problems encountered in charting. Documentation when vital signs or other assessment parameters are abnormal. The nurse must not only document the finding, but his/her actions as well. Did you call the physician or decide to monitor the patient longer? If you contacted the physician, were new orders received or none? Failing to notify the physician or to document such places the responsibility on the nurse.

The following is a list of eight common documentation mistakes commonly encountered in litigation (NSO, 2009). Failing to record pertinent health or drug information (e.g., allergies and chronic health problems that should be recorded on the admission sheet) Failing to record nursing actions Failing to record that medications have been given Recording on the wrong chart Failing to document a discontinued medication Failing to record drug reactions or changes in the patient’s condition Transcribing orders improperly or transcribing improper orders Writing illegible or incomplete records

Thorough documentation of changes in a patient's condition, physician contacts and subsequent orders, completion of the orders, and evaluation of their effectiveness can keep the physician, nurse and hospital out of trouble!

Cardiac arrest (codes) and other emergency changes in patient condition are difficult to document. Events are occurring in rapid sequence and it is difficult to keep track of interventions and the time. Most crash carts have recording sheets that streamline the process. Other emergency situations may be more difficult to reconstruct….Isn't that what paper towels are for? Paper towels serve as a good substitute in many cases. Be sure that your notes are later recorded in the chart. Paper towels don't look too sharp in court!

Annual Mandatory Education—Professional Nurse

Transfers within and between institutions must be recorded. On a related note, communication about such transfers does not tend to be well documented. The verbal transaction often times does not look like the written transfer orders.

Countersigning or co-signing documentation implies that you reviewed the entry and agree with the observations. It does not necessarily imply that you personally performed or witnessed the action. It is most desirable that the person making the observation be the one who actually records the event. This is not always possible or realistic, particularly when unlicensed assistive personnel are utilized. However, there is no legal requirement that the person documenting must be a licensed professional. It is often the policy of the organization that documentation be performed by a licensed professional.

Precharting should be avoided. Documenting something that hasn’t taken place yet leaves you legally and professionally liable – never assume that things will go as planned.

Confidentiality issues should be documented carefully. If a patient gives you permission to talk to a family member about her care, document that permission.

Personalities should be left out of your documentation. Don’t use the chart to express your personal opinions about your patient, the patient’s family, or co-workers. Worse, don’t express an opinion about the care provided by yourself or your co-workers. “I messed up” or “RT dropped the ball” are red flags for litigation.

Against Medical Advice (AMA) is a term used with a patient who checks himself out of the hospital again the advice of his physician. While it may not be medically wise for the person to leave early, in most cases the wishes of the patient are considered first. The patient is usually asked to sign a form stating that he/she is aware that they are leaving the facility against medical advice, and the AMA term in used on reports concerning the patient. This is for legal reasons in case there are complications to limit liability on the part of the medical facility. The AMA form does necessarily protect the physician from future legal implications regarding the case. Therefore documentation must be thorough.

Document any patient comments made while leaving AMA or refusing treatments, and ensure that AMA and treatment refusal forms are correctly filled out and signed. When a patient refuses to sign an AMA or treatment refusal form, document the patient’s statements, describe the patient behavior, any other witnesses to those statements; and have your observations countersigned by a colleague who witnessed the statements and behaviors that you documented.

Do Not Resuscitate (DNR) orders must be documented carefully in order to avoid going against a patient or family’s wishes for care. Institutional policies and state laws vary so it is your responsibility to know how your institution address the DNR and how it must documented.

Annual Mandatory Education—Professional Nurse

Documentation errors Documentation errors are common. It is important to correct errors properly. As already noted above, draw a single line through the word or phrase and write the correction on the same line, if possible, or above the line. Put the date, time, and your initials next to any corrections. You may write additional information in a later note and may even refer to the earlier correction in that later note. Never obliterate an error; use a single line so that even the error remains readable. Refer to a documentation error as an incorrect entry or a mistaken documentation, and be careful of words such as “error” or “mistake” in case they could be interpreted as a clinical error, rather than a documentation error.

In fact, use caution whenever you use words such as “error,” “by accident,” “unsure,” and “confused.” These words can give the impression that you may have compromised patient safety, and can come back to haunt you in a court of law. Avoid expressing opinions and stick to a factual description of what occurs.

Example: The prescriber has ordered 4 mg. of morphine for cardiac pain. The patient received 8 mg. The following is an appropriate documentation of the occurrence: Patient received 6 mg. morphine IV at 1800 for cardiac pain. Vital signs stable. Dr. Jones notified, but gave no orders.

Incident reports Incident reports are used to communicate unusual or unexpected events. Three examples of situations that require an incident report are patient falls, medication errors, and wrong site surgery. The incident form is completed and kept separate from the patient's chart. Also, incident reports should not be a part of an employee's record. Incident reports are primarily a risk management tool used for the following purposes: As a non-punitive tool used to identify potential liabilities and correct them before becoming a loss to the organization As a tracking tool for trending information to determine the frequency and severity of specific adverse occurrences To plan corrective actions to further the improvement of processes and promote safer patient care To give Risk Management a head start on claims prevention and claims management. In the Peer Review Committee meetings to determine remediation, counseling, education, and or discipline. Peer Review is a process whereby the quality of the services provided by the healthcare staff is evaluated by equivalently trained personnel. To meet the requirement for annual reporting of incident reports to specific national regulatory associations

Depending on specific state law, the incident report is a confidential document that is protected from discovery in a lawsuit at all cost. The incident report should never be copied and never be placed in the patient chart. It should also never be referred to within the patient chart. Copyright 2015, Cross Country University Page 74 of 284, Documenting Patient Care

Annual Mandatory Education—Professional Nurse

Use the following guidelines for preparing an incident report: Prepare your report as soon as possible after the incident. Make only one copy. Make the report only if you are the one who has the best and most direct knowledge of the incident. Describe as accurately as possible everything that took place during the incident. Include the names of everyone who was present including staff and patient family members. Include the statements of patients and staff about what occurred. Describe the make and model of any equipment that may have malfunctioned and what sort of malfunction occurred. Make no recommendations and give no opinions. Report only what you saw.

Abbreviations You have already read the above recommendation to use only the abbreviations approved by your institution. The issue of approved abbreviations has heated up in the last few years due to the research and intense interest by The Joint Commission (TJC). They have determined that confusing abbreviations are a major cause of sentinel events and have published an official “Do Not Use” list of potentially confusing abbreviations with which all TJC accredited facilities must comply. Memorize this list, as TJC requires facilities to strictly monitor and enforce the avoidance of the following abbreviations.

End of Documenting Patient Care Lesson

Drugs in the Workplace

What is alcohol and drug abuse? Alcohol and drug abuse, also known as substance abuse, is the excessive use of alcohol or drugs, or the use of medications without medical justification. Substance abuse leads to addiction.

Addiction is the persistent compulsive urge to use a substance (such as heroin, nicotine, or alcohol) known to be harmful or to cause negative consequences. The substance is habit-forming and the addiction is characterized by well-defined physical symptoms upon withdrawal and by tolerance.

Tolerance refers to the need to take ever-increasing amounts of a drug to get the effects once experienced with a lower dose of the same drug.

There are several ways to classify drugs. Drugs in the workplace (including alcohol) are often classified as depressants or stimulants according to the effect they have on the nervous system. A third, important group of drugs when considering drug use among hospital employees is opioids - natural or synthetic drugs similar to morphine and also known as narcotics.

Annual Mandatory Education—Professional Nurse

What are depressants? Depressants are drugs that reduce the activity of the nervous system and suppress instinctive responses such as appetite. They may be injected or swallowed and cause sedation and drowsiness.

Examples of depressants include: Alcohol Barbiturates Benzodiazepines.

Effects of depressants on the body include: Slowed pulse and breathing Lowered blood pressure Reduced pain and anxiety A feeling of well being Lowered inhibitions Poor concentration.

Potential health problems with depressants include: Fatigue Confusion Impaired memory and judgment Impaired coordination Respiratory depression and arrest Addiction.

Alcohol Alcohol is taken as a drink. It lowers inhibitions, produces feelings of euphoria, relaxation, and confusion. It also affects coordination, slows reaction times, and impairs judgment. Potential health problems (in addition to those listed above) include: liver disease, cardiac disease, birth defects, pancreatitis, ulcers, mental disorders, cancer, and brain damage.

Barbiturates Barbiturates are often prescribed to help people sleep. They may be injected or swallowed. Medical names include: seconal, nembutal, phenobarbital, and amytal. Street names are: "yellows," "reds," "barbs," and "yellow jackets." Potential health problems caused by barbiturates (in addition to those listed above) include: depression, unusual excitement, fever, irritability, poor judgment, slurred speech, and dizziness.

Benzodiazepines Benzodiazepines are prescribed to relieve anxiety and sleeping difficulties. Medical names include: halcion, valium, ativan, librium, and xanax. Street names are: "downers," "sleeping pills," "candy," and "tranks." Health problems (in addition to those listed above) include dizziness. Copyright 2015, Cross Country University Page 76 of 284, Drugs in the Workplace

Annual Mandatory Education—Professional Nurse

What are stimulants? Stimulants are drugs that increase activity in the central nervous system. They often cause restlessness or euphoria.

Examples of stimulants include: Amphetamines Cocaine MDMA (ecstasy).

Effects of stimulants on the body include: Changes in metabolism Increased heart rate and blood pressure Feelings of exhilaration and energy Increased mental alertness.

Potential health problems with stimulants include: Reduced appetite Weight loss Rapid or irregular heartbeat Heart failure.

Amphetamines Amphetamines cause the user to feel confident, cheerful, and talkative. Examples of medical names include adderall, biphetamine, and dexedrine. Street names are: “meth,” crystal meth,” "bennies," "black beauties," "crosses," "hearts," "LA turnaround," "speed," "truck drivers," and "uppers." The drugs may be smoked, swallowed, snorted, or injected. Effects on the body include rapid breathing and hallucinations, and potential health problems include: tremor, loss of coordination, irritability, anxiousness, restlessness, delirium, panic, paranoia, impulsive behavior, aggressiveness, tolerance, and addiction.

Cocaine Cocaine causes the user to feel invincible, confident, animated, and to have a sense of well-being. Street names include: "blow," "bump," "c," "candy," "charlie," "coke," "crack," "flake," "rock," "snow," and 'toot.' It can be snorted, smoked, or injected. Effects on the body include a rise in temperature, and potential health problems include: chest pain, respiratory failure, nausea, abdominal pain, strokes, seizures, headaches, and malnutrition.

MDMA (methylenedioxy-methylamphetamine) Tablets or drugs containing the drug, MDMA, are known by the street name "Ecstasy" or "E." Other names for ecstacy are "snowballs," "doves," "New Yorkers," and "burgers." Each type of tablet has slightly different effects. Ecstasy is usually taken orally. Although rare, ecstasy can be snorted or

Annual Mandatory Education—Professional Nurse

injected. Effects on the body include: mild hallucinations, increased tactile sensitivity, empathic feelings, and hyperthermia. Potential health problems include impaired memory and learning.

What are opioids? Opioids (also known as narcotics) include both natural and synthetic drugs similar to natural opiates that are derived from the opium poppy. Drugs in this group are prescribed for moderate or severe pain. Medical names include morphine, dilaudid, codeine, and meperidine. They may be injected, taken orally or inhaled, or taken through rectal suppositories.

Effects on the body include: relief of pain, fear, and anxiety, impairment of mental and physical performance, and euphoria. This drug also decreases hunger, inhibits coughing, and slows breathing. Potential health problems include: respiratory depression and arrest, nausea, confusion, constipation, sedation, unconsciousness, coma, tolerance, and addiction.

Substance Abuse in Hospitals

Substance abuse in the workplace Substance abuse in the workplace is any use of alcohol and drugs by employees at work. The behavior may or may not obviously affect work performance, the workplace environment, or the safety of individuals in the workplace.

Commonly abused drugs include: Alcohol (the most commonly abused substance) Marijuana (used by over 20 million Americans) Cocaine (6 million) Heroin (1/2 million) Methamphetamine.

How big is the problem? There are 13 million American alcoholics. 60% of the world's illegal drug market is in United States. Almost 75% of drug users are employed persons. 20% of workers in the 18-25 year age group abuse drugs on the job. 15% of workers in the 26-34 year age group abuse drugs on the job.

Studies reveal that employees who abuse drugs adversely affect the workplace. They are more likely than other employees to: Be late Be involved in workplace accidents File workers' compensation claims Have extended absences from work.

Annual Mandatory Education—Professional Nurse

Dangers of substance abuse in hospitals Hospital employees who are under the influence of drugs or alcohol pose a danger to themselves, coworkers, and patients. Because large quantities of medicinal drugs are stored and administered in a healthcare facility, there is a greater potential for employees to abuse drugs at work than in other professions.

Potential dangers include medication and treatment errors, loss of productivity, and safety risks.

Medication and treatment errors include: Errors in preparing medications Errors in dispensing medications Intentional medication errors in which a licensed clinical employee, who administers drugs, may take drugs that were ordered for patients (the most commonly "diverted" drug in hospitals is Demerol, or meperidine, and this practice leads to patients not receiving prescribed medication and suffering pain or other physical problems). Poor supervision of patients Lack of provision of needed treatments or services Carelessness, such as poor sterile technique.

Loss of productivity results from: Tardiness Accidents Absenteeism Extra sick leave Inability to perform job adequately Other employees having to "take up the slack" High employee turnover.

Safety risks may lead to: Accidents Injuries Fatalities Safety concerns for the organization.

Getting Help about Substance Abuse

Your role in a drug-free workplace A drug-free workplace starts with you. There are specific things you, specifically, can do to ensure a drug-free workplace: Know your facility's policy on drugs and alcohol.

Annual Mandatory Education—Professional Nurse

Come to work free of alcohol or other drugs that could affect judgment or performance. Do not use drugs or alcohol on the job. If you suspect you have a problem, get help. If you suspect a co-worker has a problem, speak to your supervisor.

Drug or alcohol abuse can be detected if you are aware of the signs.

Signs of drug or alcohol abuse include: Frequent absenteeism or lateness Changes in work habits (for example, an organized person becomes disorganized) Mood changes (for example, a person suddenly becomes difficult to work with) A decrease in productivity (for example, not getting things done) An increase in workplace accidents Mistakes on the job.

Substance abuse self-test Do you have a problem with substance abuse? How would you know? Take the self-assessment test. Although this type of test is not 100% reliable, it may be useful in indicating whether you should get help.

Self-assessment test Has anyone ever questioned you about your alcohol or other drug use? Have you ever used alcohol or other drugs alone? Have you ever missed work because you were sick from using too much alcohol or other drugs? Have you ever had trouble stopping once you started using alcohol or other drugs? Have you ever had legal problems because of your alcohol or other drug use? If you can't use alcohol or other drugs, do you get jumpy, shaky, cranky, nervous, or have cravings? Are you in debt because of your alcohol or other drug use? Does it now take more alcohol or other drugs to get the same effect? Have you ever used alcohol or other drugs in the morning? Have you ever been in the hospital as a result of your drinking or drug use? Have you ever used alcohol or other drugs at work?

If you answered "Yes" to one or more of these questions, you might have a problem with abuse or addiction.

If you have never taken drugs, don't start.

If you think you may have a problem with drug or alcohol abuse or addiction, get help. The earlier you get help, the better. Addiction is a disease that can be controlled with treatment, but you will need help.

Annual Mandatory Education—Professional Nurse

Either talk to your doctor, or get help at work. Your supervisor or Human Resource Department personnel can let you know where help is available. DO NOT be discouraged, but DO realize that treatment takes time.

Types of help available There are several different types of help available for people who have problems with drug or alcohol abuse or addiction.

Types of available help include: Inpatient treatment centers Outpatient treatment centers Support groups such as the 12-step programs of Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) Non-12-step programs, such as Rational Recovery (RR) Hotlines that direct people to sources of help (Center for Substance Abuse Treatment's Drug Information, treatment, and referral hotline: 800-662-HELP) Publications free from the National Clearinghouse for Alcohol and Drug information: 800-729- 5586.

Intervention in abuse situations

Common signs of drug abuse Certain signs may indicate a person is having problems with drug abuse. One suspicious instance does not necessarily indicate a problem, but if you note a persistent pattern, your co-worker could have a problem with abuse or addiction.

Some healthcare workers who use or abuse drugs look for opportunities to ingest or inject medicinal drugs while at work. If you suspect a co-worker has an abuse or addiction problem, report it to a supervisor. Common signs of drug abuse include: Sudden appearance of unusual behavior, especially if behavior seems to be getting worse Frequent volunteering to administer medication or carry the keys to the medication cupboards Pattern of administering PRN pain medications in the maximum dosage prescribed and on time, even when patient no longer requires it to be given that frequently Requests to transfer to night shift or areas with minimal supervision Requests for assignments in areas where narcotics are given frequently, such as the emergency room, critical care units or surgical units Frequent reports that drugs have been "wasted" or containers broken with no witnesses present Reports from patients that pain relief is not as effective as it was (as compared to other shifts) even though their conditions do not indicate a greater need).

Annual Mandatory Education—Professional Nurse

Helpful and unhelpful interventions If you suspect a co-worker is having problems with drugs or alcohol, there are things you can do to help.

Helpful interventions DO know your facility's policy on drugs and alcohol. DO help co-workers to face the problems they are having. DO report to your supervisor any co-worker who is under the influence of a drug. DO report to your supervisor any co-worker seen to be using drugs or alcohol on the job. DO refer a co-worker who asks for help to a supervisor or Human Resources Department staff member who can provide resource information.

Reporting substance abuse on the job not only protects the workplace from potential accidents or incidents, but it also helps your co-workers to get the help they need to handle their problems. If you suspect co-workers are having problems with drugs or alcohol, there are things you should NOT do if you are trying to help them.

Unhelpful interventions DO NOT redo or finish the other person's work. DO NOT make excuses for the other person's behavior. DO NOT lie to your supervisor about an incident involving the co-worker. DO NOT allow an impaired worker to continue to work.

If you suspect a co-worker has an abuse or addiction problem, report it to a supervisor. If you cover up a co-worker's problem, you become part of the problem because you are enabling the person to continue the abuse or addiction.

End of Drugs in the Workplace Lesson

Electrical Safety

Electrical conductors and insulators Understanding the difference between conductors and insulators helps to explain how people can safely touch an electrical cord while equipment is turned on and why damaged cords are dangerous.

Materials that allow electricity to move through them are known as conductors. Conductors include: Metals such as copper, silver, gold, aluminum, and iron Liquids such as water, saline, blood, and urine The human body.

Annual Mandatory Education—Professional Nurse

Glass Dry cloth Paper The ground Wood.

An electrical cord is made of wires that are conductors (usually copper), which are covered with an insulator, such as rubber. People can safely touch an electrical cord while equipment is turned on because the insulator stops electricity from traveling outside the cord.

If the wires are not covered or the insulator is damaged, and the equipment is turned on, you can receive a shock or injury.

Electricity follows a path Electricity travels down wires from an electrical source (the wall outlet) to the electrical equipment and back again to the electrical source. This path that the electricity follows from the outlet to the equipment and back to the outlet is called a circuit. If there is damage at any place in the circuit, electricity can leak out.

Three wires make up the circuit. The first wire, called the lead wire or the hot wire, conducts the electricity from the outlet to the equipment. A second wire conducts the electricity from the equipment back to the outlet. Cords that have a third pin on the plug, have a third wire that conducts any stray electricity from the equipment to that pin. The third pin is called the ground pin and it is a safety feature. It allows excess electricity to return to the earth, which is an insulator.

The three wires in an electric cable are the hot wire, the return wire, and the ground wire

Electricity leaking from a broken electrical cord can cause a fire if it is near flammable material. The leaking electricity can also cause electrical shock or injury to people.

Annual Mandatory Education—Professional Nurse

Rules about electrical cords to protect you, fellow employees, patients, and visitors from harm:

DO: Keep cords out of the way of traffic. Take electrical equipment with faulty cords or visible wires out of service and have them checked.

DO NOT roll beds, wheelchairs, or other equipment, over an electrical cord. This can break the wires and damage the cord.

Safe electrical plugs All electrical plugs should have three pins or prongs. The third pin, called the ground pin, is a safety feature. It allows excess current or leaking electricity to return to the earth. The ground pin is shaped differently from the other two.

Cheaters are plug adaptors that have two pins to plug into the wall outlet. A plug with three pins fits into the other end of the adaptor. The adaptor therefore cheats the three-pinned plug (by making it two- pinned) and cheats people of the ground pin safety feature. Never use cheaters.

Rules about electrical plugs to protect you, other employees, patients, and visitors from harm:

DO: Use only electrical equipment with three pins on the plug. Look at plugs for loose or broken pins or for any melted areas. Unplug equipment by handling the plug itself and not the cord.

DO NOT: Use plugs with broken pins or with only two pins. Pull on an electrical cord to unplug equipment. Pulling can damage the cord. Use cheaters. Cheaters are adaptors that convert three-pin plugs into two-pin plugs.

Annual Mandatory Education—Professional Nurse

Safety means looking at plugs and using them correctly

Keep electrical equipment safe If electrical equipment is broken, electricity can leak out. The leaking electricity can cause a fire, if it is around flammable material. It can also give somebody a shock.

If you receive a shock when using electrical equipment, immediately turn it off. Take it out of service so it can be repaired.

Rules about electrical equipment to protect you, fellow employees, patients, and visitors from harm:

DO take electrical equipment out of service and report it if the equipment: Smells "hot" Has smoke coming out of it Is not working properly Has had a liquid fall into it.

DO NOT: Use electrical equipment in wet areas. Touch electrical equipment with wet hands. Plug too many appliances into a wall outlet. The overload may cause overheating of the wires and result in a fire.

Annual Mandatory Education—Professional Nurse

End of Electrical Safety

Emergency Preparedness

Emergency Codes

Though healthcare organizations universally use emergency codes, there is no universally accepted standard for those codes. The Hospital Association of Southern California has made the following recommendations for standard coding. These may or not be the case at the organization at which you work, but all of most of these are commonly employed at most healthcare entities. Know the codes for your organization. RED for fire BLUE for adult medical emergency WHITE for pediatric medical emergency PINK for infant abduction PURPLE for child abduction GREEN for patient elopement YELLOW for bomb threat GRAY for a combative person SILVER for a person with a weapon and/or hostage situation ORANGE for a hazardous material spill/release TRIAGE INTERNAL for internal disaster TRIAGE EXTERNAL for external disaster

Types of Emergencies

Be prepared! The hospital has specific plans to be followed for different types of disasters. When casualties begin arriving, do you know what your role is? What procedures should you be following during this crisis? The time to prepare is before a disaster occurs.

In order to be able to properly care for injured people while continuing to care for the patients already in hospital when a disaster strikes, the hospital needs to be prepared for any type of emergency or disaster. A disaster is any type of situation (event) that involves large numbers of injured people being admitted for emergency treatment. To prepare for a disaster, THE JOINT COMMISSION standards require health care facilities to conduct two disaster drills each year. At least one of these drills has to be an "external disaster" drill that includes patients coming into the facility from outside. While participating in a drill, everyone should treat it as if it were "real". Copyright 2015, Cross Country University Page 86 of 284, Emergency Preparedness

Annual Mandatory Education—Professional Nurse

Types of disasters Emergencies or disasters can be classified as either "internal" or "external."

An internal emergency is one that directly involves the facility and is a threat to the staff and patients, such as an in-house fire, a toxic chemical spill, or a natural disaster such as a tornado, earthquake, or hurricane that causes damage to the facility.

An external emergency is one that occurs outside of the facility and does not directly threaten the staff, patients and others inside the building(s). The indirect effect on the facility is the possibility of large numbers of casualties arriving for treatment. External disasters include such things as: Accidents involving buses, trains, airplanes or multiple vehicles Explosions Chemical spills Large fires Violent incidents involving a large group of people Natural disasters occurring outside the facility such as tornadoes or floods. Weather watches and weather warnings Staff can plan for potential emergencies by responding to weather service forecasts of severe weather. The weather service uses the terms WATCH and WARNING to describe the chance for a particular type of weather hazard to occur in the area. A weather WATCH is a forecast that weather conditions are favorable for a particular type of weather hazard to form. For example, a tornado watch means that the environmental conditions are favorable for the formation of tornados.

The term "WATCH" may also be used to describe severe thunderstorms, winter storms, heavy snow, and flash floods. When used to describe a hurricane or tropical storm, it means that there is a chance that a hurricane or tropical storm could strike the area within 24-36 hours. A tropical storm indicates a storm with sustained winds between 39 and 73 mph and hurricanes involve even stronger sustained winds: Tropical storm: sustained winds between 39 and 73 mph Category 1 hurricane: sustained winds between 74 and 95 mph Category 2 hurricane: sustained winds between 96 and 110 mph Category 3 hurricane: sustained winds between 111 and 130 mph Category 4 hurricane: sustained winds between 131 and 155 mph Category 5 hurricane: sustained winds over 155 mph

A weather WARNING is more serious than a weather WATCH. It means that a particular weather hazard has actually been observed and threatens the area over which the warning is issued. For example, a tornado WARNING means that a funnel cloud has actually been spotted. Warnings are used to describe hazards such as tornadoes, severe thunderstorms, winter storms, heavy snow, and flash floods.

Annual Mandatory Education—Professional Nurse

When a hurricane or tropical storm warning is issued, it means that the hurricane or tropical storm has been spotted is expected to strike the warning area within 24 hours.

Earthquakes In 1994, in Northridge, California, a 6.7 magnitude quake killed 61 people and injured more than 8,000. Several area hospitals were evacuated. Every healthcare worker must know how to minimize risk to themselves and to their patients during an earthquake.

Risk, Magnitude, and Intensity If you live in California, it's almost a certainty that you've experienced an earthquake. Southern California has an estimated 10,000 earthquakes a year, though only a few will do any damage. The map below shows the relative risk of an earthquake throughout the United States (click on the map to see a full-size version).

Click here if you'd like to explore more maps and information from the USGS.

The seriousness of an earthquake is dependent upon its magnitude and intensity.

The magnitude of an earthquake is a measure of the size of the earthquake and is not dependent on the location or the amount of shaking caused. Seismographs measure magnitude.

The intensity of an earthquake is a measure of the amount of shaking caused and is dependent on the location. The effects on people and property determine an earthquake's intensity.

Annual Mandatory Education—Professional Nurse

Most earthquakes go unnoticed. However, depending on magnitude and intensity, damage can range from slight to devastating. As a worst case scenario example, it is estimated that an 8.3 magnitude earthquake in Southern California would: Cause severe damage as far as hundreds of miles from the center Collapse buildings, including tall and modern buildings, and buildings of importance such as schools, hospitals, and municipal services centers (though newer structures are built to withstand earthquakes, many are vulnerable to an earthquake reaching a magnitude of 8 or more) Disrupt communication, water, power, and transportation for more than 24 hours Cause landslides in vulnerable areas Cause tsunamis (tidal waves) Injure and kill thousands of people as a result of structural collapses (buildings, bridges, tunnels, homes)

Before the Earthquake A disaster such as an earthquake, for which there is no early warning system, often causes more casualties because the victims have no time to prepare or to leave the area.

As a result, healthcare workers must know their facility's disaster plan. What will you do if an earthquake occurs while you are at work or at home? Disruption of utilities and communications will likely prevent you from using a phone to find out what to do. You must know and prepare in advance.

Healthcare workers in a high-risk earthquake area must also be aware of, and try to correct, any of the following potential hazards in the work area: Unanchored furniture and wall fixtures more than 42 inches high Stacked furniture Tall bookcases Unanchored computers and equipment Heavy items that are stored above floor level

During the Earthquake (until shaking stops) Stay Calm If you know what to do, you will find it easier to stay calm. Stay Put If inside, STAY inside. If outside, STAY outside. Most people injured in earthquakes moved more than 10 feet once the earthquake started. Take Cover If inside o Move the shortest distance possible to a place of safety Copyright 2015, Cross Country University Page 89 of 284, Emergency Preparedness

Annual Mandatory Education—Professional Nurse

o Take cover under a bed, desk, table, or chair; against a corridor wall; or between seating rows if in a classroom. If you've taken cover under a sturdy piece of furniture, hold on to it. o Move away from windows, display shelves, and other falling hazards. If no cover is available, drop to the floor. o Stay in the building and on the same floor. Do not use the elevators. If outside o Move away from all falling hazards. The greatest risk of falling hazards is near the entrance and outer walls of buildings. If in a car o Pull over and stop as soon as you can do so safely o If possible, do not stop on or under a bridge or near power lines o Stay in your car

After the Earthquake Expect aftershocks of any magnitude and intensity Restore calm Assist others Report injuries If you are near the ocean, consider the possibility of a tsunami Follow your organizations disaster procedures! (for example, you may be required to proceed to an Emergency Assembly Point).

For More Information Here are a few websites you may find interesting:

USGS Earthquake Preparedness Website

Wikipedia Earthquake Preparedness Website

Procedures for dealing with disasters Hospitals have specific "disaster plans" to be followed for the different weather hazards that could occur in the area.

Here are some basic procedures to follow when these weather conditions occur.

High winds During high winds, flying objects can break windows. Patients need to be moved away from any windows, possibly into hallways.

Annual Mandatory Education—Professional Nurse

Power outage If there is a power outage, generator power will come on automatically to ensure that power is maintained for essential services. To conserve power, use only those electrical appliances that are absolutely necessary such as life-support equipment and basic lighting. These essential appliances must always be plugged into electrical outlets that would be serviced by the hospital generator in the case of an emergency power outage.

Rising water If rising water is a problem, move patients to higher floor levels, if possible. Depending on the situation, patients may need to be evacuated.

Emergency Response

Examples of disasters/emergencies There are many different types of disasters and emergency situations. Examples include: Meteorological disasters such as cyclones, typhoons, hurricanes, tornados, hailstorms, snowstorms, and droughts Topological disasters such as landslides, avalanches, mudflows, and floods Disasters that originate underground such as earthquakes, volcanic eruptions, and seismic sea waves Biological disasters such as communicable disease epidemics and insect swarms. Accidents involving transportation (planes, trucks, automobiles, trains and ships), structural collapse (buildings, dams, bridges, mines and other structures), explosions, fires, chemicals (toxic waste and pollution), and sanitation. Civil disasters such as riots, demonstrations, and strikes Criminal/terrorist action such as bomb threats or incidents, nuclear, chemical or biological attacks, and hostage incidents Conventional warfare, including bombardment, blockade, and siege Non-conventional warfare such as the use of nuclear, chemical, and biological weapons.

Hospital preparation for disasters/emergencies All organizations must have an emergency management plan or disaster plan so that patient care can continue if a disaster occurs.

Hospital disaster/emergency management plans must: Address both external and internal disasters Include general activities that will occur no matter what the emergency situation

Annual Mandatory Education—Professional Nurse

Allow specific responses to the types of disasters the facility might face Include a plan for evacuation of the hospital if all or part of the facility is damaged or non- functional.

A convenient way for a hospital to classify disasters is as: 1. Internal disasters 2. External disasters

Internal disasters Internal disasters are emergency situations in which only patients, visitors, and staff within the hospital are injured. Internal disasters involve taking care of injured victims and evacuation, if part of the facility is damaged or non-functional. Employees have to be flexible in making the best decisions under the circumstances. During an internal disaster, hospital workers have to limit casualties and limit damage. The hospital's main concern in all disasters is to save lives and restore normal conditions.

External disasters External disasters are emergency situations that involve the whole community. Victims are transported to the hospital for treatment while, at the same time, in-house patient care must continue. During an external disaster, community emergency organizations are responsible for limiting casualties and limiting damage. The hospital's main concern in all disasters is to save lives and restore normal conditions.

One important way that your facility learns about the effectiveness of its disaster plan is through drills. Your facility is required by THE JOINT COMMISSION (formerly, the Joint Commission on Accreditation of Healthcare Organizations) standards to conduct two drills every year. At least one of these drills has to involve patients coming into the facility. All drills should involve enough victims to adequately test the system and the organization's resources and reactions under stress.

Take disaster drills seriously. A realistic drill evaluates how well the hospital's disaster/emergency plan works. It also identifies problems or weaknesses that can be corrected before a real emergency/disaster occurs.

Your role in the hospital disaster plan An effective response to an emergency situation involves planning: It is important to know as much as you can about the disaster plan in your facility and your role within the plan. Different facilities use different names for disaster/emergency situations - make sure you know the name that your facility uses.

Annual Mandatory Education—Professional Nurse

If you hear a disaster announced over the hospital intercom or otherwise, activate the disaster plan and follow your role. If phone lines are down, your hospital may use the local radio station to notify employees.

If you are notified of a disaster, there are several things to remember: Return to the facility if you are away from work. If it is not convenient for you to put on your normal work clothes wear what you have on. Be sure that you have your identification badge with you. Follow the telephone roster if it is one your duties. If the first person on the list is not home, go down to the NEXT person. Continue down the list until you reach another person. Carry out the tasks assigned to you even though they may not be the normal duties of your job. Come to work prepared to stay for a day or longer if severe weather is forecasted, such as a winter storm with heavy snow or an approaching hurricane. If the facility waits until the disaster actually occurs, staff may not be able to come in because of hazardous road conditions.

Patient treatment during a disaster Triage is a process for sorting victims to determine the priority of medical treatment. All ambulances bring the injured to the triage area during a disaster/emergency. It is designated in advance for an external type of disaster. In an internal emergency, the triage area is moved to an area that is not exposed to danger but is close to the injured victims.

Treatment is not given in the triage area. As patients are triaged, they are identified, tagged, and sorted according to the seriousness of their injuries. They are then transported to a designated area where they will receive the appropriate care.

During triage, patients are assessed and categorized according to the level of treatment they need: Major or immediate treatment Minor treatment Morgue

Major or immediate treatment Patients who need immediate treatment or surgery to prevent loss of life or serious disability are transported to the major treatment area. Injuries that require care in this area include airway problems, internal bleeding, wounds with severe hemorrhaging, or pneumothorax.

Minor treatment In the minor treatment area, patients with injuries that are not life-threatening, such as broken bones and cuts that need suturing, receive treatment. Generally, they can either walk or be transported in wheelchairs.

Annual Mandatory Education—Professional Nurse

Morgue Patients who have already expired or whose injuries are so severe that they have no chance to live are transported to the morgue area.

Effects of disasters on non-treatment areas of the hospital Triage and treatment areas are most affected during disasters and emergency situations but other areas of the hospital are affected as well.

Examples of the effects of disasters on non-treatment areas of the hospital are: In-patient areas need to record the number of empty beds and identify patients who can be discharged to make room for disaster victims. The kitchen will need to plan on preparing meals for extra employees, families, patients, and others involved in the disaster. Environmental services could be called on to quickly prepare the rooms of discharged patients for new patients. As long as the disaster/emergency exists, elective admissions and procedures will not occur. Waiting areas have to be set up for family members of the victims. Areas must be identified for press briefings so the community is informed about the status of the emergency.

End of Emergency Preparedness Lesson

End of Life Care

Palliative versus curative care In healthcare, much of the focus is on curative care. This is as it should be. The goal is for patients to get better. The objectives of curative care are: To obtain a cure To return patients, as much as possible, to normal functioning.

Sometimes, these objectives cannot be met and the patient is considered terminally ill. The patient or family may have decided to discontinue curative treatment or there may be no curative treatment available.

The patient's care now becomes palliative. The objectives of palliative care are: To make the patient as comfortable as possible To support the family during this end-of-life period.

Annual Mandatory Education—Professional Nurse

Importance of pain control Pain control is an essential part of end-of-life care. Many cancer patients, for example, say that their biggest fear is having uncontrolled pain before they die. The challenge for healthcare professionals is to manage pain so that patients can focus on other end-of-life issues.

During this phase, it is important to reassure patients and families about your facility's commitment to pain control. Both pharmacological and non-pharmacological measures should be used to ease the patient's pain. Be sure to involve patients and families in deciding what methods work best to meet the individual needs of the patient.

You should also assure them that opioids can play an important role in controlling pain. Use of opioids to control pain will not cause addiction and can help the patient to: Rest better Be more mentally alert Avoid depression.

Patients will have been asked about any advance directives when they were admitted. You should assure them that a "Living Will" or a "Do Not Resuscitate" order will not prevent them from receiving pain relief as a part of their care.

Patients who might be good candidates for hospice care may also need reassurance. Assure the patient and family that pain control is one of the main focuses of hospice care.

Sometimes, nursing staff are concerned about giving opioids as often as ordered because of fears about side effects. Remember that the objective of palliative care is to control pain and keep the patient comfortable. Higher than usual doses may be required to control the pain effectively.

Pain relief is the priority for terminal patients.

Caring for the terminal patient When caring for the terminal patient, you should: 1. Anticipate pain needs and provide relief before the pain becomes severe 2. Remember that larger doses of analgesia may be needed because of tolerance to the drug and because of the progressive disease state 3. Assess the patient frequently for pain management needs 4. Discuss the pain management plan with the patient and family 5. Assure the family that everything possible is being done to keep the patient comfortable.

You may have to be creative in finding the best solutions for individual patients, but the family and patient provide a valuable source of help. LISTEN to your patient and his/her family.

Annual Mandatory Education—Professional Nurse

As the disease progresses, the patient may no longer wish to eat or drink. Families find it hard to see their loved ones stop eating or drinking, and denial of what is happening is common and understandable. The family needs support during this time and help to understand the process. End of End of Life Care Lesson

Ethical Care

The Ethics Committee A dilemma is usually an instance in which an undesirable or unpleasant choice must be made. An ethical dilemma occurs when two principles of ethics "collide."

For example, an ethical dilemma may arise if a patient refuses chemotherapy against physician's advice. Does the physician continue to care for the patient when he believes that continuing on this course will lead to harm for that patient? The conflict arises between the patient's right of autonomy and the physician's duty of beneficence - always to do what is best for the health of the patient.

An ethics committee deals with conflicts on principles of ethics. Your organization will have a policy or procedure for convening the Ethics Committee to discuss ethical dilemmas. The committee will listen to and discuss the problem, and provide recommendations. In most facilities, anyone can ask for an ethics consultation.

Ethical Principals Ethical care is care that helps preserve your patient's rights and well being. Accrediting bodies such as The Joint Commission and CHAP require organizations to establish guidelines for patient, staff, and physician involvement in ethical education and decision making. Ethical Principals The following ethical care principles are values and virtues that guide the behavior of healthcare providers. Autonomy: Derived from the Greek word autos (self) and nomos (rule or law), autonomy refers to self-rule. In modern use, it has broad meanings, including individual rights, privacy, and choice. It entails the ability to make a choice free from external constraints. Beneficence: The duty to do good and the active promotion of benevolent acts (for example, goodness, kindness, and charity.) May also include the injunction not to inflict harm. Confidentiality: This principle relates to the concept of privacy. Information obtained from an individual will not be disclosed to another unless it will benefit the person or there is a direct threat to the social good. Double Effect: The principle that may morally justify some actions that may produce both good and evil effect. All four of the following criteria must be filled: o The action itself is good or morally neutral o The agent sincerely intends the good and not the evil effect (the evil effect may be foreseen but not intended) Copyright 2015, Cross Country University Page 96 of 284, Ethical Care

Annual Mandatory Education—Professional Nurse

o The good effect is not achieved by means of the evil effect o There is proportionate or favorable balance of good or evil. Fidelity: Promise keeping. The duty to be faithful to one's commitment. It includes both explicit and implicit promises to another. Justice: From a broad perspective, justice states that like cases should be treated alike. A mere restricted version of justice is distributive justice, which refers to the distribution of social benefits and burdens. Nonmaleficence: The duty not to inflict as well as to prevent and remove harm. May be included within the principle of beneficence, in which case maleficence would be more binding. Paternalism: The intentional limitation of another's autonomy justified by an appeal to beneficence or the welfare or needs of another. Thus, the prevention of any evils or harm is greater than any potential evils caused by the interference of the individual's autonomy or liberty. Respect for Persons: Treating others in such a way that enables them to make their own choices. Sanctity of Life: The perspective that life is the highest good. Thus, all forms of life, including mere biological existence, should take precedence over external criteria for judging quality of life. Veracity: The obligation to tell the truth and not to lie or deceive others.

Individuals provide ethical care according to their personal and professional codes of conduct and their employer guidelines. Ethical issues and problems can occur during the provision of patient care. These issues may involve: Abuse and neglect Advance directives Pain management Do Not Resuscitate (DNR) status Patient competency Noncompliance Refusal of care Abandonment Privacy and confidentiality.

Ethical Decision-making Ethical decisions are needed when there is a conflict involving a patient's request or behavior, and the caregiver and organization's standard of care.

These conflicts result from the different points-of-view of the patient, the caregiver, and the organization. These points-of-view incorporate each participant's sense of justice, moral development, socialization, professional standards, and clinical experience. Organization's points-of-view are also influenced by policies and procedures, regulations and legislation, and budget constraints.

Annual Mandatory Education—Professional Nurse

Ethical conflicts are resolved by blending the points-of-view of all participants. That is, taking each into consideration, and arriving at a consensus that all participants can abide by. Ethical conflicts rarely have clear "right and wrong" or "winners and losers" resolutions.

The caregiver is not solely responsible for making ethical decisions. Patients also have responsibilities to the healthcare agency. Summaries of these responsibilities are agency specific, but most include: Providing a complete, accurate history Treating staff with dignity and respect Informing the agency of changes in medication or treatment Notifying the agency in advance of doctor's appointments.

Your organization has established guidelines to follow when you have questions and concerns about ethical issues. Examples of ways organizations have implemented these guidelines include: Ethical care committees On-call ethicists and ombudsmen Multi-disciplinary advisers A chain of command structure for reporting and advice.

When ethical situations occur and cause you discomfort or concern, follow your organization's guidelines.

When Personal and Professional Ethics Conflict For example, some healthcare providers may feel that it is personally unethical for them to: Provide care to a person who may be receiving treatment that the provider feels is unethical, e.g., abortion Provide care to a person being treated for a condition that results from behavior the provider feels is immoral or unethical, e.g., gender reassignment Comply with an organizational policy the provider feels is a violation of personal liberty, e.g., flu vaccination

A variety of ethical principles pertain to all of the above examples. The best choice for the healthcare provider is to plan in advance to ensure that such a situation does not arise. In other words, if there is an objection to providing care for gender reassignment, for example, the healthcare provider should take steps to ensure that the potential employer either does not provide such treatment or that accommodations can be made to ensure that the healthcare provider will not be asked to provide care in that situation.

A healthcare professional who encounters such an ethical dilemma and feels that they cannot provide care, should follow the employer’s guidelines; that typically may include immediately contacting the supervisor, and, possibly, engaging the Ethics Committee if one is available. Policies and regulations vary among employers, states, and professional organizations. However, all policies and regulations agree Copyright 2015, Cross Country University Page 98 of 284, Ethical Care

Annual Mandatory Education—Professional Nurse

that the patient must be safely cared for. A healthcare professional who abandons a patient, for any reason, without ensuring that the patient is properly cared for, may be liable for negative consequences from the employer and/or regulatory body.

End of Ethical Care Lesson

Fall Prevention In every facility, accidents and problems sometimes occur. They are called "variances," and they can be very minor or very serious. A large number of health care variances are related to injuries. In fact, injuries are a much bigger problem than many people realize.

There are several different ways that patients can be injured, but the most common cause of injury is a patient fall.

Facts about patient falls: In one study, patient falls accounted for 70-80% of all hospital variances. The majority of falls occur in patients aged 60-80. 10% of falls occur in patients who have fallen before. The average cost of fall-related injuries is $29,800 per patient. Total costs of fall-related fractures in the U.S. are more than $30 billion per year.

The effects of a patient fall can be very serious. Patients who fall are more likely to be admitted to a nursing home and those who do return to their own homes are more likely to need home-care services.

A patient fall may also result in: Longer hospital stays Permanent injury Disability Death

Causes of falls Most falls occur as a result of: Poor communication among: o Care team members, o Patient and care team member, o Patient friends and family and care team members Patient changing position Patient going to the bathroom Call bell or equipment out of reach Improper footwear

Annual Mandatory Education—Professional Nurse

Unsafe environment, e.g., obstacles on the floor between bed and bathroom

Fall risk You can also learn to recognize patients who are at risk for falls. These include: Infants and young children Older adults Sedated patients.

Infants and young children These patients are immature, and they often do not understand what they should or should not do. Their motor skills are still developing, so they can fall easily. They are also full of curiosity.

Older adults The majority of falls occur in patients over 65 with the highest number in the 80-89 age group. These patients may be unsteady on their feet. They may also have problems with hearing and eyesight.

Patients with altered awareness or level of consciousness Either from dementia or medications, these patients are at high risk of falling. They often cannot recognize dangers and may become confused.

Patient education can also help prevent falls. Teach patients and their families about: The hospital environment Potential hazards Equipment being used.

Preventing falls In light of the above causes, there are things you can do to help prevent patient falls: Maintain a safe environment Communicate patient fall risk to teammates and at change of shift Orient patients and families to their surroundings Show them how to use the call light and explain how and when to get assistance. Ensure good lighting in rooms and bathrooms Keep call bell in reach Keep beds at a low height. Make sure path to bathroom is clear

Bedrails You should be careful to use bedrails only as stated in the policy of your facility. Research shows that the improper use of bedrails increases the chance of patient falls because patients climb over them.

Annual Mandatory Education—Professional Nurse

Generally, restraint for the prevention of falls is either not allowed as per policy guidelines or is allowed only as a last resort. Sitters are a far more common and far safer alternative. Your facility may have special alarms that can be used to alert staff when patients have gotten out of chairs, wheelchairs, or beds.

Fall Protocols Over the last several years, most healthcare organizations have implemented fall protocols. These combine a variety of approaches, usually including: Fall risk assessment, patient classification, and plans of care for at-risk patients Team and/or round observation an documentation standards Patient education, live and in print Room signs and job guides for staff, family, and patients Quality management tracking and reporting Fall-specific event reporting and documentation

When a fall occurs Assess the patient’s condition If the patient is found on the floor, consider neck or spine injury when moving patient If safe to return patient to bed, keep patient in bed until cleared for activity by prescriber Assess for any environmental contributor to the fall Document as with any variance If a fall protocol is applicable, complete any required documentation

End of Fall Prevention Lesson

Fire Safety

Fire Hazards

Components of a fire Fire is one of the biggest dangers in a hospital because of the large number of people who must be evacuated. Before you can recognize fire hazards in a hospital, you must understand how a fire starts. Three things are needed to start a fire: Fuel Heat Oxygen

Fuel is anything that can burn. Examples of fuel are: Paper Rubber

Annual Mandatory Education—Professional Nurse

Cloth Patients' personal care items (deodorant, hairspray, etc.)

When fuel becomes hot enough, it can ignite and burn. In the hospital, this heat can come from: A cigarette butt A hot electrical wire A spark

Oxygen, the third ingredient needed to start a fire, makes up about 20% of the air.

A fire will keep burning as long as the fuel, heat, and oxygen are present. If you remove one of the components, the fire will go out. It is usually easier to remove the heat or the oxygen than to remove the fuel.

Potential fire hazards

Fire hazards are found in many areas of the hospital including: Patients' rooms Storage areas The kitchen Machinery and equipment areas.

Here are some specific examples of potential fire hazards: Although smoking is not permitted in hospitals, patients or visitors sometimes ignore this rule and smoke in the washroom, for example, cigarette butts may still be hot and if carelessly tossed into a wastebasket may start a fire. Misused or faulty electrical equipment (paper jammed in a printer or a coffee machines left unattended for a long period, for example) can cause a fire and so can broken electrical cords or any electrical equipment that is not working properly. Flammable substances, such as hairspray and deodorant in aerosol containers can explode and cause a fire if left too close to a source of extreme heat. Fires can occur where a patient is receiving oxygen, if there is a spark or static electricity. Cylinders that contain compressed gases such as oxygen, anesthetic, and ammonia are fire hazards and must be handled properly and stored in well-ventilated, fireproof, dry areas with controlled temperature.

How to respond to fire hazards There are several ways you can respond to or prevent fire hazards: Eliminate the hazard if you can do it safely. For example, store or dispose of flammable liquids, such as paint thinner, properly. Unplug electrical appliances from overloaded sockets.

Annual Mandatory Education—Professional Nurse

Report hazards you cannot eliminate to your supervisor immediately. If you notice a leaking sprinkler or a beeping smoke detector, report it. Any spark in an oxygen-rich space can cause a fire to ignite. Be careful when using or working around oxygen, especially if using electrical equipment. Be sure that patients and visitors understand that smoking is not permitted in medical facilities. Provide information on the smoking policy of the hospital to patients as soon as they are admitted. If the hospital has designated outside smoking areas, make sure directions to those areas are posted. Learn and follow the fire safety policies of your hospital. Know the location of fire exits and pull- down fire alarms in each area where you work.

Environmental Controls

The purpose of environmental controls Environmental controls are the built-in features of your facility that warn of fires, help to control fires, and contain smoke. All of these features are included in the hospital fire protection plan and should be inspected and updated regularly. Specific staff is responsible for maintaining these features but it is important that you understand how the systems work and what you can do to keep them working.

There are two types of built-in fire safety controls: Passive measures Active measures

Passive built-in fire measures are part of the framework of the hospital. They do not require input or action from anyone to work and most of the staff is unaware of their presence. However, passive fire safety measures should be checked regularly for damage.

Active built-in fire measures include systems that act in a specific way to fire conditions. These systems work automatically to sound an alarm warning of fire or react to fire or smoke. Staff can activate some of these systems.

Passive fire safety measures Passive fire safety measures slow down and help contain the fire. They are part of the structure of the building.

Examples of passive fire safety measures are: Firewalls Fireproofing materials.

Annual Mandatory Education—Professional Nurse

Materials used in passive fire protection measures

Firewalls should be inspected and checked regularly. They may be damaged if: They are drilled to allow the installation of cables and wires If changes are made to the structure of the building.

Structural steel or other elements of the building that have been fireproofed should be checked regularly for cracks or chipping.

Active fire safety measures Active fire safety measures are automatic systems that respond to heat, smoke or fire. Regular checks are required to make sure that they are in proper working order at all times.

Examples of active fire safety measures are: Smoke detectors Overhead sprinklers Smoke doors Fire alarm systems

Smoke detectors Smoke detectors are located in all areas and will set off the fire alarm if they detect smoke. They need to be kept in good working order. Report any damaged smoke detectors to your supervisor.

Fire sprinkler systems Overhead fire sprinklers are set off when they sense high temperatures from a fire. When set off, they pour water under pressure onto the fire. Never hang anything from the sprinklers and be sure that

Annual Mandatory Education—Professional Nurse

equipment or high shelves never block them. Items such as utility carts and dividers should not be any higher than 18 inches from the ceiling. If you find a sprinkler leaking, report it immediately.

Smoke doors Smoke doors are designed to contain dangerous smoke and close automatically if the fire alarm sounds. Never block a smoke door with equipment so that it will not close completely. Once the doors have closed, do not prop them open in any way. Once the "All Clear" signal has been given, they can be opened again.

Fire alarm The fire alarm is triggered automatically by smoke detectors or manually by pulling the alarm. When the alarm is sounded throughout the building, smoke doors close, and the ventilation system shuts down so that smoke is not carried to other areas. It also notifies the staff of the location of the fire. In most facilities, it automatically notifies the fire department of the fire. Be sure that you know the location of the manual fire pull station in the area(s) where you work. Never block it with equipment, such as spare beds or stretchers, carts, shelves or other objects.

Fire Extinguishers

Removing the components of a fire As already stated above, the three things needed to start a fire are: Fuel Heat Oxygen.

Some examples of fuel include: Papers in a wastebasket Paint remover Bed sheets.

Heat can come from: A lit cigarette or match A gas or electric burner on a stove An electric spark (from a "short" in an electrical wire or plug, for example).

Oxygen is found in the air we breathe, but could also come from an oxygen cylinder.

All three components are needed to keep a fire burning, and a fire can be put out by removing any one of them. It is usually easier to remove the heat or oxygen than to remove the fuel.

Annual Mandatory Education—Professional Nurse

Removing the heat Cooling the fire by pouring water on it is a good way to put out a wood or paper fire (a fire in a wastebasket, for example).

But never use water to put out a chemical fire, a grease fire, or an electrical fire. Pouring water on a chemical or grease fire will spread the fire and may cause burning liquid to splash out. And pouring water on an electrical fire (a burning plug, wire, or electrical appliance, for example), can cause an electric shock!

Removing the oxygen Smothering a fire cuts it off from its oxygen supply. This can be done by putting a blanket or pillow over a fire in a wastebasket, or by covering a grease fire on a stove with a pot lid.

Removing the fuel It is often quite difficult to remove the fuel. For example, a wastebasket fire can easily spread to other items in the room that can become fuel for the fire. Curtains, plastic items, carpeting, cushions and other furniture are all combustible, that is, they are able to ignite and burn. If the fire can be prevented from spreading and if the wastebasket is made of non-combustible material, the fire will go out when all the paper has burnt.

Most fire extinguishers work by cooling the fire down and smothering it - they remove both the heat and the oxygen supply. Different types of extinguishers use cold water, dry powder, or a cold, dense gas that is sprayed on the fire.

Types of fire extinguishers Fires are classified according to the fuel that is burning. In the Type A fire, the fuel may be wood, cloth, rubber, and certain types of plastic. The Type B fire involves burning liquids such as grease, oil, solvents, and other liquid chemicals. The Type C fire is an electrical fire in which the fuel may be electrical wires, plugs, or appliances.

Annual Mandatory Education—Professional Nurse

Fire extinguishers for the three types of fires

The blue symbols below indicate which type or types of fire (A, B, C, or some combination) a particular fire extinguisher is rated for.

Water extinguisher

A water extinguisher (also known as a Type A extinguisher) can be used on a Type A fire. High pressure water or foam can soak deeply into the fire to cool it down and put it out. Never use a water extinguisher on a Type B or Type C fire.

Carbon dioxide extinguisher

A carbon dioxide extinguisher is one example of a Type BC extinguisher. It can be used on grease, chemical, and electrical fires (Types B and C), which cannot be sprayed with water because of the risk of splashing and electrocution. Carbon dioxide is a compressed, cold gas that cools and smothers the fire.

Annual Mandatory Education—Professional Nurse

Halon extinguisher

Another example of a Type BC extinguisher is a halon extinguisher. It is sometimes used on valuable electrical equipment because it will put out an electrical fire without causing any more damage to the equipment (unlike dry chemical and carbon dioxide extinguishers).

Multipurpose (dry chemical) extinguisher

A Dry Chemical, multi-purpose type extinguisher extinguishes the fire by coating the fuel and therefore cutting off the oxygen supply to the fuel source. It can be used on most A, B, and C-type fires. It is the most common type of extinguisher found in medical facilities.

How to use a fire extinguisher A fire extinguisher should only be used by someone who has been trained to operate it.

The easiest way to remember all the steps is to memorize the word "PASS." The four letters, "P," "A," "S," and "S" stand for of the four steps involved in using a fire extinguisher.

Annual Mandatory Education—Professional Nurse

"P" stands for "PULL" or "PIN." The first step is to pull out the locking pin at the top of the extinguisher.

"A" stands for "AIM." The second step is to aim the nozzle of the extinguisher at the base of the flames. It is important to aim at the base of the flames, because spraying water, foam, or powder at the middle or top of the flames may actually spread the fire.

"S" stands for "SQUEEZE." The next step is to squeeze the handles together to expel the contents of the fire extinguisher. Do not touch the nozzle of the extinguisher because it may be very cold and could cause a "freeze" burn.

"S" stands for "SWEEP." The final step is to sweep the contents of the fire extinguisher across the fire. The nozzle should still be aimed at the base of the fire, but a side-to-side sweeping motion should be used so the water, foam, or powder rolls over the fire, forming a thick blanket that cools and smothers the fire.

Annual Mandatory Education—Professional Nurse

Know when to leave a fire If you ever need to use a fire extinguisher, be sure to leave a clear escape route BEHIND you in case you cannot put out the fire. NEVER let the fire get between you and the nearest exit.

Remember it is not your job to fight fires! If you are able to quickly and easily stop a small fire from becoming a large fire, do what you can. Never try to put out a large fire that is spreading - simply leave the area, making sure everyone is out and then closing doors behind you.

Professional fire fighters have the training and equipment to deal with a large, spreading fire. Finally, never try to use a fire hose if there is one in your area - fire hoses are only to be used by professional fire fighters and could cause injury if used by someone who has not been trained.

Fire Procedures

An action plan called RACE Would you know what to do if you discovered a fire while at work? People must be able to act quickly. The lives of many could be in danger.

The key to safety when a fire is discovered is to know the steps of an action plan.

The four steps are: REMOVE - If people are in immediate danger from fire or smoke, move them to a safer place. ALARM - Sound the alarm to alert others to the fire. Call the operator or the special number for fire emergencies, to give more information about the fire. CONTAIN - Close all windows and doors to stop the fire and smoke from spreading. EXTINGUISH or EVACUATE - Put out the fire, if it is safe to do so, or help evacuate people from the area.

It may be easy to remember these four steps by recalling the word "RACE". Each of the four letters "R", "A", "C", "E" stands for one of the four steps to take when a fire is discovered.

The "R" in RACE is for REMOVE The "R" in RACE stands for REMOVE - usually the first action step when you discover a fire. REMOVE anyone who is in immediate danger from the fire. If you are in a patient's room and you cannot put the fire out quickly, get all the patients out of the room.

Removing patients from a room can be hard to do. The patients may be unable to walk because: They are recovering from surgery. Equipment such as IV lines, feeding pumps, and monitors are attached to them. They need help to move and are too heavy for you to move alone.

Annual Mandatory Education—Professional Nurse

To REMOVE patients who have difficulty walking, all of the following approaches are possible: Use a wheelchair (if there is one in the room). Move the bed with the patient in it, especially if the patient is attached to equipment or lines (alternatively, IV bags and catheters can be taken down and carried on the patient's lap, and traction weights can be removed in an emergency). Place a sheet or blanket on the floor, ease the patient down on the sheet, wrap the ends around the patient, and drag the sheet. Lend your support to patients who can walk with help. Get others to help you.

The "A" in RACE is for ALARM The second action during a fire is usually to sound the ALARM. Although an automatic fire alarm may be sounding in the room, you must let others know about the fire: Activate the manual pull station or fire alarm. Call the operator and give information such as the location and type of fire. Call the special number for fire emergencies in your hospital.

If a co-worker is nearby, and you are busy moving patients, tell the co-worker to sound the alarm. The sooner the alarm is sounded, the better.

Be ready Before a fire occurs, learn where fire alarms are located in your work area and in other parts of the building. You may not be in your own work area when you discover a fire.

The "C" in RACE is for CONTAIN During a fire, recall the third action step by thinking of the third letter in the word RACE. "C" stands for CONTAIN. CONTAIN the fire as best as you can.

There are several things you can do that will help to contain a fire: Close all windows to slow down the fire. Close the door as soon as everyone is out of the room. This will keep the fire and smoke from spreading to other areas. Keep fire doors in corridors closed. If you must open a fire door, close it immediately after you go through. Remember, fire doors help to contain the fire and smoke. Never block a fire door. Before opening a door, touch it with the back of your hand. If the door feels hot, DO NOT open the door. The fire is likely behind the door. If the door is cool, open the door slowly. If a fire is in the room, opening it quickly may fan the fire. Smother a small fire, such as one in a wastebasket, by stuffing a pillow or blanket on top of the fire to cut off the oxygen supply. Copyright 2015, Cross Country University Page 111 of 284, Fire Safety

Annual Mandatory Education—Professional Nurse

The "E" in RACE is for EXTINGUISH/EVACUATE The last action step in the RACE plan is to EXTINGUISH the fire or EVACUATE the area.

To EXTINGUISH a fire: Use a fire extinguisher if you know how to use one and if the fire is small. Smother the fire. If the fire is in a wastebasket, smother the fire by stuffing a pillow or a heavy item of clothing into the wastebasket. Never use lightweight materials because they may burn and help to spread the fire. Use water. If the burning material is cloth or paper, pour water on the fire.

If you decide to try to extinguish a fire: Check the temperature of the door before returning to a room containing a fire (if it is hot, do not go back in) Keep an exit or escape route open (NEVER let the fire get between you and the door or exit) Leave the room and close the door on a fire if it gets too large to extinguish safely.

If the first attempts to put out the fire are not successful, evacuate everyone in the area from the area immediately.

To EVACUATE: Doors and windows should be closed as the last person leaves the area. Encourage people to walk, and to stay calm. Remember the biggest danger is from the smoke. Crawl on the floor if rooms or corridors are filled with smoke. In a smoke-filled room, the least smoky region is between about 24 and 36 inches from the floor. Use stairs designated as evacuation or "fire" stairs. DO NOT use elevators. Elevators may shut down due to electrical problems caused by the fire. Upon reaching the outside, go to a pre-arranged meeting place. Fire officers will determine if anyone is still in the building. Never reenter a burning building without permission from the Fire Department.

Fire Alarm Procedures

A drill or a fire? When a fire alarm sounds, you must know how to respond quickly. Quick actions can help to save lives. Remember, when a fire alarm is activated, the Fire Department (or other staff responding to the emergency) will know the location of the fire alarm but not the location of the fire.

Respond to all fire alarms. Act as if every fire alarm is for a real fire. A fire alarm may be activated for one of several reasons: There is a fire. Copyright 2015, Cross Country University Page 112 of 284, Fire Safety

Annual Mandatory Education—Professional Nurse

Someone suspects there is a fire. There is a fire drill.

When the fire alarm sounds Several safety features are automated and triggered when a fire alarm is activated: Fire doors close automatically to contain the fire and smoke. If you need to go through doors that have closed automatically, open them quickly and be sure to close them behind you. The fans in ventilations systems stop so that smoke is not spread to all areas. The Fire Department is notified immediately of the location of the activated fire alarm.

After a fire alarm sounds, do not use any elevator - it could stop working at any time because of electrical problems caused by the fire. People could be trapped in an elevator in a burning building. Use the stairs.

Hospital procedures may require all staff to return to their departments when a fire alarm sounds. The following safety precautions should be used when moving from one area to another: Before opening fire doors or smoke doors, feel them with the back of your hand. If the door is hot, DO NOT open the door. If the door is cool, open it slowly so that the draft created by opening the door does not fan a fire. Use the stairs, NOT the elevator. Crouch low (no more than 24 to 36 inches from the floor) if there is a lot of smoke in the corridors.

How you should respond All staff must respond immediately to fire alarms as if there is a fire. You should: Close all windows and doors Ask patients and visitors to stay where they are unless evacuation is necessary Clear the hallways of objects that could be in the way Follow hospital procedures Do special duties as assigned (for example, procedures may indicate that the respiratory therapist is responsible to turn off the oxygen supply system) Evacuate if you see the fire or if a fire marshal tells you to leave Stay in your assigned area until you receive directions or until you hear an all-clear message.

DO NOT: Use the elevator or allow others to use it Hold open doors that have closed automatically Open doors that are hot to touch. Evacuation Procedures

Annual Mandatory Education—Professional Nurse

Smoke, the biggest danger The biggest danger from a fire is deadly smoke. If you are in an area that is filling up with smoke, help people protect themselves from breathing the smoke.

There are three ways to protect yourself and others from breathing smoke: Cover your mouth and nose with a damp cloth or a wet paper towel to filter out the smoke. If smoke is coming in under the door, put a towel, blanket, or other material under the door to stop the smoke. Crouch low until you are 24 - 36 inches off the floor. Smoke rises so stay less than 36 inches from the floor, but do not get too close to the floor, because you may breathe deadly toxic fumes from smoldering carpeting.

Crouch low (between 24 and 36 inches from the floor) when the room is full of smoke.

Safety features in buildings Safety features in the building help you to make decisions about what to do during an evacuation. Two safety features in buildings are: Smoke/fire doors Emergency exit signs.

You need to know about these safety features to evacuate people.

Annual Mandatory Education—Professional Nurse

Smoke or fire doors These doors divide areas of a building into smoke zones that are designed to contain fire and smoke and prevent them from spreading. The smoke and fire doors close automatically when a fire alarm is activated.

Check the door temperature with the back of your hand before opening any door. If the door feels hot, do NOT open it. There is probably a fire behind the door, and opening it could spread the fire and smoke and endanger more lives.

If the door feels cool, open the door slowly. If there is a small fire behind the door, you might feed the fire with the extra oxygen by opening the door too quickly.

"EXIT" signs Emergency exit signs can be seen from any direction. They show access to the outside. They are designed to help you and others evacuate a building when smoke or fire makes it difficult for you to know where you are.

During evacuation, people move toward the outside fire exits.

Two types of evacuation There are two types of evacuation: Horizontal evacuation Vertical evacuation.

Horizontal evacuation Horizontal evacuation is movement along the same level. As a smoke zone fills up with smoke, people must move into the next smoke zone. They are always moving toward the outside fire exits and away from the fire or smoke.

Vertical evacuation Vertical evacuation is movement to another level. Once smoke has reached the zone next to an outside exit or exit stairwell, it is time to evacuate to another level away from the smoke. Vertical evacuation may be a move either up or down a level to escape smoke or fire. Vertical evacuation may be a move from one level to another level, and directly to the outside of the building. If the fire is below you in the stairwell, and behind you on your level, it will be necessary to evacuate vertically by going up a level.

How to evacuate people who cannot walk You must evacuate people who are in immediate danger from smoke or fire. If you are in a patient's room where there is fire or smoke, the first thing to do is to evacuate the patient. Some patients need help to walk.

Annual Mandatory Education—Professional Nurse

To evacuate patients, you can do any of the following: Use a wheelchair (if there is one in the room). Move the bed with the patient in it. Get others to help you, if necessary. Place a sheet or blanket on the floor, ease the patient down onto the sheet, wrap the ends around the patient, and drag the sheet. Lend your support to patients who can walk with help.

End of Fire Safety Lesson

Harassment

Workplace Harassment

What is workplace harassment? Workplace harassment is unwelcome or unsolicited speech or conduct based upon race, sex, creed, religion, national origin, age, color, or handicapping condition that creates a hostile work environment or circumstances involving quid pro quo. Workplace harassment is a form of discrimination, which is prohibited by law.

Examples of behavior that can constitute unlawful workplace harassment and/or create a hostile work environment include, but are not limited to: Making jokes about individuals based on race, sex, creed, religion, national origin, age, color, or handicapping condition Making racial or ethnic slurs Forcing employees to segregate based on race, sex, creed, religion, national origin, age, color, or handicapping condition Giving a subordinate a degrading or humiliating assignment on the basis of race, sex, creed, religion, national origin, age, color, or handicapping condition Displaying offensive literature or posters Repeatedly proselytizing fellow employees on the correctness of a particular religion

Types of workplace harassment Workplace harassment may take many forms. Any harassing activity based on one of the categories listed below that creates a hostile work environment or impairs a person's ability to do their job may be considered workplace harassment. See the previous page for some common examples.

Annual Mandatory Education—Professional Nurse

Posters or graffiti can create a hostile work environment

The following categories are known as "Protected Classes." These are categories to which people belong that are specifically protected from discrimination by federal and state laws.

Everyone is a member of at least one of these categories, and therefore anyone can be a victim of workplace harassment based on: Age - A person 40 years of age or older Color - The complexion or shades of a person's skin Creed - A system of beliefs, principles or opinions Disability - Any person who has a physical or mental impairment which substantially limits one or more major life activities; one who has a record of such impairment; or one who is regarded as having such an impairment National Origin - Characteristic of, or peculiar to, the people of a nation; of or relating to ancestral beginnings, physical, cultural, or linguistic characteristics of a particular national group Race - A local geographic or global human population distinguished as a more or less distinct group by certain characteristics such as skin color, hair texture, and facial features. A race may also be any group of people united or classified together on the basis of common history, nationality, or geographical distribution Religion - All aspects of religious observance, practice and belief which include moral or ethical beliefs as to what is right and wrong which are sincerely held with the strength of traditional religious views Gender and Sexual Orientation - The condition or character of being male or female as well as sexual orientation or preference

The harasser may be a person, group of persons, or even an employer or organization that is responsible for creating a hostile work environment for any member of one or more of the above groups.

Response to workplace harassment If you feel that are the victim of workplace harassment, take the following steps: 1. Collect and preserve evidence

Annual Mandatory Education—Professional Nurse

of what happened; be as specific as possible. Your written record will help you in when talking with your supervisor and will help both you and any investigators if you need to file a complaint. 2. Discuss your concerns with the person who is harassing you (This step may not be appropriate depending on the situation; please read the following paragraphs.)

As with sexual harassment, some harassers may not be aware that their behavior is a problem. If you think that the harasser is not intentionally trying to harass you, and that he or she may be willing to listen and correct the behavior, you might consider discussing your concerns with him or her (remember to use your notes and be specific). If the harasser stops the behavior, then no further action on your part may be necessary.

On the other hand, if you feel the harasser is intentionally trying to impair your ability to work and/or create a hostile work environment, then it may not be a good idea to discuss your concerns with him or her. Such an exchange may become confrontational. 3. Discuss the matter with your supervisor (or, depending on your own organization policy, another person such as a Human Resources representative)

Naturally, if the harasser is your supervisor, you should consider going directly to your Human Resources representative. 4. Follow your organization's policy, if necessary, for further action

Response to an accusation of harassment If a person tells you that you have harassed him or her, you should do all of the following: 1. Be a good listener.

Respect the person's point of view. Try not to become angry or overemotional. Don't treat the situation as a joke or unimportant. He or she is taking a very difficult step in bringing this situation to your attention. Take the person seriously. 2. Apologize, promise to stop the behavior, and immediately stop the behavior.

If you don't feel that you've done anything wrong, or if you disagree that you have exhibited the behavior in question, you may consider not apologizing since that could be interpreted as an admission of guilt. Instead, say you are sorry that the person has been upset by this behavior, that you will not do it, and that you would appreciate it if he or she immediately brought it to your attention if it occurs. Remember not to become angry or defensive. 3. If a complaint is made against you, cooperate fully with any investigation.

Your truthful and willing cooperation will assure the best outcome for you, whether or not you have done anything wrong. Don't criticize or otherwise try to retaliate against the person who made the complaint. 4. If a lawsuit is filed, get an attorney.

Annual Mandatory Education—Professional Nurse

Prevention of workplace harassment Everyone can help create an environment of mutual respect and goodwill by following a few simple guidelines: 1. Apologize.

We all make mistakes. If you've said or done something that someone finds offensive, apologize. Acknowledging mistakes helps create a climate of trust and prevents small problems from becoming big ones. 2. Before telling a joke, ask yourself whether it might be offensive to someone.

"It was just a joke" is not an excuse for harassment.

3. Take a stand.

When you see harassment take place even when it is not directed at you, point it out and object. 4. Respect the differences between people.

We're all unique. Cherish and respect those differences.

If you are a supervisor or manager, you can further help to prevent harassment by doing the following: Treat employees fairly and consistently, Display zero tolerance for harassing behaviors. Discuss your organization's harassment policies with your employees. Ensure that your employees know what to do if they feel they have been harassed.

Annual Mandatory Education—Professional Nurse

Sexual Harassment

The Meaning of Sexual Harassment

What is sexual harassment? Sexual harassment is uninvited and unwelcome verbal or physical conduct directed at an employee because of his or her sex. It is a form of sex discrimination and it is illegal.

Sexual harassment in the workplace often takes the form of unwanted sexual favors or verbal or physical conduct of a sexual nature which: Either reveals or implies an effect on employment Unreasonably interferes with work performance Creates an intimidating, hostile, or offensive work environment.

Who are the victims and who are the harassers? According to statistics from the American Psychological Association and the US Equal Employment Opportunity Commission (EEOC): 40-60% of working women experience at least one incident of sexual harassment in their careers 40-60% of female students in colleges and universities experience at least one incident of sexual harassment About 90% of all sexual harassment cases filed with the EEOC are by women

The harasser in a sexual harassment incident: May be a man or a woman May be the victim's supervisor, a supervisor from another area, a co-worker, or a non-employee Demonstrates conduct that is unwelcome and uninvited.

The victim in a sexual harassment incident: May be a man or woman May be of the same or opposite sex of the harasser May be the person being harassed or another person offended by the harassing conduct Does not necessarily experience financial harm or loss of employment.

Types of harassment The four types of harassment are: 1. Gender-related behavior 2. Seductive behavior 3. Acts of bribery 4. Coercion.

Annual Mandatory Education—Professional Nurse

1. Gender-related behavior Gender-based behavior includes remarks that communicate insulting or degrading attitudes about either sex. It may include obscene jokes, other comments, graffiti, or pornography.

2. Seductive behavior Seductive behavior includes unwanted and inappropriate sexual advances, which may be invitations, persistent letters, phone calls, or emails.

3. Acts of bribery Bribery involves asking for sexual favors with promise of reward.

4. Acts of coercion Coercion involves the demand of sexual favors by using threats such as negative performance evaluations, lack of promotion, or termination.

Gender-related and seductive behaviors are the most common harassment acts, while bribery and coercion are less common.

Response to Sexual Harassment

What is sexually-harassing behavior? Sexual harassment is illegal and each organization has penalties for such actions. Making another person feel uncomfortable through any of the following behaviors is sexual harassment: Certain gender-related behavior Seductive or unwanted sexual advances Bribery or promises in exchange for sexual favors Coercion or the demand of sexual favors by using threats

Gender-related behavior includes: Degrading comments Displayed pornography or pornography sent over the Internet Obscene jokes Sexist comments Sexually-explicit remarks about another person Stereotypical or demeaning language or remarks.

Annual Mandatory Education—Professional Nurse

Persistent letters.

Acts of bribery or promises in exchange for sexual favors include: Offers of promotions Offers of money Offers of rewards.

Coercion or the demand of sexual favors by using threats includes threats of: Negative performance evaluations Lack of promotion Termination.

There is zero tolerance for sexual harassment in your workplace.

What to do if you are a victim of sexual harassment You do not have to tolerate behaviors that make your workspace unwelcome or make you feel uncomfortable. If you are a victim, you should: Let the harasser know that you want the behavior stopped Report the harassing behavior to a supervisor, human resource manager, or designated person If you are being harassed by a supervisor, then you should follow your grievance procedure. Remember that this is ILLEGAL behavior that you do not need to tolerate. Your Human Resources Department should be able to assist you. Remember that management cannot retaliate against someone for registering a sexual harassment complaint.

DO NOT disregard sexually-harassing behavior, hoping it will go away.

All employees should also understand what sexual harassment is, so they do not sexually harass someone else, while believing their actions to be harmless. Harassment can involve persons of the same or opposite sex It is best to avoid sexual remarks, jokes, or material with sexual content, even if it seems harmless to you People not directly involved may be offended Women are most often the victims, but men can also be victims.

End of Harassment Lesson

Hazardous Materials

Annual Mandatory Education—Professional Nurse

New OSHA Labeling Requirements Effective June 1, 2015 In 2012, OSHA adopted new requirements for manufacturers when labeling hazardous products. Compliance with these standards is voluntary until June 1, 2015.

Label requirements now include: Name, Address, and Telephone Number Product Identifier Signal Word Hazard Statement(s) Precautionary Statement(s) Pictogram(s)

Name, Address, and Telephone Number This is information about the manufacturer, importer, or other responsible party

Product Identifier This is how the hazardous material is identified. This can be (but is not limited to) the chemical name, code number or batch number. The manufacturer, importer or distributor can decide the appropriate product identifier. The same product identifier must be both on the label and in section 1 of the SDS (See below in section titled New Safety Data Sheets—SDS Effective June 1, 2015).

Signal Word Signal Words alert the reader to a potential hazard on the label. There are only two words used as signal words, “Danger” and “Warning.” Within a specific hazard class, “Danger” is used for the more severe

Annual Mandatory Education—Professional Nurse

hazards and “Warning” is used for the less severe hazards. There will only be one signal word on the label no matter how many hazards a chemical may have. If one of the hazards warrants a “Danger” signal word and another warrants the signal word “Warning,” then only “Danger” should appear on the label.

Hazard Statement(s) Hazard Statement(s) describe the nature of the hazard(s) of a chemical, including, where appropriate, the degree of hazard. For example: “Causes damage to kidneys through prolonged or repeated exposure when absorbed through the skin.” All of the applicable hazard statements must appear on the label. Hazard statements may be combined where appropriate to reduce redundancies and improve readability. The hazard statements are specific to the hazard classification categories, and chemical users should always see the same statement for the same hazards no matter what the chemical is or who produces it.

Precautionary Statement(s) Precautionary Statements describe recommended measures that should be taken to minimize or prevent adverse effects resulting from exposure to the hazardous chemical or improper storage or handling. There are four types of precautionary statements: prevention (to minimize exposure); response (in case of accidental spillage or exposure emergency response, and first-aid); storage; and disposal. For example, a chemical presenting a specific target organ toxicity (repeated exposure) hazard would include the following on the label: “Do not breathe dust/fume/gas/mist/vapors/spray. Get medical advice/attention if you feel unwell. Dispose of contents/container in accordance with local/regional/national and international regulations.”

Pictogram(s) Pictograms are graphic symbols used to communicate specific information about the hazards of a chemical. On hazardous chemicals being shipped or transported from a manufacturer, importer or distributor, the required pictograms consist of a red square frame set at a point with a black hazard symbol on a white background, sufficiently wide to be clearly visible. A square red frame set at a point without a hazard symbol is not a pictogram and is not permitted on the label.

Annual Mandatory Education—Professional Nurse

Safety Data Sheets—SDS Effective June 1, 2015 (Formerly Material Safety Data Sheets)

What is an SDS? The Hazard Communication Standard (HCS) requires chemical manufacturers, distributors, or importers to provide Safety Data Sheets (SDSs) (formerly known as Material Safety Data Sheets or MSDSs) to communicate the hazards of hazardous chemical products. As of June 1, 2015, the HCS will require new SDSs to be in a uniform format, and include the section numbers, the headings, and associated information under the headings below:

When on the job, workers may be required to work with different chemicals that could cause injury if not used properly.

These are examples of products that contain harmful chemicals: Paint Cleaners Disinfectants

Annual Mandatory Education—Professional Nurse

Pesticides Printer cartridges Bleach Toners

You have the right to know about the different chemicals you come in contact with and how to handle them safely. All of this "right to know" information is available on the Safety Data Sheet, or "SDS."

SDS is a separate document that comes with every chemical-containing product that you use on the job. The SDS lists information about the chemical, like how to handle the chemical safely and what to do if it spills. The SDS gives more detailed information than would fit on the label of the product.

The SDS for each chemical solution that you might use on the job has to be easily available to you while you are working. If you do not know where the Safety Data Sheets are kept, ask your supervisor.

Information on an SDS While the SDS format for different products may differ, they all must contain the following information:

Section 1: Identification This section identifies the chemical on the SDS as well as the recommended uses. It also provides the essential contact information of the supplier. The required information consists of: Product identifier used on the label and any other common names or synonyms by which the substance is known. Name, address, phone number of the manufacturer, importer, or other responsible party, and emergency phone number. Recommended use of the chemical (e.g., a brief description of what it actually does, such as flame retardant) and any restrictions on use (including recommendations given by the supplier).

Section 2: Hazard(s) Identification This section identifies the hazards of the chemical presented on the SDS and the appropriate warning information associated with those hazards. The required information consists of: The hazard classification of the chemical (e.g., flammable liquid, category1). Signal word. Hazard statement(s). Pictograms (the pictograms or hazard symbols may be presented as graphical reproductions of the symbols in black and white or be a description of the name of the symbol (e.g., skull and crossbones, flame). Precautionary statement(s). Description of any hazards not otherwise classified.

Annual Mandatory Education—Professional Nurse

For a mixture that contains an ingredient(s) with unknown toxicity, a statement describing how much (percentage) of the mixture consists of ingredient(s) with unknown acute toxicity. Please note that this is a total percentage of the mixture and not tied to the individual ingredient(s).

Section 3: Composition/Information on Ingredients

This section identifies the ingredient(s) contained in the product indicated on the SDS, including impurities and stabilizing additives. This section includes information on substances, mixtures, and all chemicals where a trade secret is claimed. The required information consists of:

Substances Chemical name. Common name and synonyms. Chemical Abstracts Service (CAS) number and other unique identifiers. Impurities and stabilizing additives, which are themselves classified and which contribute to the classification of the chemical.

Mixtures Same information required for substances. The chemical name and concentration (i.e., exact percentage) of all ingredients which are classified as health hazards and are: o Present above their cut-off/concentration limits or o Present a health risk below the cut-off/concentration limits. The concentration (exact percentages) of each ingredient must be specified except concentration ranges may be used in the following situations: o A trade secret claim is made, o There is batch-to-batch variation, or o The SDS is used for a group of substantially similar mixtures. o Chemicals where a trade secret is claimed o A statement that the specific chemical identity and/or exact percentage (concentration) of composition has been withheld as a trade secret is required.

Section 4: First-Aid Measures This section describes the initial care that should be given by untrained responders to an individual who has been exposed to the chemical. The required information consists of: Necessary first-aid instructions by relevant routes of exposure (inhalation, skin and eye contact, and ingestion). Description of the most important symptoms or effects, and any symptoms that are acute or delayed. Recommendations for immediate medical care and special treatment needed, when necessary.

Annual Mandatory Education—Professional Nurse

Section 5: Fire-Fighting Measures This section provides recommendations for fighting a fire caused by the chemical. The required information consists of: Recommendations of suitable extinguishing equipment, and information about extinguishing equipment that is not appropriate for a particular situation. Advice on specific hazards that develop from the chemical during the fire, such as any hazardous combustion products created when the chemical burns. Recommendations on special protective equipment or precautions for firefighters.

Section 6: Accidental Release Measures This section provides recommendations on the appropriate response to spills, leaks, or releases, including containment and cleanup practices to prevent or minimize exposure to people, properties, or the environment. It may also include recommendations distinguishing between responses for large and small spills where the spill volume has a significant impact on the hazard. The required information may consist of recommendations for: Use of personal precautions (such as removal of ignition sources or providing sufficient ventilation) and protective equipment to prevent the contamination of skin, eyes, and clothing. Emergency procedures, including instructions for evacuations, consulting experts when needed, and appropriate protective clothing. Methods and materials used for containment (e.g., covering the drains and capping procedures). Cleanup procedures (e.g., appropriate techniques for neutralization, decontamination, cleaning or vacuuming; adsorbent materials; and/or equipment required for containment/clean up)

Section 7: Handling and Storage This section provides guidance on the safe handling practices and conditions for safe storage of chemicals. The required information consists of: Precautions for safe handling, including recommendations for handling incompatible chemicals, minimizing the release of the chemical into the environment, and providing advice on general hygiene practices (e.g., eating, drinking, and smoking in work areas is prohibited). Recommendations on the conditions for safe storage, including any incompatibilities. Provide advice on specific storage requirements (e.g., ventilation requirements)

Section 8: Exposure Controls/Personal Protection This section indicates the exposure limits, engineering controls, and personal protective measures that can be used to minimize worker exposure. The required information consists of: OSHA Permissible Exposure Limits (PELs), American Conference of Governmental Industrial Hygienists (ACGIH) Threshold Limit Values (TLVs), and any other exposure limit used or recommended by the chemical manufacturer, importer, or employer preparing the safety data sheet, where available. Appropriate engineering controls (e.g., use local exhaust ventilation, or use only in an enclosed system). Copyright 2015, Cross Country University Page 128 of 284, Hazardous Materials

Annual Mandatory Education—Professional Nurse

Recommendations for personal protective measures to prevent illness or injury from exposure to chemicals, such as personal protective equipment (PPE) (e.g., appropriate types of eye, face, skin or respiratory protection needed based on hazards and potential exposure). Any special requirements for PPE, protective clothing or respirators (e.g., type of glove material, such as PVC or nitrile rubber gloves; and breakthrough time of the glove material).

Section 9: Physical and Chemical Properties This section identifies physical and chemical properties associated with the substance or mixture. The minimum required information consists of: Appearance (physical state, color, etc.); Upper/lower flammability or explosive limits; Odor; Vapor pressure; Odor threshold; Vapor density; pH; Relative density; Melting point/freezing point; Solubility(ies); Initial boiling point and boiling range; Flash point; Evaporation rate; Flammability (solid, gas); Upper/lower flammability or explosive limits; Vapor pressure; Vapor density; Relative density; Solubility(ies); Partition coefficient: n-octanol/water; Auto-ignition temperature; Decomposition temperature; and Viscosity.

The SDS may not contain every item on the above list because information may not be relevant or is not available. When this occurs, a notation to that effect must be made for that chemical property. Manufacturers may also add other relevant properties, such as the dust deflagration index (Kst) for combustible dust, used to evaluate a dust's explosive potential

Section 10: Stability and Reactivity

Annual Mandatory Education—Professional Nurse

This section describes the reactivity hazards of the chemical and the chemical stability information. This section is broken into three parts: reactivity, chemical stability, and other. The required information consists of: Reactivity Description of the specific test data for the chemical(s). This data can be for a class or family of the chemical if such data adequately represent the anticipated hazard of the chemical(s), where available.

Chemical stability Indication of whether the chemical is stable or unstable under normal ambient temperature and conditions while in storage and being handled. Description of any stabilizers that may be needed to maintain chemical stability. Indication of any safety issues that may arise should the product change in physical appearance.

Other Indication of the possibility of hazardous reactions, including a statement whether the chemical will react or polymerize, which could release excess pressure or heat, or create other hazardous conditions. Also, a description of the conditions under which hazardous reactions may occur. List of all conditions that should be avoided (e.g., static discharge, shock, vibrations, or environmental conditions that may lead to hazardous conditions). List of all classes of incompatible materials (e.g., classes of chemicals or specific substances) with which the chemical could react to produce a hazardous situation. List of any known or anticipated hazardous decomposition products that could be produced because of use, storage, or heating. (Hazardous combustion products should also be included in Section 5 (Fire-Fighting Measures) of the SDS.)

Section 11: Toxicological Information This section identifies toxicological and health effects information or indicates that such data are not available. The required information consists of: Information on the likely routes of exposure (inhalation, ingestion, skin and eye contact). The SDS should indicate if the information is unknown. Description of the delayed, immediate, or chronic effects from short- and long-term exposure. The numerical measures of toxicity (e.g., acute toxicity estimates such as the LD50 (median lethal dose)) - the estimated amount [of a substance] expected to kill 50% of test animals in a single dose. Description of the symptoms. This description includes the symptoms associated with exposure to the chemical including symptoms from the lowest to the most severe exposure. Indication of whether the chemical is listed in the National Toxicology Program (NTP) Report on Carcinogens (latest edition) or has been found to be a potential carcinogen in the International Agency for Research on Cancer (IARC) Monographs (latest editions) or found to be a potential carcinogen by OSHA Copyright 2015, Cross Country University Page 130 of 284, Hazardous Materials

Annual Mandatory Education—Professional Nurse

Section 12: Ecological Information (non-mandatory) This section provides information to evaluate the environmental impact of the chemical(s) if it were released to the environment. The information may include: Data from toxicity tests performed on aquatic and/or terrestrial organisms, where available (e.g., acute or chronic aquatic toxicity data for fish, algae, crustaceans, and other plants; toxicity data on birds, bees, plants). Whether there is a potential for the chemical to persist and degrade in the environment either through biodegradation or other processes, such as oxidation or hydrolysis. Results of tests of bioaccumulation potential, making reference to the octanol-water partition coefficient (Kow) and the bioconcentration factor (BCF), where available. The potential for a substance to move from the soil to the groundwater (indicate results from adsorption studies or leaching studies). Other adverse effects (e.g., environmental fate, ozone layer depletion potential, photochemical ozone creation potential, endocrine disrupting potential, and/or global warming potential).

Section 13: Disposal Considerations (non-mandatory) This section provides guidance on proper disposal practices, recycling or reclamation of the chemical(s) or its container, and safe handling practices. To minimize exposure, this section should also refer the reader to Section 8 (Exposure Controls/Personal Protection) of the SDS. The information may include: Description of appropriate disposal containers to use. Recommendations of appropriate disposal methods to employ. Description of the physical and chemical properties that may affect disposal activities. Language discouraging sewage disposal. Any special precautions for landfills or incineration activities

Section 14: Transport Information (non-mandatory) This section provides guidance on classification information for shipping and transporting of hazardous chemical(s) by road, air, rail, or sea. The information may include: UN number (i.e., four-figure identification number of the substance). UN proper shipping name. Transport hazard class(es). Packing group number, if applicable, based on the degree of hazard. Environmental hazards (e.g., identify if it is a marine pollutant according to the International Maritime Dangerous Goods Code (IMDG Code)). Guidance on transport in bulk (according to Annex II of MARPOL 73/783 and the International Code for the Construction and Equipment of Ships Carrying Dangerous Chemicals in Bulk (International Bulk Chemical Code (IBC Code)). Any special precautions which an employee should be aware of or needs to comply with, in connection with transport or conveyance either within or outside their premises (indicate when information is not available). Section 15: Regulatory Information (non-mandatory) Copyright 2015, Cross Country University Page 131 of 284, Hazardous Materials

Annual Mandatory Education—Professional Nurse

This section identifies the safety, health, and environmental regulations specific for the product that is not indicated anywhere else on the SDS. The information may include: Any national and/or regional regulatory information of the chemical or mixtures (including any OSHA, Department of Transportation, Environmental Protection Agency, or Consumer Product Safety Commission regulations)Sometimes the PPE listed are needed only when the worker is exposed to large quantities of the substance and not during normal use. This section needs to be read carefully. When dealing with products that contain chemicals, read through the SDS to be sure you are appropriately handling them.

Personal Protective Equipment (PPE)

What is PPE? PPE stands for "Personal Protective Equipment." A PPE is an item you use for safety when working with hazardous materials.

These are some examples of PPEs: Utility gloves Safety glasses Goggles Gowns Ventilators Masks

You work with a lot of chemicals every day. It is important to know how to safely handle them.

These are some examples of hazardous chemicals you may use: Paint thinner Ethylene oxide Some chemotherapy drugs Pesticides Certain cleaning solutions, especially hazardous if undiluted

Whenever you are around hazardous chemicals, be sure to use the appropriate PPEs to keep you safe.

Which PPEs are appropriate in different situations PPEs are listed on the SDS (Material Safety Data Sheet) for all the chemicals you work with. The PPEs necessary for each substance are determined by the ways the substance can harm you.

Annual Mandatory Education—Professional Nurse

Having physical contact with the chemical Swallowing the chemical

Breathing the chemical The chemical may have toxic fumes that can injure your lungs if you breathe them. For example, cleaning materials, especially bleach, are toxic when inhaled.

Appropriate PPEs for toxic fumes may include: Special mask Ventilator

In addition, always use these products in a well-ventilated area. If you begin to feel dizzy or weak or have difficulty breathing when using a product, you need to leave the area immediately.

Having physical contact with the chemical The chemical may injure any part of the body that comes in contact with it. Your eyes are in danger from liquid splashing into them. Any exposed skin is also at risk.

Appropriate PPEs to prevent physical contact may include: Goggles, safety glasses, or other eye protection Gown Gloves Mask

In addition, flushing with water is usually the most immediate treatment for any accidental splashing of solutions in your eyes or on your skin.

Swallowing the chemical Some chemicals are dangerous if swallowed. To prevent swallowing a solution that may have splashed on your fingers, always wash your hands thoroughly after coming in contact with anything that should not be swallowed.

Appropriate PPEs to prevent swallowing may include: Mask (that covers your nose and mouth to prevent the solution from being splashed onto your lips) Gloves (to protect against hand to mouth transfer).

In addition, if you should accidentally swallow a harmful chemical, tell your supervisor immediately. You will probably be sent to the Employee Health Nurse or to your Emergency Department.

Annual Mandatory Education—Professional Nurse

To prevent dangerous exposure in the first place, be sure to read the SDS and use the appropriate PPEs listed. If exposure does occur, you need to tell your supervisor and get further treatment.

What to do if a chemical spills Some chemical solutions can be dangerous if they are spilled. They may give off dangerous fumes, or they may be toxic if they come in contact with skin.

Any time that a potentially toxic solution is spilled, you should do two things: Remove everyone from the area. Read the SDS for the solution before trying to clean the spill up.

If you decide that you CAN safely clean up the spill, determine which PPEs to use. It may require some special equipment and PPEs to clean it up safely.

If you CANNOT safely clean it up, you should immediately call your safety officer or the Environmental Services Department. Always notify your supervisor as well.

Biohazardous Waste

What is biohazardous waste? Biohazardous waste or biomedical waste is waste material from the hospital or medical office that involves blood or body fluids that present a risk of death, injury, or illness to individuals who handle it.

Biohazardous waste materials present a risk of death, injury, or illness to individuals who handle them.

Materials defined as biohazardous waste include: Human blood and blood products

Annual Mandatory Education—Professional Nurse

Cultures and samples taken to determine the causes of disease Laboratory waste such as culture dishes, blood specimen tubes, and devices used to transfer, inoculate, or mix cultures Personal protective equipment, clothing, and materials that have come in contact with biohazards Sharps such as syringes, needles, suture needles, and fingersticks Body parts that have been surgically removed Human waste that is infected/diseased.

Packaging and labeling biohazardous waste for disposal There are special procedures for disposing of any materials that may contain blood or other sources of germs so that these germs are not spread to others.

Treat all hospital laundry as if it contains germs. Handle it as little as possible. Always hold it away from your clothing. If laundry is visibly soiled, use gloves when removing it so that you do not touch any blood or other material. Always put soiled laundry into laundry bags with lids. Wash your hands frequently.

Any trash that has been in contact with blood or other body fluids must be placed in "biohazard" bags. These bags are usually red, are marked "Biohazard" and labeled with the facility's mailing address, and are specially designed to be leak proof. They are referred to as Red Bags. Red Bags should NOT be used for regular trash and should NEVER be discarded with regular trash; for example, a defective Red Bag should be disposed of as biohazardous waste even if it has not been used.

All sharp instruments such as needles, scalpels, suture needles, and fingersticks that have come in contact with blood or other body fluids must be put into special sharps containers. The containers are made of leak proof, rigid, puncture-resistant plastic and must be labeled with the international biohazard symbol and the word "Biohazard."

Four rules to remember when packaging sharps: ALWAYS use the safety devices required by your facility. ALWAYS be sure that the sharp has dropped completely into the container. NEVER recap needles while holding them in your hands. NEVER over-fill a sharps container. Remove the container when it is 3/4 full or sooner depending on the policy of your facility.

Annual Mandatory Education—Professional Nurse

Some canisters and containers for blood and/or body fluids are designed for disposal with the waste material in them. If they are made of glass or another breakable material, they are treated as large sharps and disposed of in large, rigid, biohazard containers.

Finally, specimens sent to the lab. for analysis must be in a specimen container or bag with a "Biohazard" label.

Under normal circumstances, eating utensils such as silverware and dishes do not need special handling. The very hot water used in dishwashing will kill any germs.

Blood spills and dried blood should be cleaned using disinfectants designed for that purpose. The Hepatitis virus can live as long as one week in dried blood.

Medical equipment can be decontaminated by: Autoclaving or steam sterilization Chemical disinfection.

Autoclaving Autoclaving or steam sterilization uses saturated steam at temperatures high enough to kill infectious agents, and is used for equipment that is re-used and must be sterile. Time and temperature requirements vary depending on the type of waste. Waste that has been autoclaved is marked with autoclave tape.

Chemical disinfection Equipment that has been contaminated with blood or other body fluids and does NOT need to be kept sterile may be decontaminated by chemical disinfection.

End of Hazardous Materials Lesson

HCAHPS

Background and rationale for this presentation The Centers for Medicare and Medicaid Services (CMS) has developed and mandated a standardized patient satisfaction survey in which recently discharged patients can assess their hospital experience. This survey is titled “Hospital Consumer Assessment of Healthcare Providers and Systems” and pronounced ‘h-caps’.

The survey was developed over several years with input from a broad representation of consumers, stakeholders, and scientists. The survey was extensively analyzed and piloted before implementation. CMS says that they went to great lengths to assure that the survey is “credible, useful, and practical.” (HCAHPS Fact Sheet, July 2010) Copyright 2015, Cross Country University Page 136 of 284, HCAHPS

Annual Mandatory Education—Professional Nurse

As of July 2007, hospitals receiving Medicare and Medicaid funding must report HCAHPS results or lose up to 2% of that funding. As of October 2012, those hospitals may receive additional, incentive funding as a result of HCAHPS performance.

Intent Ultimately, the goal of HCAHPS is to incentivize hospitals to improve patient satisfaction, and, indirectly, the quality of care. A standardized survey enables between-hospital comparisons of patient experiences. In effect, survey results will be used to compare and rate hospitals according to how well they meet their patients’ expectations. The results are publicly reported.

Hospitals have a dual incentive to address barriers to patient satisfaction: 1. Reimbursement will depend, to some extent, on survey performance, and 2. Knowledgeable consumers will make utilization decisions based on publicly available survey information.

Methodology Hospitals may use one or more of the following survey technologies: mail, telephone, mail with telephone followup, or active voice recognition (automated phone survey technology). Official language versions include Chinese, English, Russian, Spanish, and Vietnamese. All are available to the public.

Patients are surveyed between 48 hours and six weeks after discharge. A random sample of all adult patients, not just those receiving Medicare, is chosen from a variety of diagnoses.

Content The survey focuses primarily on (emphasis is the author’s):

. . . critical aspects of patients’ hospital experiences (communication with nurses and doctors, the responsiveness of hospital staff, the cleanliness and quietness of the hospital environment, pain management, communication about medicines, discharge information, overall rating of hospital, and would they recommend the hospital). -HCAHPS Fact Sheet

Additional survey questions are intended to adjust for differences between patients and hospitals, assist patients in answering the survey questions, and support mandated reporting.

Measuring and reporting Each hospital’s survey is summarized for public reporting into ten HCAHPS measures. The following table has been copied directly from the HCAHPS Hospital Comparison website. After entering a zip code, the site allows selection of up to 3 hospitals for comparison. Below, two hospitals in the 65203 zip are compared.

Annual Mandatory Education—Professional Nurse

Survey of Patients' Hospital Experiences

HCAHPS (Hospital Consumer Assessment of Remove hospital from comparision Remove hospital from comparision Healthcare Providers and Systems) is a national BOONE HOSPITAL CENTER UNIVERSITY OF MISSOURI HEALTH survey that asks patients about their BOONE HOSPITAL CENTER CARE experiences during a recent hospital stay. Use 1600 E BROADWAY UNIVERSITY OF MISSOURI the results shown here to compare hospitals COLUMBIA,MO 65201 HEALTH CARE based on ten important hospital quality topics. (573) 815-8000 ONE HOSPITAL DRIVE, ROOM Read more information about the survey of CE121, DC031,00 patients’ hospital experiences. Acute Care Hospitals - Opens in a COLUMBIA,MO 65201 new window (573) 882-4141

7.1 miles Acute Care Hospitals - Opens in a new window

10.6 miles Map & Directions

Measure Description

Map & Directions Add To My Favorites

Add To My Favorites

Patients who reported that their nurses 83% 72% "Always" communicated well.

Patients who reported that their doctors 87% 74% "Always" communicated well.

Patients who reported that they "Always" 67% 60% received help as soon as they wanted.

Patients who reported that their pain was 71% 66% "Always" well controlled.

Patients who reported that staff "Always" explained about medicines before giving it 72% 56% to them.

Patients who reported that their room and 73% 69% bathroom were "Always" clean.

Patients who reported that the area around 57% 52% their room was "Always" quiet at night.

Patients at each hospital who reported that YES, they were given information about 89% 85% what to do during their recovery at home.

Patients who gave their hospital a rating of 9 or 10 on a scale from 0 (lowest) to 10 76% 64% (highest).

Patients who reported YES, they would 82% 70% definitely recommend the hospital.

Annual Mandatory Education—Professional Nurse

As is immediately obvious, consumers have an at-a-glance ability to compare hospitals. And most importantly, the above comparison brings to light several areas in which you can strongly influence your patient’s satisfaction with care and your patient’s response to the HCAHPS survey questions.

Assuring the Best Possible Survey Responses; What You Need to Know and Do You pride yourself on the care you provide. And you want your organization to benefit from the quality of care you provide. The following section explains how to assure that your patient responds to the HCAPS survey in a way that most positively represents the care you provided.

‘Always’ is the best only answer. In the above table, note that the first seven domains score only ‘Always’ responses. The survey question allows the following responses: Always, Usually, Sometimes, Never. However, ‘Always’ is the only answer reported to consumers for those seven domains. This standard particularly applies to the following situations:

Meeting patient requests, especially bathroom requests, and answering call lights Maintaining room and bathroom cleanliness Managing pain Providing information about medications Providing information about post discharge activities and medications Maintaining a comfortable and quiet (especially at night) environment

The challenge, therefore, is to assure that your patient answers ‘Always’ as often as possible. Keep in mind that these surveys take place well after the hospital stay. The patient’s recollection of details of nursing care will likely be incomplete, and survey responses will be heavily influenced by only a few incidents that may stand out in the patient’s memory. The following behavioral techniques will help your patient to remember the good care you provide.

Make your good care explicit. Making your care explicit may be the most powerful behavioral technique you can use to reinforce your patient’s memory of good care. When performing any care that falls into one of the seven ‘Always’ categories, announce what you are doing to the patient. In other words, explicitly state to the patient that you are providing care in one of those seven categories. For example:

When entering a room to answer a call light, say to the patient, “I am answering your call light, Mrs. Brown.” And when leaving the room, make a statement that again reminds the patient of what you’ve done, such as, “I’ve answered your call light; is there anything else I can do for you?” If possible, incorporate your ‘announcement’ into the first and last things you say to the patient.

Annual Mandatory Education—Professional Nurse

Use this technique in every situation in which you are providing care in those seven ‘Always’ categories. Making your care explicit will reinforce your patient’s memory and will predispose your patient to recalling your high quality care much later on when completing the survey.

Communicate the right message. Verbal and non-verbal interaction with the patient and family members must always indicate respect and caring. A professional appearance helps meet the patient’s expectations for how a professional should look. Confident and open body language and posture will indicate a willingness to listen and respond. Good grammar and word usage reinforces that message.

Be nice. Sarah J. Breier, PhD, RN, Associate Director-MU Center for Health Ethics, has this to say about the “power of being nice” in her course on professional communication:

The common belief that 'nice [healthcare providers]' get sued less than others is true and has been well documented in the related literature. Every now and then, however, it is hard to be nice, yet it is much easier than many other risk management strategies. It is imperative to remember that when you are tired, harassed, or you find yourself in a high-stress situation, stop…… take a deep breath, and simply be cheerful and friendly. You will feel better, and it might keep you out of the courtroom some day. Here are some specific things you can do to show your patients that you care when you are in a high-stress situation:

If you have to keep your patient waiting, tell them what to expect. Never leave your patients hanging in limbo. Give the patient your full attention. Don't interrupt. Listen carefully to what your patients have to say, especially when you're in a hurry. Respect your patients' privacy. Treat patients as people, not medical conditions. A patient with potential breast cancer won't appreciate being referred to as 'the breast mass' Involve patients in decision making. Don't be a 'care dictator'! Don't be critical of other care the patient has received. Nurse's criticism of other nurses who have taken care of the patient can give rise to highly unnecessary game-playing and is in very poor taste. It can also give rise to law suits! Make sure your fellow nurses show your patients the same consideration that you do. This is also a part of your role as the patient's advocate

Focus on trouble areas. CMS tracks and summarizes HCAHPS results by state. Not surprisingly, certain items always trend lower than others, and these trends are fairly consistent regardless of the state. Please refer to the following website for a look at these interesting trends: http://www.hcahpsonline.org/files/July%202012%20Summary%20of%20HCAHPS%20Survey%20Results%20Table.pdf

Annual Mandatory Education—Professional Nurse

The following table is based on the information presented at the above site: Survey Order Rank Order Patients who 77 Patients at each 83 reported that hospital who their nurses reported that "Always" YES, they were communicated given information well. about what to do during their recovery at home. Patients who 81 Patients who 81 reported that reported that their doctors their doctors "Always" "Always" communicated communicated well. well. Patients who 65 Patients who 77 reported that reported that they "Always" their nurses received help as "Always" soon as they communicated wanted. well. Patients who 70 Patients who 72 reported that reported that their pain was their room and "Always" well bathroom were controlled. "Always" clean. Patients who 62 Patients who 70 reported that reported that staff "Always" their pain was explained about "Always" well medicines controlled. before giving it to them. Patients who 72 Patients who 70 reported that reported YES, their room and they would bathroom were definitely "Always" clean. recommend the hospital.

Annual Mandatory Education—Professional Nurse

Patients who 59 Patients who 68 reported that gave their the area around hospital a rating their room was of 9 or 10 on a "Always" quiet scale from 0 at night. (lowest) to 10 (highest). Patients at each 83 Patients who 65 hospital who reported that reported that they "Always" YES, they were received help as given soon as they information wanted. about what to do during their recovery at home. Patients who 68 Patients who 62 gave their reported that hospital a rating staff "Always" of 9 or 10 on a explained about scale from 0 medicines before (lowest) to 10 giving it to them. (highest). Patients who 70 Patients who 59 reported YES, reported that the they would area around their definitely room was recommend the "Always" quiet at hospital. night.

Be aware of the trends displayed in the right hand columns above. From this information, you can assume, for example, that patients consider hospitals noisy at night, are puzzled about their medications, and don’t feel they can reliable get help quickly. Visit your own employer’s HCAHPS results and compare those with the national trends above.

Bottom line, by focusing on the problem areas, and utilizing the behavioral techniques you’ve learned, you can strongly influence your patient’s recall of the care you provide, and impact your organization’s survey results.

Conclusion The HCAHPS rating depends, to a large extent, on the patient’s relationship with their professional healthcare provider. Hospital reimbursement and consumer choice are dependent upon those ratings.

Annual Mandatory Education—Professional Nurse

Therefore, the healthcare professional/patient relationship, your relationship with your patient, is critical to the hospital’s bottom line.

End of HCAHPS Lesson

HIPAA, HITECH, Social Media, and Patient Privacy

HIPAA Standards govern the portability and privacy of medical information Healthcare workers and organizations rely heavily on the sharing of patient information. As the rapidly growing trend toward the electronic sharing of that information continues, the healthcare industry needs standards that enable fast and accurate transmission of that information.

However, as patient information becomes more portable (easy to share), the more difficult it is to protect the privacy of that information. Therefore healthcare workers, organizations, and consumers are increasingly concerned about patient privacy.

The Health Insurance Portability and Accountability Act of 1996, commonly known as HIPAA (hip' uh), was enacted to address these issues. Still in progress are HIPAA Standards that will establish a format for the fast and accurate exchange of health information data, and for maintaining the security of that information.

One of the HIPAA Standards already in effect, The Privacy Rule, establishes certain regulations that protect the privacy of patient information, gives patients greater access to their own health care information, and gives patients more control over how that information is shared.

Covered entities must comply with the HIPAA Privacy Rule The Privacy Rule is a HIPAA Standard that protects the privacy of patient information. As of April, 2003, all healthcare organizations must be in compliance with the Privacy Rule. As a result, all medical information that is created, used, or disclosed by a covered entity must be kept private and secure. A covered entity includes any of the following: Health Care Provider A provider of medical services that bills for services or is otherwise paid for health care that it delivers Health Plan An individual or group health plan that provides or pays the cost of medical care Healthcare Clearinghouse A public or private entity, such as a billing service, re-pricing company, community health management information system, or community health information system, that serves as a go- between for the exchange of information between two or more covered entities Business Associate A person or organization who provides services within a Health Care Provider organization, but that is

Annual Mandatory Education—Professional Nurse

not part of the organization. The Business Associate would have access to Protected Health Information (PHI). Examples include organizations that provide Physical Therapy services for a hospital, or medical transcription services used by a physician's office.

All employees of covered entities must comply with the HIPAA Privacy Rule when they gather, store, and transmit healthcare information. Failure to follow HIPAA regulations can result in punitive fines for health care providers and/or individuals involved.

Protected Health Information is information that is individually identifiable The Privacy Rule protects the privacy of all Protected Health Information (PHI). PHI is individually identifiable health information that is gathered, stored, or transmitted on paper, orally, or by electronic or any other media. PHI does not include individually identifiable health information in education records and in employment records held by a covered entity in its role as an employer.

Individually identifiable health information is health information that specifically identifies the individual, or is information that could reasonably be expected to identify an individual, even if the individual is not named.

Example: Mary Smith is the only 50-year-old patient with a diagnosis of lung cancer at XYZ Hospital.

The following statement DOES NOT provide individually identifiable health information about Mary Smith and is therefore not PHI: There are presently 7 persons with a diagnosis of lung cancer at XYZ Hospital.

The following statement DOES provide individually identifiable health information: There is a 50-year-old woman with lung cancer at XYZ Hospital.

Though the second statement does not mention Mary Smith by name, it is PHI because Mary Smith is the only person who fits the description.

Compliance

Using and disclosing protected health information Without a signed or verbal authorization from the patient, Protected Health Information (PHI) can be used and disclosed ONLY: To individuals for treatment, payment, or healthcare operations To those within the organization who require the information to carry out their job responsibilities To other covered entities who need the information to provide treatment or for billing purposes

Annual Mandatory Education—Professional Nurse

To law enforcement agencies when needed for legal purposes. This includes coroners and medical examiners to public health officials If needed for Workmen's Compensation If needed to stop serious threats to health and/or safety If needed for charges of fraud or abuse With a valid authorization by the individual patient

When providing PHI, use the Minimum Necessary Rule. That is, provide only the least amount of information that is needed.

This Minimum Necessary Rule does NOT apply to: Information shared with other health care providers for treatment purposes; healthcare providers may require the entire record for treatment Information requested by the individual Information required by law

With an oral or written authorization from the patient, PHI can be disclosed to family members and to friends identified by the patient, and it can be included in a facility directory (for example, Patient Information may provide the patient's room number to callers). The patient also has the right to place restrictions on the amount of information to be given out.

A written patient authorization is required to use or disclose PHI for any other purpose, such as marketing or research.

Protected Health Information that can be disclosed does NOT include psychotherapy notes. The patient must give specific authorization for psychotherapy notes to be disclosed except: To carry out treatment, payment, or healthcare operations To the originator of the notes so that treatment can be provided To students who are training within the facility, to improve counseling skills To use as a defense if the individual has brought a suit against the agency

A Note about Psychotherapy Notes: The first bullet item above seems to indicate that psychotherapy notes may be addressed the same as any other PHI. However, in practical application, psychotherapy notes are held to a higher standard of privacy and employees must be aware of their organization's specific policies regarding the privacy of these notes. As a rule of thumb, without the patient's written authorization, the notes cannot be used by, or shared with, anyone other than the attending physician.

Healthcare organizations inform patients about the Privacy Rule HIPAA requires that a notice of the organization's privacy practices be given to each individual receiving Copyright 2015, Cross Country University Page 145 of 284, HIPAA, HITECH, Social Media, and Patient Privacy

Annual Mandatory Education—Professional Nurse

services. The purpose of the notice is to inform the individuals how their health information may be used and shared, and how they may review this information.

This Notice of Privacy Practices needs to be prominently posted in public areas and also needs to be available for patients to take with them. If the organization has a website, there must be a copy of this notice on the website, as well as a copy available for downloading. Patients sign that they have received the information. Explanatory documentation is provided if it is not possible to get the patient's written acknowledgement that the information was received.

Some of the required sections of the Notice of Privacy Practices include: A detailed description of how the information may be used for treatment, payment, and healthcare operations A description of circumstances in which protected health information may be disclosed without the individual's written permission A statement that other uses and disclosures will only be made with written authorization from the individual, and that the authorization can be withdrawn A statement of the individual's rights with respect to protected health information, as well as an explanation of how the individual can exercise those rights. A statement that the organization is required by law to maintain the privacy of protected health information and to provide individuals with notice of its legal duties and privacy practices with respect to protected health information A statement that individuals have the right to complain to the organization and to the Secretary of Health and Human Services (HHS) or any officer or employee of HHS to whom the authority involved has been delegated if they believe their privacy rights have been violated A brief description as to how the complaint may be filed A statement that there will be no retaliation towards the individual for filing a complaint The name, title, and telephone number of the person or office to contact for further information. It must also contain the effective date of the notice

Rights of patients HIPAA allows individuals certain rights as to how their Personal Health Information is used and accessed.

Individuals have the right to restrict the use and disclosure of their information. They can request that information be restricted in some manner when disclosed to others for the purpose of treatment, payment, or healthcare operations.

However, the health care organization, or other covered entity, does have the right to not agree to this restriction.

Annual Mandatory Education—Professional Nurse

Example: The patient could request that the organization not share his diagnosis with his health insurance agency. Since this would affect the way in which the organization will be reimbursed for services, the organization does not have to agree to this.

Individuals have the right to access their own Personal Health Information Individuals have the right to inspect and receive a copy of their PHI with the exceptions of psychotherapy notes and information that has been gathered in anticipation of civil, criminal, or administrative action.

Individuals have the right to amend their Personal Health Information Individuals can request that the organization change any PHI that it maintains in record sets. The organization can require that these requests for change be in writing and that the individual explain the reason for the change.

Individuals have a right to have an account of access to their PHI Individuals have a right to know the identities of those persons or agencies (Including Business Associates) that have accessed their PHI for 6 years PRIOR to the request.

Health Information Technology for Economic and Clinical Health Act of 2010 (HITECH) The American Recovery and Reinvestment Act of 2009 became Federal law on February 17, 2009. Part of this law, called the Health Information Technology for Economic and Clinical Health Act, or the HITECH Act was created to accelerate implementation of Electronic Health Records (EHR).

Incentives are provided to healthcare entities and practitioners in the form of Medicare and Medicaid reimbursement for the purchase, modernization, integration, and meaningful use of HER.

Social Media Patients enter the healthcare system with the right and the expectation of privacy. The HIPPA Privacy rule holds you to an extremely high standard in protecting patient privacy. Please ensure that you adhere to this high standard in your use of blogs and social media. It is just as easy, and just as wrong, to violate patient privacy in a blog or Facebook post, as it is in a casual discussion in the cafeteria or an elevator.

End of HIPAA, HITECH, Social Media, and Patient Privacy Lesson

Infant Abduction The standard hospital emergency code for Infant Abduction is Code Pink. Yours may differ, so know your emergency codes.

One of the most serious incidents that can occur in a healthcare facility is the abduction of an infant or child. There are criteria that can be used to identify a potential abductor.

Annual Mandatory Education—Professional Nurse

Is female Is between the ages of 16 and 45 May hang around the nursery and ask to hold or feed the babies May ask questions about when babies are fed and other nursery routines, such as shift changes and number of staff.

One common profile of an infant abductor is a woman aged 16 to 45 who hangs around the nursery.

Other suspicious signs include: Someone in scrubs or uniform without proper identification Someone carrying a baby instead of transporting in the nursery bassinet Someone cradling or carrying a large bag (may also be talking to it) that could contain a baby Any disruption that distracts the attention of staff away from the infants.

Remember that a potential kidnapper could be a visitor or an employee.

In Pediatrics, the most serious concern is that a child might be taken by a non-custodial parent. Your facility may have policies restricting visitors. In addition, when children are admitted, it is important to find out who is legally allowed to visit.

Preventing abduction There are measures that can help to reduce the risk of infant or child abduction: Parent education Visiting procedures

Annual Mandatory Education—Professional Nurse

Engineering controls.

Teach mothers how to identify nursery and other staff and inform them about usual routines. This is an important step in the protection of newborn and infant children. Your facility may also have visiting procedures stating who can visit and providing methods of identifying visitors. Engineering controls, such as closed-circuit TV cameras, exit-door and wrist-band alarms, and other security devices may also be in place.

Teach parents about usual routines and how to identify staff.

One of the most important components in the prevention of infant and child abduction is an alert staff. It is important that staff involved with care of infants and children are aware of security issues and suspicious of anyone who does not belong in the area.

If you discover that an infant is missing, follow your institution's infant abduction procedures. These usually include: Securing all exits from the facility Inspecting all stairwells, rooms, and other areas where someone might hide.

THE “TYPICAL” ABDUCTOR (Developed from an analysis of 256 cases occurring 1983-2008.) Female of “childbearing” age (range now 12 to 53), often overweight. Most likely compulsive; most often relies on manipulation, lying, and deception. Frequently indicates she has lost a baby or is incapable of having one. Often married or cohabitating; companion’s desire for a child or the abductor’s desire to provide her companion with “his” child may be the motivation for the abduction. Usually lives in the community where the abduction takes place. Frequently initially visits nursery and maternity units at more than one healthcare facility prior to the abduction; asks detailed questions about procedures and the maternity floor layout;

Annual Mandatory Education—Professional Nurse

frequently uses a fire-exit stairwell for her escape; and may also try to abduct from the home setting. Usually plans the abduction, but does not necessarily target a specific infant; frequently seizes any opportunity present. Frequently impersonates a nurse or other allied healthcare personnel. Often becomes familiar with healthcare staff members, staff members work routines, and victim parents. Demonstrates a capability to provide “good” care to the baby once the abduction occurs. In addition an abductor who abducts from the home setting is more likely to be single while claiming to have a partner. Often targets a mother whom she may find by visiting healthcare facilities and tries to meet the target family. Often both plans the abduction and brings a weapon, although the weapon may not be used. Often impersonates a healthcare or social-services professional when visiting the home.

There is no guarantee an infant abductor will fit this description.

The Joint Commission (TJC), an accrediting agency, is a private, not-for-profit organization dedicated to improving the quality and safety of medical care provided to the public. It is an agency that sets the principal standards and evaluations for a variety of healthcare organizations. Infant/pediatric security is an area of concern to TJC as a high-risk security area often referred to as “security-sensitive area.” Such areas require a specific access-control plan, initial and periodic security-related training for staff members working in those designated areas, and a critical-incident response plan. It is common for TJC surveyors to ask in-depth questions regarding the implementation of infant/pediatric security plans. infant/pediatric abductions or discharge to the wrong family are reviewable sentinel events under the sentinel-event standards of TJC.

The typical abduction from a healthcare facility involves an “unknown” abductor impersonating a nurse, healthcare employee, volunteer, or relative in order to gain access to an infant. The obstetrics unit is an open and inviting one where patients’ decreased length of stay, from one to three days, gives them less time to know staff members. In addition it can be filled with medical and nursing staff members, visitors, students, volunteers, and participants in parenting and newborn-care classes.

The number of new and changing faces on the unit is high, thus making the unit an area where a “stranger” is unlikely to be noticed. Because there is generally easier access to a mother’s room than to the newborn nursery and a newborn infant spends increasingly more time with his or her mother rather than in the traditional nursery setting, most abductors “con” the infant directly from the mother’s arms.

All healthcare personnel should be alert to any unusual behavior they encounter from individuals such a: Repeated visiting or requests “just to see” or “hold” the infants.

Annual Mandatory Education—Professional Nurse

Close questioning about healthcare-facility procedures, security devices, and layout of the floor such as, “When is feeding time?” “When are the babies taken to the mothers?” “Where are the emergency exits?” “Where do the stairwells lead?” “How late are visitors allowed on the floor?” “Do babies stay with their mothers at all times?” Taking uniforms or other means of identification within that facility. Physically carrying an infant in the facility’s corridor instead of using the bassinet to transport the infant, or leaving the facility with an infant while on foot rather than in a wheelchair. Carrying large packages off the maternity unit (e.g., gym bags, suitcases, backpacks), particularly if the person carrying the bag is “cradling” or “talking” to it.

Be aware that a disturbance may occur in another area of the healthcare facility creating a diversion to facilitate an infant abduction (e.g., fire in a closet near the nursery or loud, threatening argument in the waiting area). Healthcare facilities need to be mindful of the fact that infants can stay in or need to be taken to many areas within the facility. Thus vigilance for infant safety must be maintained in all areas of the facility when infants are present.

General Guidelines (You MUST review your facility guidelines; these are non-specific and lack the details necessary for full compliance with your local facility and regional standards.) Persons exhibiting the behaviors described above should be immediately asked why they are in that area of the facility. Immediately report the person’s behavior and response to the nurse manager/supervisor, security, and administration. The person needs to be positively identified, kept under close observation, and interviewed by the nursing manager/supervisor and security. Remember, caution needs to be exercised when interacting with people who exhibit these behaviors.

Report and interview records on the incident should be preserved in accordance with the organization’s internal procedures. (Many suggest records should be kept from a minimum of seven years up to the child reaching adulthood.)

Each facility should designate a staff person in their critical-incident response plan who will have the responsibility to alert other birthing facilities in the area when there is an attempted abduction or someone is identified whom demonstrates the behaviors described above, but who has not yet made an attempt to abduct an infant.

Proactive Practices (Again, these are general. Know your facilities standards.) As part of contingency planning, the backbone of prevention, every healthcare facility must develop, test, and critique a written proactive-prevention plan for infant abductions that includes all of the elements listed in this section. In addition measures must be taken to inform new or rotating (temporary) employees of these procedures as they join the staff. This plan needs to be tested, documented, and critiqued at least annually.

Annual Mandatory Education—Professional Nurse

Immediately after the birth of the infant and before the mother and infant are separated, attach identically numbered ID bands to both the infant (2 bands) and mother (1 band) and 1 band to the father or mother’s significant other when appropriate. Inform parents of the reason or need for the bands. If the fourth band is not used by the father/mother’s significant other, that fact must be documented. This band may be stapled to the chart or cut and placed in the “sharps box.”

An infant’s band needs to be verified with the mother when taking the infant for care as well as upon delivery of the infant to the mother after care has been rendered. The caregiver must examine and verify both the baby and the mother’s (or significant other’s) identification bands and have the mother (or significant other) do the same.

If an infant band is removed for medical treatment or comes off for any reason, immediately reband the infant after identifying the infant, using objective means such as footprint comparisons or blood testing, and change all bands, mother’s, father’s/significant other’s, and infant’s, so once again the bands all have the same number. If the band is cut or entirely removed, parents should be present at the removal and replacement.

Prior to the removal of a newborn from the birthing room or within a maximum of two hours of the birth Footprint (with emphasis on the ball and heel of the foot) the infant making sure the print is clear. Repeat if necessary. Take a color photograph or color video/digital image of the infant. Perform a full, physical assessment of the infant, and record, in the medical chart, the assessment along with a description of the infant. Store a sample of the infant’s cord blood and any other blood specimens until at least the day after the infant’s discharge. Place electronic security tags, if such a system is being used.

The footprints, photograph or video/digital image, physical assessment, and documentation of the placement of the ID bands, including their number, must be noted in the infant’s medical chart.

Require all healthcare-facility personnel to wear, above the waist and “face-side” out, up-to- date, conspicuous, color-photo ID badges. The person’s name and title need to be easily identifiable, and the person’s photograph needs to be large enough so that he or she is recognizable.

Update the photograph as the person’s appearance changes. These badges need to be returned to Human Resources or the issuing department immediately upon termination of employment.

Annual Mandatory Education—Professional Nurse

Personnel who are permitted to transport infants from the mother’s room or nursery, including physicians, should wear a form of unique identification used only by them and known to the parents (e.g., a distinctive and prominent color or marking to designate personnel authorized to transport infants). IDs should be worn above the waist, “face-side” out, on attire that will not be removed or hidden in any way. Paraphernalia should not be worn on name badges (i.e., pins, stickers, and advertisements) that hide name, face, or position. ID systems should include provisions for all personnel, who are permitted to transport infants from the mother’s room or nursery including students, “transporters,” and temporary staff members, such as the issuance of unique temporary badges that are controlled and assigned each shift (e.g., strict control should be similar to narcotics control). This unique form of identification should be periodically changed.

Limit infant transportation to an authorized staff member wearing the authorized infant- transportation ID badge.

Ensure the mother or father/significant other with an identical ID band for that infant are the only others allowed to transport that infant, and educate the mother and father/significant other about the importance of this precaution.

Prohibit leaving an infant without direct, line-of-sight supervision.

Require infants to be taken to mothers one at a time. Prohibit “grouping” infants while transporting them to the mother’s room, nursery, or any other location.

Prohibit “arm carrying” infants, and require all transports to be via a bassinet. Require family members transporting the infant outside the mother’s room, including the mother, father, or significant other, to wear an ID wristband.

Distribute the guidelines for parents in preventing infant abductions

Always place infants in direct, line-of-sight supervision either by a responsible staff member, the mother, or other family member/close friend so designated by the mother, and address the procedure to be followed when the infant is with the mother and she needs to go to sleep/the bathroom and/or is sedated. If the mother is asleep when the infant is returned to the room, staff members should be careful to fully awaken her before leaving the room. In rooming-in situations, place the bassinet so the mother’s bed is between the exit door(s) to the room and the bassinet.

Do not post the mother’s or infant’s full name where it will be visible to visitors. If necessary, use surnames only. Do not publish the mother’s or infant’s full name on bassinet cards, rooms, status or white boards. Do not leave charts, patient index cards, or any other medical Copyright 2015, Cross Country University Page 153 of 284, Infant Abduction

Annual Mandatory Education—Professional Nurse

information visible to anyone other than medical personnel. Be aware that identifying information in the bassinet such as ID cards with the infant’s photograph and the family’s name, address, and/or telephone number may put the infant and family at risk after discharge. Keep this information confidential and out of sight. Do not provide patient information via the telephone.

Conform with an access-control policy for the nursing unit, nursery, maternity, neonatal- intensive care, and pediatrics to maximize safety.

Require a show of the ID wristband for the person taking the infant home from the healthcare facility and be sure to match the numbers on the infant’s bands, as worn on the wrist and ankle, with the bands worn by the mother and father/significant other.

Know and conform with your facility’s critical-incident-response plan to respond to an infant abduction.

End of Infant Abduction Lesson

Infection Control, Part 1: Basics

Transmission of Disease

What are hospital-acquired infections? Also known as nosocomial infections, they are infections that are contracted while patients are in hospital. A 2012 Centers for Disease Control (CDC) report estimates “1.7 million infections and 99,000 deaths each year as a result of nosocomial infections. Of those infections: 32 percent of all healthcare-associated infection are urinary tract infections 22 percent are surgical site infections 15 percent are pneumonia (lung infections) 14 percent are bloodstream infections” http://cdc.gov/ncidod/dhqp/hai.html

Consequences of contracting an infection while in hospital can include: The development of more serious health problems Longer stays in hospital Larger hospital bills.

Hospital-acquired infections or healthcare-associated infections (HAI), are terms that have become more common as they are used increasingly to describe certain well-known problems such as HAP, hospital- acquired pneumonia; to differentiate HAIs from community-acquired infections (CAI); and as terms of

Annual Mandatory Education—Professional Nurse

convenience when discussing the relatively recent rise of diseases caused by ‘Superbugs’, the drug- resistant organisms.

The chain of infection Three components must be present for the transmission of germs to occur. This is known as the chain of infection. An infection is transmitted ONLY IF all three components of the chain are in place.

The three components are: The host The method of transmission The receiver.

Host The host is the place where germs grow and it is generally a human being. Inside the host, germs grow in blood, sputum, infected wounds, or other body fluids.

Method of transmission The method of transmission is the way the germs travel from the host to the receiver. It may be a sneeze or a cough, through blood contact, or through direct contact.

Receiver The receiver is the person who becomes infected. It is often someone especially susceptible to a germ, such as an infant or young child, an elderly person, a patient recovering from surgery, a patient with a chest tube, foley catheter or central IV line, or a person with weakened resistance from a certain disease.

Methods of transmitting germs Germs may be transmitted through several different methods, and it is important to understand all of them.

There are four main methods of transmission: Droplets Airborne Blood borne Direct contact

Droplet Method: The droplets of a cough or sneeze can contain germs. If another person breathes in just one such droplet, that infection can spread. Examples include the common cold and the flu.

Annual Mandatory Education—Professional Nurse

Airborne Method: Airborne germs, lighter than droplets, can live in the air for a long time. These germs, when breathed in by another person, can cause the spread of infection. Examples include tuberculosis, chicken pox, and measles.

Blood Borne Method: Germs can live in the bloodstream and in other body fluids that contain blood components, such as seminal fluid. A person's skin prevents germs from entering into the body, but if the skin is broken because of even a tiny cut, it is possible for infected blood of another individual to enter. Mucous membranes, found in the mouth, vagina, or rectum may also allow germs to spread through contact with blood and/or secretions containing blood. Unprotected sexual contact can lead to this method of transmission.

Direct Contact Method: Germs can spread by touching sores, body wastes (or other body fluids), or lacerations in the skin, and then touching an open cut or putting your hands in your mouth. Most direct contact occurs through a person's hands. An example is infection in a surgical incision that occurs as dressings are changed. The best protection against direct contact transmission is proper hand washing.

How to prevent transmission of infections in hospital There are several steps that can be taken by hospital workers to protect patients from developing infections.

Those steps include: Following the Infection Control policies of your facility Identifying the people, patients, and staff, who are most at risk Washing your hands Staying healthy by getting plenty of rest, eating properly, and exercising Getting vaccinated against flu and hepatitis B Washing your hands Following the standard recommended precautions with everyone NOT coming to work if you are sick.

Hand Hygiene

Hand Hygiene and The Joint Commission’s National Patient Safety Goals The Joint Commission’s National Patient Safety Goals for 2009 include Goal 7; reduce the risk of health care associated infections, and sub goal, 07.01.01, Comply with current World Health Organization (WHO) hand hygiene guidelines or Centers for Disease Control and Prevention (CDC) guidelines. This section of the Infection Control lesson titled, Hand Hygiene, teaches to the CDC guidelines.

Annual Mandatory Education—Professional Nurse

The purpose of hand hygiene Hand hygiene is a term for the behaviors that healthcare workers perform to prevent the spread of germs and nosocomial infections. Hand hygiene includes handwashing with soap and water or with an alcohol hand rub, and keeping fingernails clean and short.

Hand hygiene is the most important thing you can do to prevent the spread of germs and nosocomial infections - infections that patients acquire while under medical care that are not related to their original illness.

It is estimated that 2.4 million Americans acquire an infection in a hospital each year and that these infections cause or contribute to 100,000 deaths per year. Half of these infections are preventable by proper-hand hygiene.

Routine hand hygiene helps prevent the spread of germs: From one person to another From one part of the body to another, such as from hands to eyes or mouth To other articles such as food, door handles, and dishes.

Hand hygiene also prevents the spread of diseases such as: Hepatitis Gastrointestinal diseases that cause diarrhea Colds and flu.

Six steps in routine handwashing with soap and water Handwashing with soap and water, when done correctly is an effective way for hospital staff to prevent the spread of deadly germs.

The six steps in routine handwashing are: 1. Wet hands thoroughly under running water. Warm or hot water is best. 2. Lather with soap from a dispenser rather than a bar. Your facility may require that you use an antimicrobial soap. 3. Wash hands thoroughly, for 15 seconds, using friction. Be sure to include the backs, palms, wrists, between fingers, and under fingernails. 4. Rinse hands thoroughly under running water. 5. Leave the water running and use a paper towel or an air dryer to dry hands thoroughly. 6. Turn off the water using the paper towel. This prevents you from picking up germs left on the tap from your hands, the hands of another person, or airborne germs.

Annual Mandatory Education—Professional Nurse

Alcohol hand rubs (See below) are approved in some hospitals as an alternative to washing with soap and running water.

If you wish, you may use a hospital-approved hand lotion, to protect your hands and prevent damage from over washing. Lotions with a water-based, greaseless formula are best. They should also be silicone-free and petroleum-free to prevent damage to latex gloves.

Alcohol hand rubs Healthcare workers use alcohol-based hand rubs as a convenient and effective method to maintain prevent the spread of germs.

Alcohol hand rubs are waterless; healthcare workers pour the solution directly from the bottle onto their hands. In busy areas or in situations in which handwashing stations are not available, alcohol hand rubs are a convenient alternative.

Annual Mandatory Education—Professional Nurse

Alcohol hand rubs are effective. They rapidly kill germs on the hands, and regrowth of germs is generally slow. Many studies have confirmed that alcohol hand rubs are at least as effective as soap and water in preventing the transfer of healthcare-related germs.

The four steps to using an alcohol hand rub are: Pour the alcohol hand rub in the palm of one hand (use the amount recommended by the manufacturer) Rub both hands together Rub all parts of the wrist, hand, and fingers Rub until completely dry

When Not to Use an Alcohol Hand Rub Use soap and water to remove large amounts of visible dirt, body fluids, or other materials.

Skin Dryness and Irritation Frequent use of alcohol hand rubs can cause skin dryness and irritation. Routine use of skin lotion will help prevent this problem. Many alcohol hand rubs already contain skin conditioners. Skin lotions with a water-based, greaseless formula are best. They should also be silicone-free and petroleum-free to prevent damage to latex gloves.

Situations that require handwashing If you are not sure whether or not you should wash your hands, wash your hands either with soap and water or an alcohol hand rub. All areas of the hospital are at risk of spreading germs and infections.

Situations that require routine handwashing with soap and water or an alcohol rub: When coming on duty Before and after patient contact Before putting gloves on and after taking them off Before eating Before preparing medication After using the toilet After sneezing or coughing into hands After contact with objects that might be contaminated After any accidental exposure to body fluids, mucous membranes, or skin with cuts and sores.

Long natural nails and artificial nails increase infection risk Artificial nails and long natural fingernails retain more germs than short, natural nails - even after careful handwashing.

Nosocomial infections have been linked to long natural nails and to artificial nails worn by healthcare workers. Copyright 2015, Cross Country University Page 159 of 284, Infection Control, Part 1: Basics

Annual Mandatory Education—Professional Nurse

As a result, the Centers for Disease Control (CDC) issued recommendations on long natural nails and artificial nails: Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (e.g., those in intensive-care units or operating rooms) Keep natural nail tips less than ¼ inch long.

Your organization may already have put in place specific requirements for nail type and length. Know your healthcare organization's policy regarding this important issue.

Presented here, as an example, are typical elements of a fingernail policy for workers providing direct patient care: No artificial fingernails (may be limited to specific high-risk areas) Fingernails will not extend more than ¼ inch beyond fingertips Fingernail polish must not be chipped

Standard Precautions

Two levels of precautions Healthcare workers are often exposed to the body fluids of patients, including blood. Because serious diseases can be transmitted not only through blood, but also by other means, the Center of Disease Control (CDC) has recommended a two-level or "two-tier" system of precautions to prevent the spread of infections.

The two tiers of precautions are: Standard Precautions Special Precautions

Standard Precautions The CDC has recommended that ALL patients be treated according to Standard Precautions which provide protection against the spread of diseases through contact with blood or other body fluids. Follow Standard Precautions with ALL patients at ALL times.

Special Precautions The CDC has also recommended that certain Special Precautions be added to the Standard Precautions for diseases that spread in ways other than through infected blood.

The meaning of Standard Precautions Standard Precautions are practices designed to help prevent the spread of diseases carried by the blood. They are called standard because they apply to everyone. Nobody, not even you, can tell by looking at a

Annual Mandatory Education—Professional Nurse

person whether or not that person is HIV-positive or has some other disease. That means you need to apply Standard Precautions when dealing with ALL patients.

All body substances of all patients are considered potentially infectious. Traces of blood cannot always be seen and may be present in any body fluid. If you are involved in any situation involving blood or other body fluids, be sure to follow Standard Precautions to avoid contact with them on your skin or mucous membranes.

Use Standard Precautions to reduce your risk at work. Protect yourself and others. Keep in mind the incidence of AIDS is growing in the over-50 population.

The basics of Standard Precautions Be sure to use all precautionary practices recommended by your facility. Some basic practices that can keep you from coming into contact with the body fluids of another person include: Hand protection Body protection General protection.

Hand protection Protect your hands by wearing latex/hypoallergenic gloves (the correct size) when: Emptying a foley catheter Emptying a bedpan Starting an IV Dealing with trauma in the emergency room Pricking the finger for blood glucose Handling blood specimens Drawing arterial or venous blood Cleaning biomedical equipment.

Body protection Wear gown, mask, and goggles to cover any part of your body that could be splashed or sprayed (or otherwise come in contact with) the blood and/or body fluids of another person (for example, when caring for a trauma patient in the Emergency Department or when assisting in a procedure where exposure is possible).

General protection Dispose of all materials containing blood in the proper waste containers. Use a barrier device such as a shield or mask instead of performing direct mouth-to-mouth ventilations during CPR. Avoid contact with blood from needles by using safety devices provided by your facility. Never recap a needle (if you miss, you could jab your finger). Copyright 2015, Cross Country University Page 161 of 284, Infection Control, Part 1: Basics

Annual Mandatory Education—Professional Nurse

Dispose of all sharps (needles, blades, IV catheters) in the proper disposal box. Wash your hands after removing gloves. Do not eat, drink, put on make-up or put in contact lenses in areas where exposure to body fluids is possible.

Devices are available, such as safety syringes and special IV catheters that help protect health care workers. The Occupational Safety and Health Administration (OSHA) directs medical agencies to use recommended safety devices. Although they take a little time to learn, the effort could save a life - maybe yours.

Know and follow your facility's procedures for reporting injury and/or exposure to body fluids. Your facility has an Employee Exposure Control Plan that lists all areas where precautions are needed and also has procedure to follow if you are exposed to blood or other body fluids. It is important to know what the plan is and to follow it if you are exposed. Report ANY needlestick-type injury or ANY other exposure to blood or body fluids. You will need to be evaluated and may also need follow-up care.

If you have any questions about how to follow Standard Precautions in your organization, ask your supervisor.

Special Precautions

Two levels of precautions Health care workers are exposed to the body fluids of patients, including blood. Because serious diseases can be transmitted not only through blood, but also by other means, the Center of Disease Control (CDC) has recommended a two-level or "two-tier" system of precautions to prevent the spread of infections.

The two tiers of precautions are: Standard Precautions Special Precautions.

Standard Precautions The CDC has recommended that ALL patients be treated according to Standard Precautions. Follow the procedures outlined by your particular facility. Anyone could have a disease that is spread through the blood or other body fluids. Many people are unaware they have a disease, and many do not tell others they have a disease. Due to confidentiality laws, workers are sometimes told only on a need to know basis, and you may not need to know. To protect yourself and others from infection, follow Standard Precautions with ALL patients at ALL times.

Special Precautions Special Precautions are practices used in health care to help prevent the spread of diseases that can be

Annual Mandatory Education—Professional Nurse

transmitted without contact with body fluids. They are implemented after a patient has been diagnosed and the method of transmission is known. The Special Precautions are always used in addition to Standard Precautions.

Special Precautions are used to prevent the spread of disease through germs transmitted by: Droplets Air Contact (direct or indirect).

Droplet Precautions Droplets infected with germs can cause infections. They can come from a sneeze or from procedures, such as suctioning. The germs are not carried very far because droplets are heavy.

Infections that can be spread through droplets and require droplet Special Precautions include: Pneumonia Influenza Meningitis.

Protection against droplet infection is important for anyone who will be close to (within three feet of) the patient - caregivers, other patients, and family members. The patient and their family should be instructed about precautions used. Droplet Precautions are used in addition to Standard Precautions.

Examples of Special Droplet Precautions: Caregivers wear a mask. Patients remain in their rooms as much as possible. Patients wear a mask when they go to other areas of the hospital (for X-rays, for example). Patients with same type of infection may share a room.

Airborne Precautions Airborne germs are found in tiny droplet nuclei - much smaller than droplets - that are spread by coughing, sneezing, talking, or breathing. Droplet nuclei are so small that they can travel long distances, remain in the air for a long time, and are tiny and light enough to travel through a ventilation system.

Infections that can be spread through the air and require airborne Special Precautions include: Tuberculosis Chicken pox Measles (rubeola).

Protection is important for everyone in the area. Airborne Precautions are used in addition to Standard Precautions. Patients and their families should be instructed about Airborne Precautions being used.

Annual Mandatory Education—Professional Nurse

Examples of Special Airborne Precautions: Provide patients with a private room, preferably a special negative pressure room that vents to the outside and changes its air several times per hour. Keep the door to the patient's room closed. Keep patients in their rooms. If it is necessary for the patient to leave the room, he/she must wear a surgical mask. Do not enter the room of a patient with chicken pox or measles, unless you have been vaccinated or have already had the disease. Encourage patients to use tissues for coughs and sneezes and to dispose of them immediately. With tuberculosis patients, wear a special mask before entering and while in the room.

Contact Precautions Germs spread through contact are found on the skin and excretions of infected patients. They are spread through direct contact with others or indirectly through germs found on room surfaces or on patient-care articles.

Infections that can be spread through direct and indirect contact and require Special Precautions include: Hepatitis A Scabies Lice Shigella Salmonella Methicillin-Resistant Staphyloccus Aureus (MRSA) Staphylococcus skin infections.

Protection is important for everyone entering the room. Patients and their families should be instructed about precautions being used.

Examples of Special Contact Precautions: Wash hands thoroughly after any patient contact. Wear a protective gown if clothing might come into contact with patient drainage as a result of splashing or gross contamination of room surfaces. Wear gloves if contact with contaminated surfaces is possible. Change gloves after contact with infected material (such as wound drainage, feces, etc.). Remove gloves when leaving the room. Wash hands thoroughly after removing gloves. DO NOT share patient equipment.

Annual Mandatory Education—Professional Nurse

End of Infection I Control, Part 1 Lesson

Infection Control, Part 2: HAI, Ebola, MRSA, HAP, TB, HIV/AIDS

Ebola, Preventing Hospital Acquired Infections Glossary Case fatality rate The reported case fatality rate (CFR) is a measure of the severity of a disease and is defined as the proportion of reported cases of a specified disease or condition which are fatal within a specified time. World Health Organization, 2014 Disseminated Intravascular A systemic process of thrombosis and hemorrhage that is initiated by Coagulation (DIC) several disorders. DIC, in response to EHD, is an acute onset of blood leaking from wounds, IVs, and catheters; deep tissue bleeding; and anemia. Index patient The first patient in a particular population with a disease or condition that is being described or investigated. It may be the first patient with that condition. It may or may not be the first person in that population to actually have the condition, and it may or may not be the person who represents the source of subsequent transmissions. Sometimes referred to Patient Zero. Infectivity The ability of an agent/pathogen to infect a host. A highly infective agent requires less exposure to cause an infection. Measles is an example of a highly infective pathogen. Leprosy is a minimally infective pathogen. Natural reservoir The living organism or inanimate object in which normally resides an agent that causes a disease or condition in humans. Secondary In the transmission of a disease from the one infected individual to infection/secondary another, that subsequent infection is a secondary infection. outbreak A secondary outbreak is a series of newly infected individuals resulting from exposure to one individual. Virulence The number of clinical cases resulting in severe morbidity and death. Case Fatality Rates (CFR) are often used as a measure of virulence. Rabies, with a CFR approaching 100% is extremely virulent. Chickenpox, though almost 100% infective, is minimally virulent.

Etiology (origin of the Ebolavirus and of EVD) Ebola refers to both the disease and the causative agent, the Ebolavirus. The disease is also known as Ebola Hemorrhagic Fever (EHF), and as Ebola Virus Disease (EVD). EVD is a type of viral hemorrhagic fever (VHF), a general category of diseases caused by different viruses, but sharing in common the symptoms of fever and of being complicated by disseminated intravascular coagulation.

Dengue and Yellow Fever are VHFs, though their respective causative agents are not closely related to the Ebolavirus. EHF and Marburg Virus Disease are severe forms of VHF caused by filoviruses, a family of viruses that have an elongated, filamentous shape.

Annual Mandatory Education—Professional Nurse

The Ebolavirus with its characteristic 'shepherds crook' shape. CDC/Cynthia Goldsmith - Public Health Image Library, #10816

‘Ebolavirus’ is now the preferred term to refer to the Ebolavirus genus, the family of closely related viruses. There are five subtypes, or species, of the Ebolavirus: Ebola virus (EBOV) Sudan virus Tai Forest virus Bundibugyo virus Ebola-Reston

The Ebola virus (EBOV) is responsible for most outbreaks and is the pathogen responsible for the current outbreak that originated in West Africa. All but the Reston variety were first identified in Central or West (sub-Saharan) Africa. The Reston variety originates in the Philippines and is not infectious to humans.

EVD in humans is a zoonosis, a disease transmitted from animals to humans—rabies is another example. Humans are exposed to the virus when they come in contact with an infected animal, killing, butchering, drying, eating, and selling wild animals for food (bushmeat) is a common practice and has been associated with EVD. Monkeys and bats are common sources of bushmeat.

Ebolavirus has been documented only in mammals, especially bats, monkeys, and apes. There is no current evidence that insects can be infected with or transmit Ebolavirus.

Sporadic epidemics of disease caused by Ebolavirus kill non-human primates, monkeys, and antelope (an animal epidemic is more correctly termed an epizootic). These epizootics may be related to human outbreaks. Some research suggests that fruit bats may be a natural reservoir, but this is not yet confirmed. As with rabies, there may be several animal reservoirs.

Summary of etiology Ebola is both a virus, e.g. EBOV, and a disease, e.g., EVD The natural reservoir of Ebola is an animal or animals living in Western and Central Africa. The disease is transmitted to humans when they have close contact with an infected animal. EBOV is a highly infective and virulent pathogen

Annual Mandatory Education—Professional Nurse

The current outbreak of EVD and its spread to the United States In 1976, two separate sub-Saharan African outbreaks of the disease were the first attributed to the Ebola virus. Since then, there have several sporadic outbreaks of the disease. The EBOV strain was originally referred to as Zaire Ebola virus in recognition of its role in this initial outbreak in Zaire, now known as the Democratic Republic of Congo.

This most recent concern with EVD is a result of a March, 2014 outbreak in Guinea, a West African country. After spreading to Sierra Leone and Liberia by August 2014, the World Health Agency (WHO) declared an international public health emergency. As of October, 2014, more than 9,000 cases and 5,000 deaths have been reported worldwide, and those numbers, according to WHO, may be underreported.

Ebolavirus has two characteristics that make it such a deadly agent: it is highly infective and virulent. The virus is easily transmitted between individuals and it kills a high proportion of its victims. Without treatment, EHR's case fatality rate (CFR) is 90%. With modern medical treatment, the CFR is about 56%. The CFR of this current widespread outbreak in several West African countries is estimated at 71%.

In late September, 2014, Ebola was diagnosed for the first time in the United States. A Liberian visiting family in Dallas was diagnosed with EVD and died a few days later. By October 14, two nurses who had cared for that patient in Dallas were diagnosed with the disease. As of October 20, more than 70 employees of Texas Presbyterian Hospital were being monitored.

Five Americans have been evacuated to the US from West Africa for Ebola treatment. They have been treated at Emery University Hospital in Atlanta, Nebraska Medical Center in Omaha, University of Nebraska Medical Center in Omaha, and National. In addition, as of October 16, one of the infected nurses from Dallas was being treated at the National Institutes of Health (NIH) in Bethesda, Maryland.

Summary of the current outbreak of EVD and its spread to the United States Ebola was first identified in sub-Saharan Africa in 1976 The first identified U.S. case occurred in Dallas Two secondary cases have been diagnosed in healthcare workers who cared for the Dallas patient EVD patients have been, or are being, treated in the U.S. in Dallas, Atlanta, Omaha, and Bethesda

Signs and symptoms and exposure risk A still apt clinical description from the 1976 outbreak says "The illness is characterized with a high temperature of about 39°C, hematemesis, diarrhea with blood, retrosternal abdominal pain, prostration with "heavy" articulations, and rapid evolution death after a mean of three days."

Annual Mandatory Education—Professional Nurse

Symptoms usually begin within two to 21 days as a sudden, flu-like state characterized by malaise, fever greater than 100.4 F., muscle and joint pain, headache, and sore throat. These symptoms are often followed in day or more by nausea, vomiting, diarrhea, and abdominal pain.

Within a few days, some patients experience shortness of breath, chest pain, severe headaches, confusion, and a maculopapular rash. DIC may occur within five or more days.

Death usually occurs within six to 16 days.

Recovery usually begins within seven to 14 days from symptom onset. Survivors may have chronic muscle, joint, liver, and hearing difficulties.

Current recommendations from CDC when evaluating a patient for EVD include:

Clinical findings Fever > 100.4 F Severe headache Weakness Muscle pain Vomiting Diarrhea Abdominal pain Unexplained hemorrhage

Exposure risk, high versus low In addition to symptomatology, the probability of EVD varies with the risk of exposure: Contact with blood, body fluids, or human remains of a known or suspected Ebola patient Residence in or travel to an area with a current EVD outbreak Handling of bats, rodents, or primates in sub-Saharan Africa

The CDC makes the following recommendations regarding evaluating patients for Ebola based on level of risk.

High-risk exposure Test all persons for Ebola virus who, within 21 days of a high risk exposure, experience an onset of fever and/or other clinical symptoms or indicative lab findings. High-risk exposure includes: Skin, percutaneous, or mucous membrane exposure to blood or body fluids from an infected person Handling infected blood, body fluids, or decedent without appropriate personal proactive equipment (PPE) or biosafety precautions

Annual Mandatory Education—Professional Nurse

Low-risk exposure Evaluate further for possible testing, all persons who, within 21 days of low-risk exposure, for severity of illness, lab findings such as platelet counts, and alternative diagnoses. Low risk exposure includes: Household, community, or healthcare facility contact with a person with Ebola disease—a contact is defined as being with three feet of within the room or care area for a prolonged period of time while not wearing PPE, or having a brief direct contact such as handshaking while not wearing PPE. Recent residence in or visit to an outbreak area

Summary of evaluating for presence of EVD; signs and symptoms and exposure risk Upon patient presentation, two categories of information will help determine whether or not EVD is present: 1. Signs and symptoms, and 2. Exposure risk. Know the CDC symptom list and the CDC definitions of high and low risk exposure.

Infection Prevention and Control

Transmission Once a human is infected by contact with an infected animal, then human to human transmission occurs. Those at the highest risk for EVD are the patient’s family, close friends, healthcare providers, and death care providers.

A person with EVD is considered infectious as soon as they experience symptoms of the disease. Symptoms occur, usually between two and 21 days after exposure, though that period may extend up to 40 days in rare cases. A recovered patient can no longer transmit the disease, except in via semen which can transmit Ebolavirus up to three months after recovery.

Person to person transmission of the virus occurs with close personal contact with the blood or body fluids of an infected individual, living or dead. It is currently undetermined whether direct skin to skin contact can transmit Ebola.

Though most scientific and public health organizations say Ebola is not transmitted over long distance via aerosol particles. However, Ebolavirus can be aerosolized by coughing, diarrhea, and sneezing. Patient care activities that can possibly aerosolize Ebolavirus include:

“Bilevel Positive Airway Pressure (BiPAP), bronchoscopy, sputum induction, intubation and extubation, and open suctioning of airways." CDC's Standard, Contact, and Droplet Precautions, October 17, 2014

As a result of the possibility of aerosolization and the extreme virulence of the pathogen, CDC recommendations include the use of respirator masks.

Ebolavirus can enter the body via the nose, mouth, eyes, cuts, and abrasions.

Annual Mandatory Education—Professional Nurse

Ebolavirus can be transmitted through contact with: Blood and body fluids such as (but not limited to) saliva, vomit, feces, sweat, tears, breast milk, urine, and semen Contaminated needles and syringes Infected animals (Possibly) skin to skin contact

Prevention of hospital acquired infections in healthcare workers WHO guidelines for prevention of EVD HAIs include the following key points: Ensure that Standard Precautions are in place and rigorously adhered to when caring for ALL patients regardless of condition. When not wearing PPE, maintain a distance of at least three feet from anyone suspected of having EVD. As soon as practical, isolate patients who have, or are suspected to have, EVD in single rooms or in specific cohort areas. Keep confirmed cases separate from suspected cases. Healthcare workers caring for these patients should only be assigned to these patients. PPE in isolation areas must include gloves, gown, boots/closed shoes with overshoes, mask, and eye protection for splashes (CDC has added respirator masks and disposable full face shield to this requirement). Adhere to regular and rigorous environmental cleaning and decontamination; manage handling or waste, linen, and sharps according to guidelines. Ensure safe processing of lab samples. Maintain all prevention measures when handling decedents. Immediately evaluate, care for, and isolate if necessary healthcare workers exposed to blood or body fluids from suspected or confirmed EVD patients.

The CDC continues to evolve new and better guidance for the prevention of hospital acquired infection in response to encounters with EVD at Emory, Nebraska Medical Center, and National Institutes of Health. This enhanced guidance is centered on three principles (From CDC Fact Sheet, Tightened Guidance for U.S. Healthcare Workers on Personal Protective Equipment for Ebola): All healthcare workers undergo rigorous training and are practiced and competent with PPE, including putting it on and taking it off in a systemic manner No skin exposure when PPE is worn All workers are supervised by a trained monitor who watches each worker putting PPE on and taking it off.

Healthcare personnel followed these principles while caring for patients treated at Emory University Hospital, Nebraska Medical Center and the National Institutes of Health Clinical Center; none contracted the illness.

Annual Mandatory Education—Professional Nurse

Principle #1: Rigorous and repeated training Focusing only on PPE gives a false sense of security of safe care and worker safety. Training is a critical aspect of ensuring infection control. Facilities need to ensure all healthcare providers practice numerous times to make sure they understand how to appropriately use the equipment, especially in the step by step putting on and taking off of PPE. CDC and partners will ramp up training offerings for healthcare personnel across the country to reiterate all the aspects of safe care recommendations.

Principle #2: No skin exposure when PPE is worn Given the intensive and invasive care that U.S. hospitals provide for Ebola patients, the tightened guidelines are more directive in recommending no skin exposure when PPE is worn.

CDC is recommending all of the same PPE included in the August 1, 2014 guidance, with the addition of coveralls and single-use, disposable hoods. Goggles are no longer recommended as they may not provide complete skin coverage in comparison to a single-use, disposable full-face shield (bold added by author). Additionally, goggles are not disposable, may fog after extended use, and healthcare workers may be tempted to manipulate them with contaminated gloved hands. PPE recommended for U.S. healthcare workers caring for patients with Ebola includes: Double gloves Boot covers that are waterproof and go to at least mid-calf or leg covers Single-use fluid resistant or impermeable gown that extends to at least mid-calf or coverall without integrated hood. Respirators, including either N95 respirators or powered air purifying respirator (PAPR) Single-use, full-face shield that is disposable Surgical hoods to ensure complete coverage of the head and neck Apron that is waterproof and covers the torso to the level of the mid-calf (and that covers the top of the boots or boot covers) should be used if Ebola patients have vomiting or diarrhea

The guidance describes different options for combining PPE to allow a facility to select PPE for their protocols based on availability, healthcare personnel familiarity, comfort and preference while continuing to provide a standardized, high level of protection for healthcare personnel.

The guidance includes having: Two specific, recommended PPE options for facilities to choose from. Both options provide equivalent protection if worn, put on and removed correctly. Designated areas for putting on and taking off PPE. Facilities should ensure that space and layout allows for clear separation between clean and potentially contaminated areas Trained observer to monitor PPE use and safe removal Step-by-step PPE removal instructions that include: Disinfecting visibly contaminated PPE using an EPA-registered disinfectant wipe prior to taking off equipment

Annual Mandatory Education—Professional Nurse

Disinfection of gloved hands using either an EPA-registered disinfectant wipe or alcohol-based hand rubs between steps of taking off PPE.

Principle #3: Trained monitor CDC is recommending a trained monitor actively observe and supervise each worker putting PPE on and taking it off. This is to ensure each worker follows the step by step processes, especially to disinfect visibly contaminated PPE. The trained monitor can spot any missteps in real-time and immediately address

PPE is Only One Aspect of Infection Control It is critical to focus on other prevention activities to halt the spread of Ebola in healthcare settings, including: Prompt screening and triage of potential patients Designated site managers to ensure proper implementation of precautions Limiting personnel in the isolation room Effective environmental cleaning

Think Ebola and Care Carefully The CDC reminds health care workers to “Think Ebola” and to “Care Carefully.” Health care workers should take a detailed travel and exposure history with patients who exhibit fever, severe headache, muscle pain, weakness, diarrhea, vomiting, stomach pain, unexplained hemorrhage. If the patient is under investigation for Ebola, health care workers should activate the hospital preparedness plan for Ebola; isolate the patient in a separate room with a private bathroom, and to ensure standardized protocols are in place for PPE use and disposal. Health care workers should not have physical contact with the patient without putting on appropriate PPE.

Summary of Infection Transmission and Control Know the CDC three principles of guidance: rigorous and repeated training, no skin exposure, and trained monitor.

PPE for Ebolavirus Video View the following CDC video. It is an excellent review of current CDC guidance, and includes guidance on the various equipment alternatives, e.g., N95 mask v. PAPR.

Please hold down the ‘Ctrl’ key and click the image below to view the video. To follow along with the procedure by looking at the detailed CDC descriptions of PPE donning and doffing, you can see the descriptions in the resource section of the document linked here.

Remember to hold down ‘Ctrl’ when clicking the below linked image. Holding ‘Ctrl’ will launch the video in a separate browser window so you can see have both this document and the video open at the same time.

Annual Mandatory Education—Professional Nurse

PPE points of emphasis The following information expands on the PPE points of emphasis in the previous Infection prevention and transmission section. The information is copied directly from the CDC document linked in the Resources section of this course: "Guidance on Personal Protective Equipment To Be Used by Healthcare Workers During Management of Patients with Ebola Virus Disease in U.S. Hospitals, Including Procedures for Putting On (Donning) and Removing (Doffing)"

Healthcare workers must understand the following basic principles to ensure safe and effective PPE use, which include that no skin may be exposed while working in PPE:

Donning PPE must be donned correctly in proper order before entry into the patient care area and not be later modified while in the patient care area. The donning activities must be directly observed by a trained observer. Double gloving provides an extra layer of safety during direct patient care and during the PPE removal process. Beyond this, more layers of PPE may make it more difficult to perform patient care duties and put healthcare workers at greater risk for percutaneous injury (e.g., needlesticks), self-contamination during care or doffing, or other exposures to Ebola. If healthcare facilities decide to add additional PPE or modify this PPE guidance, they must consider the risk/benefit of any modification, and train healthcare workers on correct donning and doffing in the modified procedures.

During Patient Care PPE must remain in place and be worn correctly for the duration of exposure to potentially contaminated areas. PPE should not be adjusted during patient care. Healthcare workers should perform frequent disinfection of gloved hands using an ABHR, particularly after handling body fluids. If during patient care a partial or total breach in PPE (e.g., gloves separate from sleeves leaving exposed skin, a tear develops in an outer glove, a needlestick) occurs, the healthcare worker must move immediately to the doffing area to assess the exposure. Implement the facility exposure plan, if indicated by assessment.

Annual Mandatory Education—Professional Nurse

Doffing The removal of used PPE is a high-risk process that requires a structured procedure, a trained observer, and a designated area for removal to ensure protection PPE must be removed slowly and deliberately in the correct sequence to reduce the possibility of self-contamination or other exposure to Ebola virus A stepwise process should be developed and used during training and daily practice

Training on Correct Use of PPE Training ensures that healthcare workers are knowledgeable and proficient in the donning and doffing of PPE prior to engaging in management of an Ebola patient. Comfort and proficiency when donning and doffing are only achieved through repeated practice on the correct use of PPE. Healthcare workers should be required to demonstrate competency in the use of PPE, including donning and doffing while being observed by a trained observer, before working with Ebola patients. In addition, during practice, healthcare workers and their trainers should assess their proficiency and comfort with performing required duties while wearing PPE. Training should be available in formats accessible to individuals with disabilities or limited English proficiency. Target training to the educational level of the intended audience.

Use of a Trained Observer Because the sequence and actions involved in each donning and doffing step are critical to avoiding exposure, a trained observer will read aloud to the healthcare worker each step in the procedure checklist and visually confirm and document that the step has been completed correctly. The trained observer is a dedicated individual with the sole responsibility of ensuring adherence to the entire donning and doffing process. The trained observer will be knowledgeable about all PPE recommended in the facility's protocol and the correct donning and doffing procedures, including disposal of used PPE, and will be qualified to provide guidance and technique recommendations to the healthcare worker. The trained observer will monitor and document successful donning and doffing procedures, providing immediate corrective instruction if the healthcare worker is not following the recommended steps. The trained observer should know the exposure management plan in the event of an unintentional break in procedure.

Methicillin Resistant Staph Aureus

What is antibiotic resistance? Pathogens develop resistance by being exposed to an antibiotic. A few individual organisms may survive that exposure due to random mutations in their genes that confer resistance. Those survivors then pass on those genes to the next generation, and also transfer those genes to other individual organisms nearby. This process is well-known to biologists as natural selection, the motor of evolution, as random beneficial variations in individuals are passed on to successive generations who survive preferentially as a result of those inherited traits.

Annual Mandatory Education—Professional Nurse

Causes of the spread of resistant pathogens There is a general acceptance, and even dependence, on antibiotics that has created a culture of overuse in most of the world. Prescribers overprescribe antibiotics and especially broad-spectrum antibiotics, livestock are treated in order to improve growth and disease resistance, and common household cleaners and even toys now contain antibiotics.

Definition of MRSA MRSA stands for Methicillin Resistant Staph Aureus. The term could be a bit misleading because these variants of S. aureus bacteria are resistant to an entire class of antibiotics that includes methiciliin, but also includes other common antibiotics such as amoxicillin and penicillin. Vancomycin has been the treatment of choice for broadly resistant MRSAs, but vancomycin-resistant MRSAs have been in evidence since 2002.

Types of MRSAs HA-MRSAs, that is hospital acquired MRSAs, are also resistant to nearly all available antibiotics. CA- MRSAs are usually susceptible to trimethorprim/sulfamethoxazole (Bactrim) and certain other drugs.

Scope, treatment, and prevention MRSAs are the most common antibiotic resistant pathogen in US hospitals. MRSAs represent a serious problem in the healthcare environment and are a growing public health problem as well. Manifestations include skin infections, pneumonias, bloodstream infections, septic arthritis, and endocarditis. Treat MRSAs according to culture and susceptibility. Prevent MRSAs by scrupulous attendance to infection control guidelines and practices and educate patients with MRSAs about hand hygiene.

Hospital-Acquired Pneumonia

What is hospital-acquired pneumonia (HAP) HAP is a nosocomial infection that develops at least 48 hours after admission, and is associated with poor patient outcomes and increased costs and length of stay. Subcategories of HAP include postoperative pneumonia, ventilator-associated pneumonia (VAP), and healthcare-associated pneumonia (HCAP) which is associated with chronic care and outpatient facilities.

Risk Factors More than 85% of HAPs are VAP, and as many as 23% of all ventilated patients develop VAP. Risk factors for non-ventilated patients include previous antibiotic treatment, presence of stress ulcers, and various common comorbidities such as cardiac, hepatic, renal, and pulmonary problems. The most important risk factors for postoperative pneumonia are advanced age and abdominal or thoracic surgery.

Prevention If possible, maintain ventilated patients in a semi-upright or upright position in order to reduce the risk

Annual Mandatory Education—Professional Nurse

of aspiration. Ventilation with continuous positive airway pressure (CPAP) has a lower risk for HAP than with an ET tube. Incentive spirometry will help prevent postoperative pneumonia.

Tuberculosis

Facts about tuberculosis Tuberculosis (TB) is a disease that affects the lungs and/or other parts of the body. It is the largest single cause of death among people diagnosed with AIDS. Tuberculosis is curable, but it involves taking medication for a very long time.

TB is caused by airborne bacteria, which remain in the air for a long time and travel considerable distances. Tuberculosis spreads through coughing, sneezing, talking, laughing, and breathing. In the U.S., over 25,000 people are diagnosed with tuberculosis every year. Worldwide, over 8 million people are infected with TB every year, and 3 million people worldwide die of the disease.

About 90% of people infected with TB may not show signs of the disease even though the germ is present in their bodies. This condition is referred to as LATENT TB. These people are most at risk of developing ACTIVE TB within 2 years of the exposure. TB may also develop if they have (or develop) another disease that affects the immune system, such as AIDS.

Symptoms of TB include: Chest pain Prolonged productive cough Coughing up of blood Fever and chills Night sweats Weight loss Feeling run down or easily tired

Risks, detection, and protection People are more prone to contracting TB when they: Live in close quarters, such as homeless shelters, prisons, migrant camps, nursing homes or other crowded home situations Are affected by a disease that affects the immune system, such as AIDS Take medication that affects the immune system Live in geographic areas where TB is common, such as Asia, Africa and Latin America Are exposed to people who have TB.

Healthcare professionals and persons exposed to TB need to have a Purified Protein Derivative (PPD) skin test or a chest X-ray. Positive test results indicate the person is infected with TB but may not have Copyright 2015, Cross Country University Page 176 of 284, Infection Control, Part 2: HAI, Ebola, MRSA, HAP, TB, HIV/AIDS

Annual Mandatory Education—Professional Nurse

TB disease. He or she may be given preventive therapy to kill germs that are not doing any damage now, but could break out later.

Facts: If a PPD test shows positive, all PPD tests taken after it will show positive as well, and each reaction will be more severe. If a person has had a positive PPD test in the past (even if the TB was treated), a skin test should NOT be administered (it will indicate positive). A chest X-ray MUST be taken instead to determine if the person has ACTIVE TB. People who have received the Bacillus Calmette-Guerin (or "BCG") vaccine will have a positive skin test.

Your facility may require you to have a routine PPD test or chest X-ray at specified intervals or on exposure to TB. Most hospitals require that every employee be tested at least once a year. However, testing may be more or less frequent depending on the risk of exposure to patients with tuberculosis.

Treatment Tuberculosis can be cured with medication.

Latent TB If a doctor decides a person with Latent TB should have treatment to prevent it from becoming Active TB, the usual prescription is a daily dose of isoniazid (INH). The person takes INH for six months (up to a year for some patients), and should have periodic medical checkups.

Active TB People with Active TB show symptoms of the disease. They may have to spend a short time in the hospital and can then continue taking medication at home. Sometimes the patient will not have to stay in the hospital at all. As long as they are taking the medication correctly, most patients can return to normal activities after a few weeks, and not have to worry about infecting others. However, it is VERY important that patients take the medicine correctly for the full length of treatment - usually, six to nine months or longer.

Multi-Drug Resistant TB Tuberculosis, a disease that was once considered to be almost eradicated, has become more widespread in recent years. One reason is that, in some instances, TB is resistant to the drugs normally used to treat the disease. Resistance may occur when people who are being treated start feeling better and stop taking their medication too soon. The TB germs are not completely destroyed and the person will start showing signs of the disease again. Drugs previously used will no longer be effective. This condition, referred to as Multi-Drug Resistant TB, is extremely difficult to cure.

Annual Mandatory Education—Professional Nurse

If a person with Multi-Drug Resistant TB infects another person, that other person will also have Multi- Drug Resistant TB.

Special Precautions used for tuberculosis Tuberculosis is caused by airborne bacteria. To protect yourself and others from contracting tuberculosis, follow your facility's recommended Special Precautions in addition to Standard Precautions.

Special Precautions for the treatment of TB patients: Place TB patients in private rooms. Ventilate rooms directly to the outside if possible, to prevent the circulation of TB germs to other areas of the facility. Wear a special "fit-tested" mask (and receive training in how to wear it correctly) when entering the room and while in the room. Explain to patients and visitors how to use special masks. Keep patients in their rooms as much as possible. Encourage patients to cough or sneeze directly into tissues and to dispose of them. Have patients wear masks when being transported to other areas of the hospital (for X-rays, etc.).

HIV/AIDS

What are HIV and AIDS? HIV HIV (Human Immunodeficiency Virus) is the virus that causes AIDS. Once this virus enters and infects the

Annual Mandatory Education—Professional Nurse

body, the person is said to be "HIV Positive." However, the person may be infected with the virus for up to 10 years or more before developing AIDS.

HIV in the US Between 800,000 and 900,000 people are infected with HIV. Approximately 40 thousand new HIV infections occur each year. 70% of new infections are in men and 30% are in women. Half of all newly infected people are under the age of 25. One-third of people infected with HIV do not know they are infected.

HIV worldwide At the end of 2000, it was estimated that 36.1 million people worldwide were infected with HIV. 70% of all HIV-infected people are in the sub-Sahara region of Africa. Approximately equal numbers of men and women are infected with HIV. 1.4 million of those infected with HIV are children under the age of 15.

AIDS AIDS stands for Acquired Immune Deficiency Syndrome. Most people who are HIV positive will eventually develop AIDS.

AIDS worldwide in 2000 3 million people died from HIV/AIDS-associated illnesses in 2000. Children under the age of 15 made up approximately 500,000 of those deaths. By the end of 2000, it was estimated that 21.8 million people worldwide have died from AIDS or AIDS-related causes.

From HIV to AIDS A person is "HIV positive" when the virus is present in the body.

Once someone is infected, the virus begins to attack the body's "immune system" (the body's defense against infection). HIV seeks out special immune cells known as "CD4 cells" and uses them to manufacture copies of the virus, which then go on to attack other CD4 cells and other types of immune cells. The normal role of CD4 cells is to direct other immune cells to fight germs that could cause an infection or disease.

An HIV positive person may not feel sick or even know they have the virus for ten or more years. During that time, the virus (a blood borne pathogen) can infect other people. A person may only know they are HIV positive by having specific blood tests.

A positive HIV test does not mean that a person has AIDS. A diagnosis of AIDS is made under either of two conditions: Copyright 2015, Cross Country University Page 179 of 284, Infection Control, Part 2: HAI, Ebola, MRSA, HAP, TB, HIV/AIDS

Annual Mandatory Education—Professional Nurse

1. If the CD4 cell count (normally 800-1000/microliter of blood) falls below 200/microliter, whether or not symptoms of the disease are present 2. If a person shows signs of having infections that healthy people are usually able to fight off such as tuberculosis, Kaposi's Sarcoma, Pneumocystis Carinii Pneumonia.

Can I get AIDS? Yes, you can get AIDS. The HIV virus is passed from one person to another through contact with infected blood or body fluids.

Methods of spreading HIV include: Sexual contact with an infected person Sharing needles (as in IV drug injection, tattooing, ear piercing, etc.) with someone who is infected Transfusions of infected blood or blood clotting factors (very rare in countries where blood is screened) From HIV-infected mothers to infants during childbirth or through breast-feeding Through contact with infected blood or other body fluids in the healthcare setting.

A healthcare worker can be infected with HIV if he or she is stuck with a needle containing HIV-infected blood, or if infected blood gets into a worker's cut or onto a mucous membrane (for example, in the eyes or nasal cavity).

There is no evidence of HIV being transmitted in other ways such as through the air, water, or by insects.

Protecting yourself and others against AIDS Following Standard Precautions, such as using recommended procedures and wearing personal protective equipment can help prevent the spread of HIV to healthcare workers. To further protect yourself and others: Abstain from sex or sex-related activities when the HIV status of your partner is doubtful or not known. The use of latex condoms can reduce the risk of contracting the virus and is referred to as "safer sex." However, there is no such thing as "safe sex" when the HIV status of your partner is unknown. If you are HIV infected and pregnant, take appropriate medication to reduce the chances of passing the virus to your unborn child. If you are HIV infected, DO NOT breastfeed. NEVER share needles, including needles used for tattoos, body piercing, or injecting steroids. If you have ever engaged in high-risk activities (IV drug injection, sex with multiple partners), have an HIV test.

There is no vaccine that will prevent AIDS and no drug that will cure AIDS. However, medications have been developed that both slow the progression of HIV Positive to AIDS and lengthen the survival of Copyright 2015, Cross Country University Page 180 of 284, Infection Control, Part 2: HAI, Ebola, MRSA, HAP, TB, HIV/AIDS

Annual Mandatory Education—Professional Nurse

people with AIDS. There is some evidence that the recently developed “cocktail” drug treatments have had an impact on survival rates.

Hepatitis

What is hepatitis? Hepatitis is a serious disease of the liver, an organ necessary for life. Hepatitis B and C, the two most serious kinds of hepatitis, are similar kinds of liver infection that are caused by different viruses. Although there are fewer new Hepatitis C infections each year compared with Hepatitis B, there are more deaths in the long term due to Hepatitis C which is a more serious chronic disease.

About 50% of Hepatitis B infections and 75% of Hepatitis C infections cause NO initial symptoms. When symptoms are present, they include: Jaundice Nausea Loss of appetite Abdominal pain Fatigue.

Chronic hepatitis When left untreated, 6-10% of Hepatitis B infections and more than 85% of Hepatitis C infections lead to chronic disease. Cirrhosis (degeneration) and cancer of the liver are often the result of chronic hepatitis.

Some facts about hepatitis: An estimated 3.7 - 4.0 million Americans presently have chronic hepatitis. 85% of individuals who contract Hepatitis C will develop chronic liver disease, including many who are initially asymptomatic. There are more deaths annually from the effects of chronic Hepatitis B than from initial symptoms.

How hepatitis is transmitted Hepatitis B and Hepatitis C viruses are transmitted through blood and body fluids. Infected blood can be transmitted from one person to another through openings in the skin or through contact by both individuals with a sharp tool.

Methods of blood-borne transmission of both Hepatitis B and C include: Blood splashes from minor cuts and nosebleeds Procedures that involve blood (especially in health care) Hemodialysis (using kidney machines) Sharing personal items like nail clippers, razors, and toothbrushes Sharing needles for intravenous drug use Copyright 2015, Cross Country University Page 181 of 284, Infection Control, Part 2: HAI, Ebola, MRSA, HAP, TB, HIV/AIDS

Annual Mandatory Education—Professional Nurse

Body piercing and tattoos.

Hepatitis B and, to a lesser extent, Hepatitis C can also be transmitted as a result of: Close household contact with an infected person Unprotected sex with multiple partners Childbirth (from mother to baby).

About one third of Hepatitis C patients never find out how they contracted the virus.

Accurate detection techniques were developed for Hepatitis B in 1972, and for Hepatitis C in 1992. Before these dates, the virus could not be detected reliably, so some people received infected blood in blood transfusions. If you had a blood transfusion or organ transplant before these dates, ask a doctor to test you for the appropriate virus or viruses.

Who is at high risk for hepatitis? Any time the skin is broken, there is the opportunity to contact another person's blood or body fluids and the risk of hepatitis infection increases. People who routinely come into contact with other people's blood are at high risk. These include: Healthcare workers Tattoo artists, people doing body piercing People with multiple sex partners. Drug users

Healthcare workers People who are exposed to blood and body fluids are at high risk for hepatitis. This includes people who: Work in the lab and handle specimens Work directly with patients and come in contact with body fluids Change the diapers of infected babies Work in housekeeping and come in direct contact with garbage or laundry.

All healthcare workers are at a greater risk because of their job.

Tattoo artists and people doing body piercing Equipment that has not been properly sterilized and shared ink may contain the hepatitis virus. The following people are at risk: The person receiving the tattoo or piercing The tattoo artist or the person doing the piercing.

People with multiple sex partners The risk of getting hepatitis is high for people having unprotected sex with multiple partners.

Annual Mandatory Education—Professional Nurse

Drugs Users People who share needles when injecting drugs are at a high risk for hepatitis. People without medical training, who inject themselves or others, are at high risk for getting or giving the disease. Re-use of needles is one of the most common causes of the spread of hepatitis.

Prevention is the best treatment Healthcare workers are at high risk for hepatitis. The best treatment is prevention.

There is a vaccine available for Hepatitis B. It is now a routine vaccination for children. The employer must provide all healthcare workers with the Hepatitis B vaccine at no cost if they are not immune to the virus. The vaccine does not contain any live virus. It is given in a series of 3 injections, and the most common side effects from hepatitis B vaccination are pain at the injection site and mild to moderate fever.

Though no Hepatitis C vaccine is currently available, recent treatment breakthroughs have resulted in cure rates of up to 75%. Even more effective treatments are currently being trialed.

Rules in your facility All staff must follow Standard Precautions. All blood transfusions must be screened for Hepatitis B and C. All staff must be offered the Hepatitis B vaccine at no cost, if they are not immune to the virus. Children must be routinely vaccinated for Hepatitis B.

Your personal role Improve sanitation when possible. Maintain good personal hygiene habits. Encourage prevention through vaccination. Have yourself vaccinated if you are not immune to Hepatitis B.

End of Infection Control, Part 2 Lesson

Latex Allergy

Background to Latex Allergy

What is latex? Latex is a rubber compound found in many products that you use on your job. It is produced from rubber trees in the Tropics.

Annual Mandatory Education—Professional Nurse

The most common medical use of latex is in disposable sterile and non-sterile exam gloves. However, the potential number of items in a medical setting that may contain latex is vast and includes other items such as masks and tubing.

Latex seems ideal for medical uses because it is impermeable, which means that no liquid or gas can pass through it. The problem with latex products is that increasing numbers of people are becoming allergic to it.

It is thought that some of the allergic reactions to latex might be due to the chemicals used on the rubber plant or in the processing, rather than to the latex itself.

Allergy or "hypersensitivity" to latex increased in the late 1980s when Universal Precautions for healthcare workers were adopted to control the spread of blood-borne pathogens. Universal Precautions, also known as Standard Precautions, mandate that healthcare workers wear latex gloves whenever contact with the secretions or excretions of any patient is likely. This dramatic increase in the use of latex gloves by all healthcare workers is believed to have caused the increase in latex allergy.

Products that contain latex Many common products are made from latex because it is inexpensive and versatile.

Medical products: Endotracheal tubes Tourniquets Intravenous tubing Electrode pads Gloves Surgical masks Goggles Respirators Rubber aprons Anesthesia masks Catheters Wound drains Injection ports Rubber tops of multidose vials Dental dams

Annual Mandatory Education—Professional Nurse

Motorcycle and bicycle handgrips Carpeting Swimming goggles Racquet handles Shoe soles Expandable fabric (waistbands) Dishwashing gloves Hot water bottles Condoms Diaphragms Balloons Pacifiers Baby bottle nipples

Symptoms of latex allergy People can have allergic reactions from latex that range from a mild rash to a full-blown allergic reaction.

Reactions include: Itching Burning sensations Hives Wheezing Shortness of breath Asthma Shock

Reactions may begin to occur even during seemingly trivial latex exposures and may progress rapidly. If exposure to latex continues, signs and symptoms of allergic reactions tend to become more severe.

The actual prevalence is not entirely clear. Some studies indicate between 8-12% of healthcare workers are affected by latex allergy. Patients also may have latex allergies. For example, it is estimated that up to 60% of all spina bifida patients have latex allergy.

People who are frequently exposed to latex are the most at risk. As with any allergy, the greater the exposure to the substance, the greater the chance of developing allergies.

If you or someone nearby begins to experience symptoms of latex allergy, get medical attention immediately.

Annual Mandatory Education—Professional Nurse

Prevalence and Symptoms of Latex Allergy

What is latex allergy? Allergic reactions to latex may include itching, burning sensations, hives, wheezing, asthma, and shock.

It is thought that some of the allergic reactions to latex might be due to the chemicals used on the rubber plant or in the processing, rather than to the latex itself.

The Universal Precautions for healthcare workers mandate that latex gloves be worn whenever contact with the secretions or excretions of any patient is likely. This dramatic increase in the use of latex gloves by all healthcare workers is believed to have caused the increase in latex allergy.

How prevalent is latex allergy? The actual prevalence is not entirely clear, but some studies indicate between 8-12% of healthcare workers are affected by latex allergy.

The people most at risk are those who are frequently exposed to latex. As with any allergy, the more the exposure to the substance, the greater the chance of developing allergies.

Patients may also have latex allergies. For example, it is estimated that up to 60% of all spina bifida patients have latex allergy.

Latex allergy is more common in people who are allergic to the following foods: Avocados Potatoes Bananas Tomatoes Chestnuts Kiwi Melon Celery Papaya

People who have problems with eczema are also at risk for latex allergy.

Degrees of sensitivity to latex There are several degrees of sensitivity to latex:

Contact dermatitis This reaction appears shortly after exposure to latex. It involves itching, dry, red skin, sometimes with cracks in the skin. Once the latex is removed (for example, when the person removes exam gloves), the Copyright 2015, Cross Country University Page 186 of 284, Latex Allergy

Annual Mandatory Education—Professional Nurse

symptoms begin to go away. Other parts of the body are not affected. For this reason, it probably is not a true allergy. This reaction may be caused by several other things: Powder in the gloves Perspiration Not drying hands thoroughly before putting on gloves

Chemical sensitivity This reaction may be due to contact with chemicals used in making the latex item, rather than the latex itself. A rash that resembles poison ivy with blisters appears 24-48 hours after exposure. The rash can also appear on other parts of the body.

Allergic reaction This reaction may occur after being exposed numerous times to latex. It is a true allergic reaction with symptoms ranging from hives and itching to breathing problems and anaphylactic (allergic) shock. Note: Anaphylactic shock is an acute emergency. If it is not treated immediately, it can be fatal.

If you or someone nearby begins to experience any of these symptoms of latex allergy, get medical attention immediately.

Prevention and Treatment of Latex Allergy

Reducing reactions to latex Latex contains proteins that can cause mild to severe allergic reactions. Chemicals that are combined with the latex during processing, and powder that is added to the gloves to make them easier to put on may also cause allergic reactions.

People who are frequently exposed to latex are the most at risk for developing an allergy. As with any allergy, the more the exposure to the substance, the greater the chance of developing an allergy. If you show any signs of latex allergy, it is important to limit your exposure to latex and to other agents to which you may be allergic.

Use the following methods if you need to limit your exposure to latex:

Use non-latex utility gloves for non-clinical work. When there is NO potential risk of contact with infectious material (when you are NOT working with patients or with clinical material), it is NOT necessary to wear latex gloves. For example, a housekeeper cleaning an oven does not need to wear latex gloves - non-latex utility gloves are adequate for these tasks.

Annual Mandatory Education—Professional Nurse

Use approved hypoallergenic gloves for ALL clinical work. When there is ANY potential risk of contact with infectious material (whenever you are working with patients or with clinical material such as blood or other body fluids), you MUST wear approved hypoallergenic gloves (which do not contain latex), to provide proper protection against infection. Your facility is required to supply you with hypoallergenic gloves, if you are allergic to latex.

Learn to recognize the symptoms of latex allergy: Skin rashes Hives Flushing Itching Nasal, eye, or sinus symptoms Asthma Shock

If you develop symptoms of latex allergy, avoid all contact with latex gloves and products until you can see a physician experienced in treating latex allergy.

Even if you are not allergic to latex, you should take the following precautions:

When wearing latex gloves, do not use oil-based hand creams or lotions. Oil-based products can cause glove deterioration. Your hands should be clean and dry before wearing gloves.

Dry hands completely before putting on gloves. Moisture trapped in the gloves may result in dry, itchy, irritated areas on the skin.

After removing latex gloves, wash hands with a mild soap and dry thoroughly. Washing and drying your hands after wearing gloves removes any residue that may cause a reaction.

How to protect people who are allergic to latex The number of people who experience sensitivity to latex products is increasing. Therefore, you should always protect yourself and others who may be allergic.

If you have latex allergy, use the following precautions: (Be sure to consult your physician first.) Avoid contact with latex gloves and other products. Your facility is required to supply non-latex gloves if you need them. Avoid areas where you might inhale the powder from the latex gloves worn by others. Tell your employers, physicians, nurses, and dentists that you have latex allergy.

Annual Mandatory Education—Professional Nurse

Wear a medical alert bracelet. A medical alert bracelet is a wrist band with written information about any medical conditions you have and what someone should do if you are experiencing a medical problem. Use latex-free "crash carts" and procedure trays. Carry an epinephrine injection kit (similar to the allergy kits carried by people who are allergic to bee stings) in case of a reaction to latex. Injection of epinephrine is an emergency treatment for an allergic reaction.

Also, protect other people who have a latex allergy. For example, screen patients for latex allergy. Clearly identify those patients with allergies to ensure that only latex-free equipment is used.

What to do if someone has an allergic reaction to latex Reactions to latex can range from mild contact dermatitis to a severe allergic reaction.

If the reaction is mild (itching or redness): Remove the latex product Wash and thoroughly dry the skin area.

If someone is experiencing a severe allergic reaction (difficult breathing, coughing spells, or shock): Remove any sources of latex Get immediate emergency medical help.

Reactions usually begin within minutes of exposure to latex, but they can occur hours later and can produce various symptoms.

It is best for anyone who experiences symptoms to be evaluated by a physician, since further exposure could result in a serious allergic reaction. A diagnosis is made by using the results of a medical history, physical examination, and tests.

Report allergic events related to latex medical devices to the Food and Drug Administration MedWatch Program, 1-800-FDA-1088.

End of Latex Allergy Lesson

Management of Assaultive Behavior Workplace Violence in the Hospital

What is workplace violence? Definitions Workplace is any place where an employee performs job duties.

Annual Mandatory Education—Professional Nurse

Violence is any act that causes physical or emotional harm, and includes the threat of being harmed. Workplace violence is any act or threat that causes physical or emotional harm in a place where an employee performs job duties.

Examples of violence that could occur in a hospital An employee who is a victim of domestic violence may be stalked and/or assaulted by a partner in the workplace. Gang members may attempt to continue violent acts inside the hospital. Substance abusers may be violent if they are reacting to drugs or if they are trying to obtain drugs. Family members may become violent when treatment that goes against their religious beliefs is ordered (by court) for a child. Medical conditions, such as Alzheimer's, sometimes result in violence.

Facts Nonfatal assaults and violent acts by industry, 2000 Incidence rate per 10,000 FTEs

Nursing & Private Health Social Personal Sector Services Services Care Overall Overall Facilities Source: U.S. Department of Labor, Bureau of Labor Statistics. (2001). Survey of Occupational Injuries and Illnesses, 2000.

85% of non-fatal workplace injuries occurred in healthcare facilities. (Occupational Safety and Health Administration, OSHA) Copyright 2015, Cross Country University Page 190 of 284, Management of Assaultive Behavior

Annual Mandatory Education—Professional Nurse

One million healthcare workers are injured in violent incidents every year.

A nationwide survey of emergency nurses between May 2009 and February 2010 found that in hospitals: 97.1% of physical violence was perpetrated by patients and their relatives. 80.6% of physical violence occurred in patients' rooms; 23.2% in corridors, hallways, stairs and elevators; and 14.7% at nurses' stations. 38.2% of physical violence against emergency nurses occurred while they were triaging patients, 33.8% while restraining or subduing patients, and 30.9% while they were performing invasive procedures. 15% of male nurses reported having been victims of physical violence compared with 10.3% of female nurses. 13.4% of violent acts occurred in large urban areas compared with 8.3% in rural areas.

Risk factors Your facility has policies for handling violence in the workplace. Do you know what the policies are? Are you aware of risk factors associated with employment in the healthcare field?

Many factors contribute to the risk of violence in a hospital. Hospitals are open 24 hours a day. Employees and patients enter and leave at all times of the day and night. There is no way of knowing a person's purpose for being in the hospital. There are usually fewer working staff visible or available during times of increased activity, such as meal times and visiting hours. At certain hours, especially at night, there are only small numbers of staff working in isolated areas of the building. There are a lot of people who are under emotional stress as a result of their illness and/or a long wait to be treated. Patients and staff bring money and valuables into the hospital. Hospitals are known to have a large supply of drugs, which attracts substance abusers. Many hospitals have poorly lighted parking areas. Gang members and other violent individuals are treated in the emergency room for injuries sustained in gang violence. Weapons, especially handguns, are brought into hospitals by gang members and by other patients who carry weapons for self-defense.

Prevention of Violent Incidents

Types and effectiveness of security Your facility has security devices you should use and security practices you should follow to help reduce the risk of violence. Copyright 2015, Cross Country University Page 191 of 284, Management of Assaultive Behavior

Annual Mandatory Education—Professional Nurse

Security devices include entrance controls, lighting, surveillance equipment, motion detectors, and other equipment used to monitor traffic in and around the hospital. Be aware of these devices in your facility and learn how to use them correctly. For example, a door may be designed to limit access to a particular area. If you prop that door open, you will be providing an opportunity for an unauthorized person to enter and violence to occur.

Security policies and procedures of your facility are in place for your safety. Keep safety in mind and develop security practices that will help you to reduce the risk of violence. For example, identification (ID) badges may be required for entry to a particular lab. Do not hold the door open to allow someone to enter with you, and question any person who does not have an ID badge, even if that person is wearing the proper uniform or lab coat.

Security personnel and equipment

Security equipment may include bright lighting, cell phones, automatic locks, alarms, video cameras, and ID badges

Your facility has security personnel, equipment, and devices intended to reduce violence in the workplace. Do you know what they are? Do you know where they are? Do you know how to use them?

Physical security measures at your facility could include: Security personnel at entrances, to patrol inside and outside buildings, to monitor sensitive areas, and to provide escorts to and from parking lots Access controls such as ID badges, key codes, and automatic door locks (after hours, people are normally escorted by security personnel) to restricted-access areas such as the pharmacy, laboratories, obstetrics, and pediatrics Copyright 2015, Cross Country University Page 192 of 284, Management of Assaultive Behavior

Annual Mandatory Education—Professional Nurse

Security equipment such as effective lighting (in isolated areas, parking garages and lots, doorways, hallways, and stairways), alarms and emergency call buttons, video cameras (their presence alone is a deterrent), metal detectors, bullet-proof windows, cellular phones, and curved mirrors in hallways (for visibility around corners) Structural planning such as safe rooms (containing at least two exits) and minimal furniture and objects that could be used as weapons in counseling rooms.

Be sure you know about the physical security that is available at your facility. Determine where they are located and learn how to use them properly.

Security practices Your facility has security policies and procedures intended to reduce violence in the workplace. Do you know what they are? Do you use security practices to help prevent workplace violence?

Security practices at your facility could include: Access control policies such as using ID badges for entry, questioning anyone without ID badges, and signing-in all visitors Awareness issues such as being especially sensitive to patients and families during stressful situations, keeping people informed during long waits to reduce stress and frustration, monitoring gang activity and reporting interference with duties, and developing awareness of items that could be used as weapons (pens, syringes, lamps, books, IV poles, etc.) Sensitivity issues such as separating persons angry with each other and keeping patients in states of psychiatric crises separated from other patients Personal practices including wearing minimal jewelry (so it cannot be grabbed), wearing hair short or close to the head (so it cannot be grabbed), avoiding stairways at night or when fewer staff are around, using a buddy system to avoid being alone in areas of potential risk, and withholding personal information (concerning yourself or others) from patients and their families, such as address, phone number, names of family members, etc. Hospital policies including prosecuting to the full extent of the law for acts of violence, reporting all threats and incidents to supervisors for investigation, providing security and/or escorts when travelling to and from parking areas (especially at night), and using code words to alert others of a problem or when discussing sensitive topics such as drugs or money.

Be sure you know the security policies and procedures of your facility. Use security practices properly to help prevent violence in your workplace.

Diffusion of Violent Incidents

Signs of anger Violent incidents are often the result of someone's anger.

Annual Mandatory Education—Professional Nurse

Anger is a normal, healthy, human emotion. It is a warning sign that something is wrong. Anger varies from mild irritation to intense rage and may result in violence. It may be triggered by the action of a single person or event or it can be caused by stress and worrying too much. When people feel threatened or weak, they react with anger because it makes them feel strong and in control.

Everyone gets angry at one time or another. When anger gets out of control, it can lead to problems at work, in personal relationships, and in the quality of a person's life. Anger is a learned behavior. If people have seen their parents use anger to resolve an issue, they are likely to use the same approach.

A red face, clenched fists, and swearing are signs that indicate a person is angry.

When people get angry, their heart rate, blood pressure, and adrenaline levels rise. These signs are not visible, but there are other signs that will help you recognize that a person is angry or getting angry.

Signs of anger include: Reddening of the face Staring eyes Rapid breathing Shouting (although some people may become quieter) Clenching fists Swearing Pacing Challenging behavior.

Causes of anger Anger can lead to loss of control, which may result in violence. Understanding the causes of anger will prepare you to respond to anger and diffuse a potentially violent incident before it happens.

Annual Mandatory Education—Professional Nurse

Causes of violence include: Stress Frustration Feeling that no one is listening Feeling of being powerless.

Stress Hospitals are stressful places for patients, visitors, and staff. Stress associated with pain and anxiety may lead patients or their family members to become angry. Staff may become angry because of the stress of dealing with irrational behavior by patients.

Frustration Patients recovering from illness or injury often become frustrated with the progress of their recuperation. They may direct their frustration at healthcare workers.

Feeling that no one is listening Long waits in emergency rooms can cause patients and their family members to become angry, frustrated, and hostile. It is natural for ill or injured patients to want to be seen as soon as possible. When they perceive they are not getting the attention they should, they think that staff are not interested in their problem. This perception can lead to a build-up of anger.

Feeling of being powerless Family members who are not allowed into the treatment room and are not kept informed of the condition of the patient may feel powerless. This feeling could lead to anger and violence. For example, they may try to force their way into the treatment room.

Responding to anger When you notice that someone is angry or getting angry you want to keep the situation from escalating and resulting in harm to people and property.

Follow these steps as you try to calm a person down: 1. Take the person out of the public area. 2. Allow the person to talk about the problem. 3. Listen to what happened. 4. Identify with the person's feelings. 5. Get help.

Take the person out of the public area Take the angry person out of the public area but avoid isolating yourself. If you go to another room, never let the other person come between you and the exit.

Annual Mandatory Education—Professional Nurse

Allow the person to talk Allow the person to talk about the problem and encourage him or her to say more. Hear the person out and do not try to give any explanation at this point. When people are angry they are unable to reason and will not understand or focus on the explanations. Once they have said everything they want to say, they may be able to listen to you.

You CAN say: "This has upset you." "Sounds like things are not going as you planned." "You felt like no one was listening to you." "And then?" "Go on ... tell me what happened."

You MUST NOT say: "You are wrong." "That could not have happened." "Just calm down!" "Relax ... don't get upset!"

Listen to what happened Your goal is to listen to what happened, without interrupting, so the person knows that someone is paying attention. It does not matter right now whether the person is right or wrong. This is what he or she thinks happened and it is real to him or her.

Identify with the person's feelings It is OK to identify with the person's feelings by saying something like, "When you had to wait so long, you felt that you were being forgotten." Once the person is calmer, you may be able to deal with the situation and offer an explanation. If an error has been made, your focus should be on how to correct it.

Get help If you feel uncomfortable dealing with a situation or if it gets out of hand, call for help or let someone else handle the incident.

Response to Violent Incidents

Get help! When you are confronted by someone who is threatening you, do not try to be a hero. Get help! Your life is priceless.

Annual Mandatory Education—Professional Nurse

If you see a co-worker being threatened by another employee, a patient, or a visitor ask them if they need help if the need is not obvious. Then get help!

Your facility may have codes to help you and your co-workers in this type of situation. Examples of codes include: Code alert that can be broadcast to get help to your area Code word(s) such as, "I need Dr. Armstrong." Facility alarm codes that you can use to call your supervisor

DO NOT use force in this type of situation especially if you have not been trained how to do so properly. Special programs are used by employees in psychiatric medicine for "taking down" a violent person. If these programs are not used correctly, serious and fatal injuries can occur.

Protect yourself! What you should do when a person is angry and out of control depends on the situation and the circumstances.

Annual Mandatory Education—Professional Nurse

If you feel that a person is getting out of control and may attack you, take the following precautions to protect yourself: Don't try to be a hero. ... Get out! Loosen or take off items of clothing such as a scarf or necktie that the angry person could grab. Remove high heels if you feel you may need to run. Move to a place where the furniture in the room is not blocking the exit or the pathway to the door. Stay at least six to seven feet away from the angry person. If the person comes toward you, hold your arms up with the palms facing outward. Trust your instinct; get out if you feel it is necessary.

Annual Mandatory Education—Professional Nurse

After the violent incident Once the violent incident is over, there are three areas of concern: Medical help Emotional help Debriefing

Medical help If you have been injured, you will need immediate medical attention.

Emotional help Even if you have not been physically injured, you have been through a crisis situation and need time to recover. Your facility will have resources available to you to help you through this time. It is normal to need some additional help and counseling. Take advantage of help that is available. If you were not the person involved, be supportive to any co-workers who were involved. Emotional recovery may take some time. Do not make unrealistic expectations for yourself.

Debriefing Your facility will have some specific debriefing procedures once the incident is over. This debriefing typically involves everyone who was involved in the incident. It gives everyone the opportunity to discuss exactly what occurred. The information from the briefing can help prepare you for dealing with future situations.

End of Management of Assaultive Behavior Lesson

Medical Gas Safety

What is a medical gas? Medical gases are gases, in any form, prescribed for use with patients. Uses can include inhalation, application, ventilation, inflation of a body cavity, support of extracorporeal circulation, etc.

The most common are: Oxygen, Medical Air, Vacuum, Nitrous Oxide, and Entonox (50/50 Oxygen and Nitrous Oxide). This module is intended for general care areas, so only oxygen safety is addressed her.

The air we breathe is mainly Nitrogen (78%) and Oxygen (21%). Oxygen is highly reactive, though it is not flammable, it supports combustion and will causes other substances to become more highly flammable.

Altering the concentration of gases in a work environment such as a patient room or storage area can seriously affect the health and safety of patients and personnel. Consequences include poisoning, intoxication, asphyxiation, fire, and explosion. Copyright 2015, Cross Country University Page 199 of 284, Medical Gas Safety

Annual Mandatory Education—Professional Nurse

Basic Gas Safety Oxygen enrichment is a gas hazard that occurs when ambient oxygen exceeds the usual 21%. The gas is colorless and odorless and an excess cannot be detected without monitoring equipment. This hazard increases the risk of fire and explosion; even fire-retardant materials can become flammable in the presence of oxygen. A 4% increase of oxygen concentration in the air doubles the risk of fire, and the higher the concentration, the greater the risk.

Oxygen enrichment is caused by any of the following: Leaks from damaged equipment Poor connections Excessive flow rates Poor area ventilation

These are common items vulnerable to combustion, especially in an oxygen enriched environment: Hair and clothing Linens, mattresses, curtains Dressings Disinfectants Hand-rubs and gels Paper and cardboard Cleaning supplies Electrical and electronic equipment

Reduce the risk of fire when using oxygen, nitrous oxide, and Entonox as follows: Keep hands and clothes clean and free of oil, grease, and hand rubs and creams Use only authorized gas equipment Ensure gas equipment such as flowmeters and regulators are inspected and serviced regularly Use appropriate flow rates appropriate to the delivery method Always turn gases off at the source when not in use Store cylinders only in designated areas Never store cylinders with flammable materials

End of Medical Gas Safety Lesson

Medication and Treatment Errors and Sentinel Events

Causes of errors Errors in delivering a treatment, procedure, or medication can have serious consequences. Every year, more than 7,000 deaths occur because of medication errors alone. Medication errors can include:

Annual Mandatory Education—Professional Nurse

Wrong patient Wrong medication Wrong dosage or concentration Medication given incorrectly Medication prescribed to which patient is allergic.

Sometimes, these errors involve drugs that have similar names or that come in similar packages. In all, the wrong medication being given accounts for 15% of medication errors. In many cases, the drugs involved in medication errors are those kept on floor stock. These are less likely to have gone through a pharmacy check or to have been checked by another person before being given.

Other reasons that errors are made include: Lack of knowledge about the drug Lack of information about the patient Violations of rules and procedures Lapses and slips in memory Transcription errors when copying names or dosages Faulty patient identity checking Miscommunications between different services in the facility Improper dose checking Problems with delivery equipment (such as an infusion pump).

Many of these factors can also contribute to procedure or treatment errors: Faulty patient identity checking could result in lab tests being performed on the wrong patient. Miscommunications between services could result in breakfast being served to someone who is scheduled to have surgery or a diagnostic test and is classified as NPO (not allowed to take anything by mouth). Violations of rules and procedures, such as not following the surgical checklist, could result in performing the wrong surgery or other serious consequences.

Identifying system problems If you know that you have made an error, or if you discover an error made by someone else, it is important to report it. Your facility has a procedure that you should follow for reporting medication or treatment errors.

Most errors are not the fault of one person. There is a combination of factors in the process of delivering a treatment, procedure, or medication. It is important to find out what went wrong, so that the system can be corrected and future errors of the same type can be avoided.

Annual Mandatory Education—Professional Nurse

Pharmacy gets the order. The pharmacy technician gets distracted and fills the patient medication bin with Chlorpropamide (the unit dose packages look similar). When the carts are checked, the mistake is not noticed. When the nurse gives the medication, the mistake is not noticed.

Result: The patient receives an incorrect medication and also does not receive the prescribed medication.

What went wrong? The mistake is not the fault of one person. The error is a result of a combination of factors. Correcting this problem would involve investigating: Why the pharmacy technician was distracted Why the drugs are stored so that they could be confused Why the nurse did not notice the error.

The goal of reporting and investigating is not to blame someone. The goal is to fix problems in the system so that the same error will not happen again.

Preventing medication errors, the Five Rights There are things that you can do to help prevent medication errors. One of these is to follow the "Five Rights": Right patient: Always check patient identification. Right medication: Read the labels. Follow the system that your facility uses to make sure that you have the right medication and concentrations. Right dosage: Check the concentrations and amounts. Right time: Give medications according to the patient's treatment schedule. Right route: Administer the medication via the right route (orally, intramuscular injection, intravenously, etc.)

Some facilities have automated systems for delivering medications. This can greatly reduce errors, but will not eliminate them. Your common sense is also important. If something doesn't seem right, stop and INVESTIGATE.

For example: If an order seems incorrect, INVESTIGATE. If the patient says that the medication is different or not right, INVESTIGATE. DOUBLE-CHECK any order you are unsure of.

Classifying and Reporting Patient Injuries and Near Misses The Joint Commission emphasizes PREVENTION - identifying problems and correcting them before anything happens. The organization has definitions that you need to know for the following terms: Copyright 2015, Cross Country University Page 202 of 284, Medication and Treatment Errors and Sentinel Events

Annual Mandatory Education—Professional Nurse

Error Sentinel Event Near Miss Hazardous Condition

Error

An Error is an unintended act of either omission or commission, or an act that does not achieve its intended outcome. In other words, an Error is: Something done by accident Something that should have been done but was not Something that was done that did not have the expected result.

An example of an Error is a patient's blood pressure not being measured when it should have been.

Sentinel Event A Sentinel Event is an unexpected occurrence which actually happened and which either resulted in death or serious physical or psychological injury, or carried a significant risk thereof. Serious injury specifically includes loss of limb or function.

An example of a Sentinel Event is the wrong dose of medication being given to an infant, causing death.

Certain types of events are reported to The Joint Commission under their Sentinel Event policy, whether they actually or potentially resulted in death or serious injury. These events are: Rape Patient suicide Infant abduction or discharge to the wrong family Hemolytic transfusion reaction involving administration of blood or blood products Surgery on the wrong patient or wrong body part.

Near Miss This term is used to describe any process variation which could have led to a Sentinel Event, but the Sentinel Event did not actually happen because of some kind of intervention. A recurrence of the process variation carries a significant chance of a serious adverse outcome.

Here is an example of a Near Miss. By mistake, a patient is handed a medication to which she is allergic, and which could lead to death or serious illness. Fortunately, she recognizes the medication is different from what she is usually given, questions staff about it, and ultimately receives the correct medication, instead. In this case, the process variation is that the patient is not wearing a wrist band listing her allergies, and that the information about her allergies is not available to staff anywhere else.

Annual Mandatory Education—Professional Nurse

Hazardous Condition This refers to any set of circumstances (other than the disease or condition for which the patient is being treated) which significantly increases the likelihood of a serious adverse outcome.

In other words, a Hazardous Condition is: Something that could cause the patient harm Something other than the patient's disease or condition.

An example of a Hazardous Condition is a power outage and simultaneous failure of the back-up generator that shuts down life-support systems for some patients, meaning staff must manually ventilate affected patients until power is restored.

Deteriorating Patient Condition Whether or not your role includes direct patient care, you may be the first person to encounter a patient or visitor who has become ill or is in distress. When you think a patient is experiencing a medical emergency, you must follow the procedures specific to the healthcare facility/entity to which you’ve been assigned. In other words, you must be aware of that facility’s procedures for initiating medical assistance in an emergency.

Generally, in patient care areas, you would notify the patient’s nurse, or any nurse or physician in the area. If not in a patient care area, or if no one is available, each organization will have a notification system for such emergencies, generally a phone extension number that you would call. In some situations such as organization parking lots, outpatient clinics, and homecare visits, for example, the appropriate action may be to call 911.

In short, get help, either by notifying the person responsible, or by initiating the emergency response system.

It is your responsibility to know how to initiate the appropriate emergency response system.

End of Medication and Treatment Errors and Sentinel Events

National Patient Safety Goals of The Joint Commission

Background

In 1996, The Joint Commission (TJC) established the Sentinel Event Policy requiring accredited organizations to report and analyze all sentinel events*. The information collected as a result of this policy identified the following most common causes of sentinel events:

Annual Mandatory Education—Professional Nurse

Patient suicide Operative/post operative complications Wrong site surgery Medication errors Delays in treatment

In 2002, TJC began implementation of the National Patient Safety Goals program. Each year, experts recommend, emphasize, or de-emphasize certain patient safety goals based on analysis of the sentinel event program.

The National Patient Safety Goals promote and improve patient safety in certain identified problem areas. Where possible, the goals will focus on system-wide solutions. TJC monitors accredited organizations' compliance with those goals, and expects organizations to be in compliance.

*A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. . . Such events are called "sentinel" because they signal the need for immediate investigation and response. (TJC’s Sentinel Event Policy and Procedures Revised: July 2002)

How Do Healthcare Organizations Address the National Patient Safety Goals? According to TJC, “the NPSGs are prioritized from a “pool” of recommendations identified by the Patient Safety Advisory Group as evidence- or consensus-based, cost-effective and practical.” Each organization chooses to address and implement the goals in the manner that makes the most sense for that organization, and those organizations may even offer alternatives to the specific recommendations of TJC.

When answering the exam questions, use the following Joint Commission (TJC) documents as your guide. The first document is TJC’s quick guide to the 2015 Goals, the second is the list of Do Not Use abbreviations, and the third is their list of drug names that are often confused.

Annual Mandatory Education—Professional Nurse

2015 Hospital National Patient Safety Goals

Annual Mandatory Education—Professional Nurse

TJC “Do Not Use” List

Annual Mandatory Education—Professional Nurse

ISMP List of Confused Drug Names

Annual Mandatory Education—Professional Nurse

End of NPSG Lesson

Organ and Tissue Donation

Annual Mandatory Education—Professional Nurse

Healthcare facilities are credentialed by, and work with state and federal agencies to provide donated organs. Standards and procedures are necessarily specific to each healthcare facility. Know your local standards.

Live donors are often family members of the recipient; when not a family member, the donor is referred to as an altruistic donor.

There are two sets of conditions that pertain when the the donor is deceased: I. Cardiorespiratory death Definition: Loss of cardiac and respiratory function Potential donation: Cornea Heart valves Skin Long bones Saphenous veins

II. Non-recoverable brain injury Definition: Irreversible loss of all brain stem function, or impending withdrawal of life support Potential donation: Bone Cartilage Cornea Heart Heart valves Kidneys Liver Lungs Pancreas Skin Small bowel Tendons

Patients who meet appropriate criteria (see your local standards) are referred to the appropriate referral network affiliated with your healthcare facility. Most organ donors are patients who have been declared brain dead.

A typical process for the determination of brain death is a clinical exam by an LIP with an apnea test, then confirmatory tests of cerebral brain flow, and/or an additional exam with an apnea test 6 hours after the initial exam and test. Copyright 2015, Cross Country University Page 211 of 284, Organ and Tissue Donation

Annual Mandatory Education—Professional Nurse

Referral process Know your local standards. Typically, a healthcare professional contacts a representative of the referral network which then conducts a phone evaluation that includes demographics, cause of death, neuro status, medical history, family information, hospitalization and current medical status. Based on the phone assessment, a transplant coordinator conducts an onsite evaluation.

Approaching the family about organ donation Know your local standards. Generally, an approach is only made in collaboration with the state referral network. And that approach is typically not made until after medical suitability for referral has been determined by the network. Local standards will determine who can authorize the donation.

Donor management Maintain organ function, oxygenation, and hemodynamic stability. Key parameters include urine output, CVP, systolic BP, pH, electrolytes, and O2 saturation. In addition, there are organ and tissue-specific procedures depending on what will be donated.

Nurse’s role in organ and tissue donation • Refer appropriate patients (know your local standards) to state referral network • Ensure that discussions take place only with participation of the referral network • Assist in maintaining organ viability

End of Organ and Tissue Donation Lesson

Pain Management Pain Facts; Pain Myths

What is pain? Pain is the most common reason that people in the United States seek medical care. Every year, pain- related complaints result in: Approximately 140 million physician visits More than $100 billion in healthcare costs and lost work time.

More than 2.6 million people routinely take prescription medication for pain. But what is pain?

Pain can be defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage."

It is important to remember that pain is very subjective. Pain is whatever the patient says it is. It is experienced differently by different people.

Annual Mandatory Education—Professional Nurse

Previous experience with pain Meaning of pain for the individual Beliefs about pain Usual coping mechanisms Psychological state

Family and social expectations can also play a role. The experience of pain may be influenced by the way that the patient was brought up to view and deal with pain, and by the expectations of the patient's culture or society. Finally, some people are physically more or less sensitive than others to actual or anticipated injury.

Acute and chronic pain Pain is often described as either acute or chronic. These terms describe the duration of the pain and the way it may respond to treatment. They do not describe how severe the pain is.

Acute pain Acute pain is caused by a specific physical condition. It includes such things as: Pain following surgery Pain of a sore throat Pain of an injury.

Acute pain has a well-defined onset, is temporary, is predictable, and is treatable. Once the condition causing the pain no longer exists, the pain will go away.

Chronic pain

Chronic pain is different because it may not have a specific onset or timecourse. Chronic pain: Lasts more than a month May not respond predictably to treatment May not result from a particular injury or event.

Pain resulting from an injury or surgery may also be classified as chronic pain, if the pain continues much longer than the normal healing period.

Cancer Pain Cancer pain is sometimes considered as a separate type of pain. Cancer pain can be acute or chronic. If the cancer is not curable, the pain may get worse and worse as the disease progresses. Cancer pain may be caused by: The disease itself Treatments (such as surgery, chemotherapy, and radiation) Infections. Copyright 2015, Cross Country University Page 213 of 284, Pain Management

Annual Mandatory Education—Professional Nurse

Nociceptive and neuropathic pain Pain can arise in two different ways: Nociceptive pain - injury to body tissues which is transmitted to the brain by nerves Neuropathic - direct damage to the nerves that transmit pain signals

Nociceptive pain results from actual damage to tissues. There are two sub-types: somatic pain and visceral pain.

Somatic pain involves injury to skin, joints, bones, or muscle. Patients commonly describe somatic pain as: Throbbing Aching Dull Pressure Sharp.

Somatic pain is very localized, meaning the patient can point to the spot that hurts.

Visceral pain is another kind of nociceptive pain. It involves damage or obstruction in the larger organs and it is generally difficult to localize. Visceral pain may be described as: Cramping Gnawing.

It may also be described similarly to somatic pain.

Neuropathic pain Neuropathic pain comes from damage to the nerves that transmit pain signals. This can make areas more sensitive or result in pain that occurs suddenly with no warning. Patients commonly describe neuropathic pain as: Burning Shooting Tingling Numbing Heavy.

Examples of neuropathic pain include such conditions as "phantom-limb syndrome," which occurs when a limb has been amputated but the brain still receives pain impulses from it, or diabetes related nerve damage, which can make it feel as though one is walking on nails. Neuropathic pain may not respond well to traditional pain treatments.

Annual Mandatory Education—Professional Nurse

Effects of pain Every patient has the right to adequate pain control. In addition to discomfort, lack of pain relief can affect: Immune system function Activities of daily living, such as sleep, nutrition, and mobility Ability to work Length of hospital stay.

Chronic pain and cancer pain can cause the most serious problems by: Interfering with the patient's lifestyle and activities Reducing the patient's quality of life Wearing the patient down Causing the patient to give up hope Causing the patient to consider suicide.

Myths about pain There are many MYTHS about pain. These can have a negative influence on effective pain management.

One common MYTH is that pain medication (especially opioids like morphine, Demerol, or codeine) should not be used for long-term illness until there is no other choice, because they are addictive. This may mean, for example, that an opioid medicine may not be ordered for someone with cancer pain until the patient is dying, in order to prevent addiction. In some cases, pain medication may be withheld even at the end of life, because of side effects.

Other common MYTHS are: Chronic pain cannot be managed Sleep is a sign that a patient has no pain Pain in the absence of obvious injury or other factors is a sign of serious illness People of certain ethnic or cultural backgrounds will over-report pain and other groups will under-report pain Someone in pain will always have changes in vital signs.

Assessment of Pain

When to assess pain Pain is now considered the fifth vital sign. As with the traditional vital signs, steps must be taken to correct the situation when assessment shows something wrong.

Every patient has the right to effective pain management. Treatment of pain is also important to the patient's recovery. Uncontrolled pain can: Lengthen the patient's hospital stay Copyright 2015, Cross Country University Page 215 of 284, Pain Management

Annual Mandatory Education—Professional Nurse

Decrease the patient's activity level Cause the patient's body unnecessary stress.

Like the other vital signs, pain needs to be assessed at certain times during treatment. This should begin when the patient is first admitted. After admission, follow-up pain assessments should take place: At regular intervals After any intervention to decrease pain (to find out if the intervention helped) At discharge.

The Joint Commission (TJC) has standards for the assessment and management of pain. Under TJC standards: All patients are screened for pain when admitted Patients are re-assessed regularly for pain Patients are taught about pain control Patients are given discharge instructions about pain management.

Physical signs of pain There are a number of physical signs that can show that someone may be in pain. Physical signs include: Grimacing Crying Moaning Tension Withdrawal Restlessness Guarded movements Rubbing area of pain.

Increased pulse, respirations, and blood pressure may also be signs of pain. These may not be accurate signs, however, so they should only be used when the patient is not able to report pain verbally.

Record any physical signs you see, as well as the patient's report of any pain. This will help you and other staff to be alert for the signs later. Remember that every patient experiences pain differently. Any signs you observe apply only to that patient.

How to assess pain Even though there may be some physical signs, the best indication of pain is what the patient says.

To assess pain, your facility has a pain assessment tool. The tool will have some kind of a rating scale. For example, it might ask patients to rate their pain on a scale from 1 to 10, with 1 being no pain and 10 being the worst pain imaginable. Some facilities use a graphic scale with faces that range from a smiley

Annual Mandatory Education—Professional Nurse

face to one with a big grimace of severe pain. You need to become familiar with the assessment tool your facility uses.

When a patient does report pain, you need to know the following information: Onset: When did the pain begin? Duration: Is the pain continuous, or does it come and go? If the pain is not continuous, how long does it last? Location: Where does it hurt? Description: What kind of pain is it (for example: burning, stabbing, cramping, aching, biting, dull, sharp, and gnawing)? Severity: How severe is the pain (using your facility's pain assessment tool)? What kinds of things make the pain worse? Is the pain associated with any particular activity (for example: eating)? Relief: Does anything relieve the pain and, if so, for how long? What prescribed or over-the- counter medications (including dosage and frequency) has the patient taken to relieve the pain? Effects: How does the pain interfere with the patient's normal activities of daily living?

In addition to assessing patients for pain, you should discuss your facility's policy regarding pain control. Explain to the patient and family the facility's commitment to pain management, and tell them whom to notify if: The patient experiences pain The pain is not relieved after an intervention.

Pain scales for pre- and non-verbal patients Most organizations employ one or more of a variety of visual pain scales. The patient can identify the severity of pain by indicating its location on a continuum.

Annual Mandatory Education—Professional Nurse

Management of Pain

Pain management concepts Pain management decisions are not made by healthcare professionals alone. Patients and families are also involved in the process. Opportunities should be provided for patients and families to discuss: The pain experience Expectations and beliefs about pain Effectiveness of pain management interventions.

When developing a pain management strategy, it is important to anticipate the patient's pain needs and to take a preventive approach. This is especially true when the patient is undergoing procedures that are known to be painful, such as surgery.

It is also important to recognize that pain can increase because of: Social and emotional factors Changes in disease state.

Remember: It is easier to manage pain BEFORE it becomes severe.

A preventive approach to pain management can help to minimize stress on the patient and family. This approach also reduces problems associated with poor pain management, such as: Longer hospital stay Reduced mobility Increased stress on immune system Decreased energy reserves.

Pain is a unique experience for each individual, and pain management strategies should be designed to meet the needs of each individual patient. Patient education is also an important part of the process. Effective pain management includes: Involving patients and families in all pain management decisions Explaining how the treatment plan works and what kinds of things the patient should report Rejecting MYTHS about opioid use and fears of addiction Informing the patient and family of the facility's commitment to pain relief and how to get help if needed Teaching the patient about continuing pain management as a part of the discharge process.

Types of interventions Pain control measures must be selected to meet the individual needs of each patient. This requires an assessment of the pain and an assessment of the effectiveness of previous interventions.

Annual Mandatory Education—Professional Nurse

Pharmacological interventions Non-pharmacological interventions

Pharmacological interventions are pain control methods that use medications. These include: 1. Opioids, such as morphine and codeine 2. Non-opioids, such as acetaminophen 3. Adjuvants, a variety of drug types that are usually used to supplement opioids or non-opioids.

Non-pharmacological interventions are alternative measures that do not use drugs. The methods that are selected will depend on the needs of the patient. Non-pharmacological pain management methods include: Relaxation and distraction techniques Physical interventions.

Relaxation and distraction techniques These techniques work best if they are practiced before they are needed for pain relief. They include: Deep breathing (with focus on breathing techniques) Listening to music Guided imagery Biofeedback Hypnosis.

Physical Interventions Physical interventions that can help in the treatment of pain include: Massage Exercise (especially for chronic pain) Application of heat or cold (not longer than 20 minutes; be careful of extremes of heat or cold that could damage tissue) Acupuncture Position change TENS unit (trans-electrical nerve stimulation therapy).

A TENS unit controls pain by stimulating the nerves at the pain location and helping to block pain signals. A mechanism of action of acupuncture has not been determined. There is no evidence for the “energy fields” mechanism commonly described, and much evidence against its existence. The effect may simply be placebo, but in any case, many patients report pain relief with acupuncture and it is widely accepted as a legitimate physical intervention for pain.

Non-opioid medications When using drugs to control pain, the best strategy is to use the least strong drug which still gives adequate pain relief. If the intervention does not relieve the pain, it may require: Copyright 2015, Cross Country University Page 219 of 284, Pain Management

Annual Mandatory Education—Professional Nurse

An increase in dosage An increase in frequency An increase to the next level of drug.

Usually, pain control measures begin with non-opioid (non-narcotic) drugs. Non-opioids, such as acetaminophen (Tylenol) are generally available in both over-the-counter and prescription strengths. Non-opioids are usually taken orally or by suppository. The most common side effect of acetaminophen is hepatotoxicity (liver involvement). This is most common with an overdose.

Non-opioids also include NSAIDS (non-steroidal anti-inflammatories), such as Advil and Motrin. These may also be used in combination with opioids. The most common side effects of NSAIDS are: Gastric irritation Prolonged bleeding time.

Opioids and adjuvants The name, opioids, refers to drugs that are based on opium. They can be either natural or synthetic. Opioids are used for moderate to severe pain.

Pure agonists One class of opioids, known as "pure agonists", which refers to their specific mechanism for pain relief, includes: Morphine Hydromorphone (Dilaudid) Fentanyl Codeine.

Increased dosage of pure agonists provides increased analgesia (pain relief) and increased side effects. Side effects include: Euphoria Sedation Constipation Nausea Vomiting Itching Urinary retention Hypotension Respiratory distress.

Over time, patients may develop a tolerance for opioids, meaning they require higher dosages to achieve the same pain relief. However, the usual reason for increasing dose is because of disease progression. Patients who have received opioids for a long period of time may experience withdrawal Copyright 2015, Cross Country University Page 220 of 284, Pain Management

Annual Mandatory Education—Professional Nurse

when the drug is stopped. This means that patients should not be taken off the drug suddenly but should gradually decrease the drug level over several days.

There are two important things to remember about opioids and other pain drugs: Drug-seeking behavior is NOT a sign of addiction. Drug-seeking behavior IS a sign of inadequate pain relief.

Other opioids Other types of opioids, nalbuphine (Nubain) and butorphanol (Stadol), provide less analgesia, but also fewer side effects. There is also a limit to their effectiveness. After a point, higher doses do not increase analgesia. These drugs are sometimes used to reverse analgesia and side-effects caused by pure agonists.

Administration of opioids Opioids can be given orally. As pain level increase, they are administered in other ways which deliver a higher level of pain relief: Sublingually (under the tongue) Bucally (placed in the cheek area if patient unable to swallow) Dermal patch (for continuous release) Intravenous (IV) by continuous infusion or intermittent dosage Patient-controlled analgesia (PCA) using intravenous delivery Intramuscular or subcutaneous injection Suppository.

Adjuvants Other drugs that may help in pain control are called adjuvants. These include: Corticosteriods Antidepressants Local anesthetics Anticonvulsants.

These drugs are used to: Enhance the effectiveness of a primary analgesic Limit the side effects of a primary analgesic (usually an opioid) Treat concurrent symptoms that increase pain Provide analgesia for certain types of pain that are not relieved by opioids.

End of Pain Management Lesson

Annual Mandatory Education—Professional Nurse

Patient Rights and Responsibilities

The Patients’ Bill of Rights

The purpose of the Patients' Bill of Rights is to promote and assure healthcare quality and value, and support consumers and workers in the healthcare system. The seven areas of rights and responsibilities in the Bill of Rights are: Information disclosure Choice of providers and plans Access to emergency services Participation in treatment decisions Respect and nondiscrimination Confidentiality of health information Complaints and appeals

The seven areas of rights and responsibilities in the Bill of Rights are:

1. Information disclosure Patients have the right to receive accurate and easily understood information about their health plan, the healthcare professionals, and facilities. If patients speak another language, have a physical or mental disability, or do not understand something, assistance will be provided to help them make informed healthcare decisions.

2. Choice of providers and plans Patients have the right to a choice of healthcare providers that so that they have access to appropriate high-quality health care.

3. Access to emergency services Patients who have severe pain, injury, or sudden illness that convinces them that their health is in serious jeopardy, have the right to receive emergency services for screening and stabilization whenever and wherever needed, without prior authorization or financial penalty.

4. Participation in treatment decisions Patients have the right to know treatment options and to participate in decisions about their care. Parents, guardians, family members, or other individuals can represent patients if they cannot make their own decisions.

5. Respect and nondiscrimination Patients have a right to considerate, respectful and nondiscriminatory care from their doctors, health plan representatives, and other healthcare providers.

Annual Mandatory Education—Professional Nurse

6. Confidentiality of health information Patients have the right to talk in confidence with healthcare providers and to have their healthcare information protected. They also have the right to review and copy their own medical records and request that their physician amend their records in the case of error or misunderstanding.

7. Complaints and appeals Patients have the right to a fair, fast, and objective review of differences with their health plan, doctors, other personnel, or the hospital. This includes complaints about waiting times, operating hours, the conduct of healthcare personnel, and the adequacy of healthcare facilities.

Patient Responsibilities

Patients have rights, but they also have responsibilities. When they enter the healthcare system, they are entering into an agreement that is two-sided. Patients have the right to expect the healthcare system to do its best for them. Patients must also do their best to help the healthcare system provide what is best for them.

Patient Responsibilities include: Providing accurate and complete information to the best of their knowledge about their present conditions, past illnesses, hospitalizations, and medications Sharing concerns and asking for information when they do not understand something Complying with instructions and treatment plans developed with their healthcare teams Accepting responsibility for outcomes if treatment is refused or instructions are not followed Being aware of financial obligations and understanding the requirements of their insurance carriers and the limitations of their insurance policies Complying with the rules and regulations of the organization Being considerate of the rights of others.

Your role in helping patients to meet their responsibilities Although patients have responsibilities, the organization also has an obligation to help them understand and meet their responsibilities. There are several ways healthcare workers do this: You must be sure patients understand that giving the facility false or incomplete information may result in inaccurate care and could be harmful. For example, if a patient has a history of using drugs and does not share that information, the patient might receive inadequate or incorrect anesthesia or pain medication. You must do whatever is necessary to make patients understand everything they need to know about their care, their condition, and their instructions for treatment. You must be sure patients understand the consequences of refusing treatment or not following instructions. Although they have the right to do so at any time, they must be aware that refusing treatment continually negates the reason for being in the hospital.

Annual Mandatory Education—Professional Nurse

You must provide patients with full explanations of recommended treatments, reasons for giving treatments, potential benefits of receiving treatments, and risks of refusing treatments. For example, if cancer patients refuse to accept chemotherapy treatments, they must be made to realize that although there are risks associated with treatment, there are also risks associated with not accepting treatment and the disease may progress without it. You must let patients know that they have to provide accurate information about insurance coverage and determine if they understand the limits of their policies. They must be made aware that they are responsible for procedures not covered by their insurance company. You may not only have to inform patients and their visitors of hospital rules and regulations, but you may also have to enforce the rules and regulations. For example, visitors may have to be told that visiting hours are over and they must leave the hospital. You may have to tell patients that they must respect the rights of other patients. For example, if they are playing music too loudly and it is disturbing others, you may have to tell them to lower the volume.

End of Patient Rights Lesson

Patient Transfers and Body Mechanics

Bed to Chair Transfer

Safe practice when performing transfers Research shows that injuries to healthcare workers happen most often during patient transfers. In fact, more than one third of workplace injuries in hospitals and nursing homes occur when staff try to move patients. Most of these are injuries to the back.

The back is the main support structure for the body. It carries most of the body's weight, and it is the main pathway for the nervous system. The backbone, or spine, is a column of small bones called "vertebrae." Between each pair of vertebrae is a cushion-like pad called a "disc," which acts as a shock absorber. The vertebrae and discs are supported by ligaments and muscles.

A healthy spine has three natural curves. These natural curves form an S-shape when your back is properly aligned. You know your back is properly aligned when your ears, shoulders, and hips are in a straight line. We often refer to this as good posture.

Anything that forces the back out of its natural S-shape can strain muscles and damage discs. Back problems and pain are almost certain to follow.

Healthcare professionals often perform physically demanding tasks with patients. Following proper transfer techniques can help you to maintain a healthy back and to: 1. Work more efficiently and comfortably Copyright 2015, Cross Country University Page 224 of 284, Patient Transfers and Body Mechanics

Annual Mandatory Education—Professional Nurse

2. Minimize lost time from work with costly and painful injuries 3. Increase patient satisfaction by providing good, consistent care.

Patient assessment Before transferring a patient from a bed to a wheelchair or chair, it is important to assess the situation. How much can the patient help?

The answers to 3 questions will help you to decide how much the patient can assist and what method of transfer should be used: 1. Is the patient cooperative? 2. Can the patient support his or her own weight? 3. Is the patient too heavy to transfer alone?

Is the patient cooperative? Assessing whether patients are cooperative means deciding if they have the awareness to assist you. This may include considerations such as: 1. Are they sedated? 2. Are they weak or dizzy? 3. Are they able to follow simple directions?

If the patient is not able to understand the process or to cooperate, a lifting aid is recommended.

Can the patient support his or her own weight? If the patients is able to support his/her own weight, assistance from an employee may not be needed. The patient may be able move from the bed to a chair or wheelchair without help. You should only stand by for safety as needed.

If patients are able to partially support their own weight, assistance will be necessary. This may involve a stand and pivot technique and may include the use of a transfer belt. Sometimes, patients who cannot bear weight on their legs may have upper body strength. In such cases, transfer may be assisted with a transfer belt until the patient learns to move independently.

Remember that a manual transfer is intended to assist, NOT lift a patient. For patients who cannot help to support their weight, a mechanical lifting aid is recommended. However, you should not use a mechanical lifting aid, such as a hoist, unless you have been trained to do so. Improper use or malfunction of a lifting aid can cause serious injury or death.

Is the patient too heavy to transfer alone? Avoid injury to the patient and to yourself. If the patient is heavy, two people should assist in the transfer. This does not mean a patient is overweight. Some sources suggest that a lifting hoist should be used for patients over 154 pounds.

Annual Mandatory Education—Professional Nurse

The transfer belt A number of aids are available to help you to transfer patients safely. One frequently-used aid is the transfer belt.

A transfer belt is placed around the patient's waist and secured snugly. The belt can be adjusted to fit different patients and usually fastens with Velcro and a buckle. If the transfer belt has loops, hold these loops to support the patient more firmly during transfer; if the belt does not have loops, hold onto the belt itself. You should use a transfer belt with patients who can partially support their own weight but need assistance.

Transfer belts enable employees to grip patients more firmly and control their movement during transfer.

Studies show that using a transfer belt increases patient satisfaction. Lifting patients manually without a transfer belt may cause the patient discomfort under the arms. Patients also prefer the transfer belt because they feel more secure. The belt gives the employee the ability to better control the patient's movement during a transfer.

A transfer belt should not be used with some patients. These include: Pregnant patients Patients who have undergone recent abdominal surgery Patients who are experiencing pain in the abdomen Patients who have ostomies (such as a colostomy, ureterostomy, iliostomy) Patients who are unable to tolerate the pressure of the belt.

Remember that a transfer belt is to assist in the transfer of a patient. It is NOT intended to lift a patient.

Annual Mandatory Education—Professional Nurse

Sit-to-stand pivot transfer A common technique for helping a patient to move from a bed to a wheelchair or chair is the "Sit to Stand Pivot Transfer."

Before transferring a patient from a bed to a chair or wheelchair: Explain the process to the patient Position the chair at the head of the bed on the patient's strong side (if applicable) and remove any obstacles Lock any wheels on the chair and bed If transferring to a wheelchair, remove the arm nearest the bed and remove the leg rests or swing them out of the way Adjust bed height so that the patient's hips will be slightly above the knees with the feet flat on the floor Make sure that the floor is dry and that both you and the patient are wearing non-slippery footwear Apply a transfer belt to the patient's waist.

The transfer itself is a simple process of standing the patient up, pivoting, and sitting the patient down. To perform this transfer, carry out the following steps: Stand close to the patient to avoid leaning or over-reaching and place your foot that is closer to the head of the bed on the floor between the patient's legs. Reach around the patient's waist and grip the transfer belt. Ask the patient to push against the bed with the arms and to stand with you on the count of 3. Using a rocking motion, count to 3, and then stand the patient up. Holding the patient close to your body, pivot on the foot between the patient's legs until the backs of the patients' legs touch the front of the chair. With your knees bent, lower the patient into the chair using the transfer belt. Throughout the process, ensure that your back is properly aligned with your ears, shoulders, and hips in a vertical line.

Annual Mandatory Education—Professional Nurse

When performing this transfer, if patients wish to hold on to you for support, ask them to hold on to your upper arms, forearms, or waist. Never allow a patient to hold on to your neck. If you are concerned that a patient may grab your neck, you may grip the transfer belt by placing your arms around the patient's arms.

If a second employee is available to help with the transfer, a similar process is used. The second employee should be behind the patient with one knee on the bed. The second employee grips the transfer belt from the back. The first employee uses a gentle rocking motion to stand the patient up. As soon as the patient clears the bed, the second employee shifts the patient to the chair.

Bed to Stretcher Transfer

Safe practice when performing lateral transfers Healthcare is a physically demanding occupation. In fact, the nursing profession has one of the highest rates of work-related back injuries. Many of these injuries occur during patient transfers.

Annual Mandatory Education—Professional Nurse

Reposition in bed.

It is important to follow proper transfer techniques to reduce the chance of injury. In addition, whenever you move a patient or lift, push, or pull an object, it is important to use good body mechanics. Even a light load can cause lower back strain if poor body mechanics are used.

Using good body mechanics includes keeping your back in proper alignment. To maintain the back's natural S-shape, keep the ears, shoulders, and hips in a straight line. When bending forward, this straight line is maintained by bending at the hips, not the waist.

In addition to back injuries, there are other risks to both patients and employees from improper transfer techniques. These risks might include falls, dislocation, and shoulder strain to name a few.

Types of lateral sliding aids A lateral transfer is the movement of a patient, who is in a lying down position, from one flat surface to another. One example of a lateral transfer is a transfer from bed to stretcher.

There are many types of aids available to make the process of a manual lateral transfer easier. A sliding aid should always be used when performing a lateral transfer. Lateral sliding aids include draw sheets, transfer pads, and transfer boards.

Annual Mandatory Education—Professional Nurse

Types of lateral sliding aids

Draw sheets A draw sheet or any short sheet can be used as a sliding aid. There are also specially designed roller sheets. These are made of special fabrics that have low-friction inner surfaces. The layers of fabric roll or slide over one another during the patient transfer.

Transfer pads Various types of pads are also available. These may be quilted pads with pull straps and a roller sheet underneath. The pads may also come with slats that can be used to bridge small gaps between surfaces.

Transfer boards Transfer boards are also used. These may use various low-friction or roller technologies so that the patient can be pulled across easily.

Annual Mandatory Education—Professional Nurse

Performing a lateral transfer Before transferring a patient from a bed to a stretcher, it is important to assess the situation. How much can the patient help?

If a patient is able to move from the bed to stretcher without help, you should only stand by for safety as needed.

If a patient can assist only partially or not at all, a lateral transfer will need to be done. Two employees should always participate in a lateral transfer and a lateral sliding aid should be used. If the patient is very heavy, three employees should assist or a mechanical transfer device should be used. You should not use any mechanical devices, however, if you have not been trained to use them.

One common method of lateral transfer involves the use of a draw sheet or short sheet. Before transferring a patient from a bed to a stretcher using a draw sheet: Explain the process to the patient Position the stretcher alongside the bed Adjust the height of the bed and stretcher so that they are level Lock wheels on both the bed and stretcher If there is not already a draw sheet in place, position the draw sheet or short sheet beneath the patient in the same manner that you would do so when changing an occupied bed.

To transfer a patient using a draw sheet or other short sheet: Roll up the sides of the sheet next to the sides of the patient One employee stand at one side of the patient Another employee stand at the other side of the stretcher Each employee hold the rolled up sheet close to the patient's body Use the sheet to move the patient onto the stretcher Both healthcare workers should maintain correct alignment of the back throughout the process.

Annual Mandatory Education—Professional Nurse

Other sliding aids can also be used to transfer a patient from a bed to stretcher. Whatever type of aid is used, always remember to: Follow any procedures established by your facility Become familiar with the type of sliding aids available Make sure there is enough space to perform the transfer Remove any obstacles Keep your center of gravity as near the patient as possible Eliminate reaching and twisting Raise the bed to a comfortable height whenever possible Apply brakes on both bed and stretcher Clean the sliding aid between uses to prevent infection.

Ambulating with the Patient

Safe practice when ambulating with the patient| Your back is very important. It provides balance and support to your whole body. Suffering a back injury can have a serious impact on the way you live and on the things you can do.

When ambulating with a patient, you walk beside the patient and provide assistance. If you are ambulating with a patient, performing a transfer, or doing any other job that requires lifting, follow these guidelines to help maintain a healthy back: Maintain the back's natural curves by keeping the ears, shoulders, and hips aligned. Lift and lower with your legs, not your back. Keep the weight close to your body. Bend at the hips, not the waist. Avoid twisting or turning the upper body when carrying or lifting. Copyright 2015, Cross Country University Page 232 of 284, Patient Transfers and Body Mechanics

Annual Mandatory Education—Professional Nurse

Explain what you are doing to patients and other employees who are participating. Make sure that both you and the patient are wearing non-slip footwear. Be sure the floor is dry and obstacles are removed. Get assistance whenever possible.

Other factors that can help to maintain a healthy back include: Eating a proper diet Exercising regularly Reducing stress Removing hazards.

Preparing to ambulate safely Every time you prepare to move a patient, you should assess the situation. You need to know how much the patient can help and what other assistance you might need.

For example, a patient who has suffered a stroke may be much stronger on one side than the other. In this case, it will be important to support the patient's weak side by walking on that side of the patient.

If the patient is unstable, dizzy, or confused, you may need additional assistance. This may include the help of another employee or the use of a transfer belt.

It is also important to prepare the area before ambulating with the patient. Make sure that the room is not cluttered and remove any obstacles. A cluttered room increases the chances of trips or falls.

You should also be aware that a small room, such as a bathroom, may restrict your movements. Think about how you will deal with such spaces before you get there.

Walking with the patient When ambulating, or walking, with a patient, you may sometimes wish to use a transfer belt. A transfer belt, or gait belt, is fitted snugly around the patient's waist. The belt is simple to apply and provides a secure grip to assist the employee in transferring or walking with a patient. Some belts have loops that can be used like handles to give a better grip.

One employee may ambulate safely with patients who need some help walking, but are reasonably stable. If one side is weaker than the other, support the patient's weak side by walking on that side. Support the patient by: Using one hand to support the patient's elbow Placing an arm around the patient's shoulder Gripping a transfer belt around the patient's waist.

Annual Mandatory Education—Professional Nurse

Two employees should participate if patients are unstable or confused. To ambulate a patient safely with 2 employees: 1. Ask the patient to sit on the side of the bed 2. Apply the transfer belt 3. Stand the patient up (as if starting a sit-to-stand pivot transfer) 4. Two employees stand on either side of the patient 5. Place your arm round the patient's back and hold the transfer belt on the far side of the patient 6. Walk with the patient.

If patients are not used to getting up, allow them to sit on the side of the bed for a few minutes before standing. This can help to prevent dizziness.

If the patient begins to fall, DO NOT try to stop the fall. Instead, ease the patient down gently. Provide support, bending your knees not using your back, and guide the patient to the floor. Do not try to get the patient up off the floor by yourself.

A transfer belt is not intended to lift a patient. You are also not in a position to maintain good body mechanics and support the patient's entire weight. Trying to hold the patient up could cause serious injury to both the caregiver and the patient.

End of Patient Transfers and Body Mechanics Lesson

Annual Mandatory Education—Professional Nurse

Population Served Becoming Knowledgeable about the Patients You Care for

Background This module is intended to raise awareness of The Joint Commission’s (TJC) requirement that training and orientation for healthcare professionals (HCPs) be relevant to the populations they served, and to place the Caregiver Safety Series in that context.

This terminology, ‘population served’, can be seen as a maturation of the TJC’s earlier campaign to integrate age-specific care into facilities’ orientation programming. HCPs care for people all across the lifespan, and quality care and the assurance of patient safety depend on that knowledge. It is obvious that many other issues are as vital as age and developmental stage to quality care and patient safety.

In addition to age and transcultural issues, the concept of population served incorporates broader demographic data, morbidity, socioeconomic status, and access (and barriers) to care. Population served is a concept that encompasses the nature of the people and families and even of the region served by the healthcare facility.

Naturally, as a program intended for Cross Country travelers and per diems (or HCPs employed by Cross Country allies), our orientation materials must necessarily be from a high-altitude, national, and generic point of view. As a result, there are two primary aims of this module:

1. Provide the knowledge and point of view you will utilize in your study of the Caregiver Safety Series.

As you complete the various components of the training, please focus on, and look for, the special relevance of those components to the patients for whom you will be caring at your next assignment.

2. Provide the knowledge and tools you will utilize in your own investigations and discussions about population served prior to, and after, arrival at your assignment.

In preparation for your assignment, please try out some of the suggested methods below that will enable you to gain as much information as possible about the demographics and health issues of the population for whom you will be caring.

Regional differences in populations Each healthcare facility serves a unique population that differs from the population served by other facilities in a variety of ways.

Social Explorer at http://www.socialexplorer.com/pub/home/home.aspx displays graphic versions of US Census Data that demonstrate how populations trend in different regions.

Annual Mandatory Education—Professional Nurse

The map below shows the median age for different areas of the country; darker areas have a higher median age than lighter areas.

The following map shows concentrations of members of the Muslim religion in the United States. Darker areas have higher concentrations.

Health data is a bit harder to find than census data, but the Centers for Disease Control provides a wealth of data to the public on national and regional health issues and trends.

One excellent publication is the Health United States publication:

Annual Mandatory Education—Professional Nurse

http://www.cdc.gov/nchs/data/hus/hus07.pdf#listfigures

The following section will provide some tools and suggestions for identifying local and regional demographic and health information.

Identifying the Population Served

Sample investigation: Broward County While it may be difficult to research a particular facility’s population prior to an assignment, the nature of that facility’s population can be easily investigated. For example, if your next assignment was at a hospital in Broward County, Florida, here are some of the steps you might take to get a feel for the population served by your facility.

Regional demographic data The US Census Bureau provides an excellent summary of state and county statistics at the following address: http://quickfacts.census.gov/qfd/

Annual Mandatory Education—Professional Nurse

The above page is easy to use. Clicking on a state or selecting a state from the drop-down box results in a long list of state statistics and the ability to select cities or counties in that state. Here’s the result for Broward County:

Broward County, Florida Further information Want more? Browse data sets for Broward County Broward People QuickFacts County Florida Population, 2007 estimate 1,759,591 18,251,243 Population, percent change, April 1, 2000 to July 1, 2007 8.4% 14.2% Population, 2000 1,623,018 15,982,378 Persons under 5 years old, percent, 2007 6.5% 6.3% Persons under 18 years old, percent, 2007 23.6% 22.2% Persons 65 years old and over, percent, 2007 14.3% 17.0% Female persons, percent, 2007 51.4% 50.9%

White persons, percent, 2007 (a) 69.6% 80.0% Black persons, percent, 2007 (a) 25.3% 15.9% American Indian and Alaska Native persons, percent, 2007 (a) 0.4% 0.5% Asian persons, percent, 2007 (a) 3.0% 2.3% Native Hawaiian and Other Pacific Islander, percent, 2007 (a) 0.2% 0.1% Persons reporting two or more races, percent, 2007 1.4% 1.3% Persons of Hispanic or Latino origin, percent, 2007 (b) 23.4% 20.6% White persons not Hispanic, percent, 2007 48.1% 60.8%

Living in same house in 1995 and 2000, pct 5 yrs old & over 47.1% 48.9% Foreign born persons, percent, 2000 25.3% 16.7% Language other than English spoken at home, pct age 5+, 2000 28.8% 23.1% High school graduates, percent of persons age 25+, 2000 82.0% 79.9% Bachelor's degree or higher, pct of persons age 25+, 2000 24.5% 22.3% Persons with a disability, age 5+, 2000 310,454 3,274,566 Mean travel time to work (minutes), workers age 16+, 2000 27.4 26.2

Housing units, 2007 803,064 8,718,385 Homeownership rate, 2000 69.5% 70.1% Housing units in multi-unit structures, percent, 2000 47.5% 29.9% Median value of owner-occupied housing units, 2000 $128,600 $105,500

Annual Mandatory Education—Professional Nurse

Median household income, 2007 $52,504 $47,804 Per capita money income, 1999 $23,170 $21,557 Persons below poverty, percent, 2007 11.4% 12.1%

Note the link at the top of the page to “Browse data sets for Broward County.” Clicking that link will produce, among many interesting tables, a “Profile of General Demographic Characteristics: 2000.”

SEX AND AGE Male 783,232 48.3 Female 839,786 51.7

Under 5 years 103,041 6.3 5 to 9 years 110,142 6.8 10 to 14 years 109,132 6.7 15 to 19 years 95,161 5.9 20 to 24 years 82,834 5.1 25 to 34 years 230,864 14.2 35 to 44 years 278,547 17.2 45 to 54 years 215,086 13.3 55 to 59 years 76,548 4.7 60 to 64 years 60,554 3.7 65 to 74 years 116,641 7.2 75 to 84 years 101,417 6.2 85 years and over 43,051 2.7

Median age (years) 37.8 (X)

18 years and over 1,240,089 76.4 Male 586,807 36.2 Female 653,282 40.3 21 years and over 1,189,386 73.3 62 years and over 296,169 18.2 65 years and over 261,109 16.1 Male 105,784 6.5 Female 155,325 9.6

RACE One race 1,568,597 96.6 White 1,145,287 70.6 Black or African American 333,304 20.5 American Indian and Alaska Native 3,867 0.2 Asian 36,581 2.3 Asian Indian 14,217 0.9 Chinese 8,230 0.5 Filipino 4,314 0.3 Japanese 989 0.1 Korean 2,256 0.1 Vietnamese 2,697 0.2 Other Asian 1 3,878 0.2 Native Hawaiian and Other Pacific Islander 916 0.1 Native Hawaiian 202 0.0 Guamanian or Chamorro 154 0.0 Samoan 130 0.0 Other Pacific Islander 2 430 0.0 Some other race 48,642 3.0 Two or more races 54,421 3.4

Annual Mandatory Education—Professional Nurse

Race alone or in combination with one or more other races 3 White 1,175,608 72.4 Black or African American 360,611 22.2 American Indian and Alaska Native 8,140 0.5 Asian 45,601 2.8 Native Hawaiian and Other Pacific Islander 3,086 0.2 Some other race 86,944 5.4

HISPANIC OR LATINO AND RACE Total population 1,623,018 100.0 Hispanic or Latino (of any race) 271,652 16.7 Mexican 19,451 1.2 Puerto Rican 54,938 3.4 Cuban 50,911 3.1 Other Hispanic or Latino 146,352 9.0 Not Hispanic or Latino 1,351,366 83.3 White alone 941,674 58.0

RELATIONSHIP Total population 1,623,018 100.0 In households 1,603,094 98.8 Householder 654,445 40.3 Spouse 301,745 18.6 Child 445,172 27.4 Own child under 18 years 341,255 21.0 Other relatives 103,814 6.4 Under 18 years 33,751 2.1 Nonrelatives 97,918 6.0 Unmarried partner 41,638 2.6 In group quarters 19,924 1.2 Institutionalized population 13,063 0.8 Noninstitutionalized population 6,861 0.4

HOUSEHOLDS BY TYPE Total households 654,445 100.0 Family households (families) 411,403 62.9 With own children under 18 years 191,804 29.3 Married-couple family 301,745 46.1 With own children under 18 years 131,559 20.1 Female householder, no husband present 81,818 12.5 With own children under 18 years 47,190 7.2 Nonfamily households 243,042 37.1 Householder living alone 193,701 29.6 Householder 65 years and over 81,408 12.4

Households with individuals under 18 years 210,779 32.2 Households with individuals 65 years and over 188,789 28.8

With just a few clicks, it is possible to view age, ethnicity, income, income, disability status, health insurance coverage, and many other key demographics that help develop a picture of the population served by Broward County hospitals.

Regional health data The Centers for Disease Control is an excellent source of health date. Their DATA2010 website is easy to

Annual Mandatory Education—Professional Nurse

use and provides a state by state breakdown for diseases by age and other demographics. http://wonder.cdc.gov/data2010/

Though not county specific, here’s a screenshot of the tiny portion of the data set that was displayed by selecting the years 1999 through 2005 for people 65 and older:

Data shown include diabetes-related deaths for that age group as well as rates of flu and pneumonia vaccinations.

Numerous diseases, conditions, and healthcare structural issues (such as access to care) can all be investigated at this site.

Annual Mandatory Education—Professional Nurse

In looking for closely at local health concerns, it is usually possible to find that information at the local health department. A few minutes browsing the Broward County Health Department website gives a nice appreciation for that area’s health issues and concerns. Here is a site map from that website, http://browardchd.org/Services/Administration/SiteMap.htm#Disease : Copyright 2015, Cross Country University Page 242 of 284, Population Served

Annual Mandatory Education—Professional Nurse

Children • Chicken Pox • Diarrhea • Drowning Prevention • Head Lice • Immunization Schedule Clinics • Fort Lauderdale • Hollywood • Plantation • Pompano • Dental • Family Planning • Flu • Hepatitis • HIV • Immunization • Northwest Health Center • Pregnancy Prevention • Refugee • Sexually Transmitted Disease • Teen • Travel • Tuberculosis • Women Infants Children: WIC Disease • Chlamydia • Cold or Flu? • Encephalitis • Gonorrhea • Hepatitis A • Hepatitis B • Hepatitis C • Influenza: the Flu • Meningitis • Pneumonia • Rabies • Salmonellosis • Scombroid • Shingellosis

Annual Mandatory Education—Professional Nurse

• West Nile Virus *108KB • Many More from DOH Emergency • Cities Readiness Initiative • CRI Minutes • Emergency Operations • Emergency Information • Emergency Training Health • Boil Water Orders Breast Cancer • Certification • Cervical Cancer • Flood & Disinfection of Wells • Food Storage • Heat Stroke • High Blood Pressure *28KB • Home Water Filter • Household Flies & Disease *48KB • Mold • Practitioner License Review Hurricane • Broward County Emergency • Family Preparedness *274KB • Home Disaster Safety • National Hurricane Center • Weather Other • Complaints • Coping With Trauma • Data & Statistics • Domestic Violence Awareness • External Resources Safety • Beach Conditions • Fireworks Lead Poisoning • Mercury Fact Sheet & Clean up Guidance • Radon • Sharps Disposal Seniors

Annual Mandatory Education—Professional Nurse

• Assistance & Information HIV Intervention Project: SHIP • Reporting Abuse • Retiring to Florida Services • AIDS & HIV • AIDS in Seniors (SHIP) • Birth Certificates • Body Piercing Class • Cancer • Communicable Diseases/Events • Death Certificates • Dental • Environmental Health • Health Education • Immunization • KidCare • Medical • Nursing • Nutrition & WIC • Pharmacy • Social Services • Sexually Transmitted Disease • Statistics (AIDS & HIV) • Vital Statistics Teens • Links for Teens • Services

Facility and department specific data Naturally, facility and department information will be hard to investigate prior to assignment. However, the process for identifying the population served is an easy one at this point. Though healthcare facilities collect these data in a formal way, you do not need to ask administration or Risk Management for these studies.

Instead, discuss with your supervisors and department manager(s) the following issues related to your assigned facility and department(s): Facility specific training and orientation materials addressing population served Prevalence of various age groups Types and prevalence of various ethnicities and languages Types and prevalence of the diseases, admission diagnoses, and nursing diagnoses

Annual Mandatory Education—Professional Nurse

Health and healthcare access issues may predominate

The above is just a short list of examples. Start the conversation and see where it leads. Because you have researched the region, you’ll be prepared to hear and understand how local health issues are framed, and already have come armed with a good idea about the major sources of concern for staff, patients, and families.

Hopefully this presentation has demonstrated what is meant by population served and has pointed the way to several sources of data on that population that can be accessed even before arriving at your assignment.

End of Population Served Lesson

Procedural Sedation

Procedural Sedation is defined here as the use of minimal and/or moderate sedation for the purpose of diagnostic and therapeutic interventions (e.g., minor surgery). Minimal and moderate sedation occupy a middle ground in the depth of sedation continuum:

Purposes of procedural sedation Mild Sedation reduces patient anxiety, and as a result, reduces discomfort and enhances compliance. A common example of mild sedation is the preoperative administration of a benzodiazepine for the relief of anxiety.

Moderate sedation reduces anxiety and pain, enhances compliance, maintains stable vital signs, produces amnesia, and speeds recovery when compared to anesthesia.

Deep Sedation produces a decreased level of consciousness to the extent that it enables the patient to experience a painful procedure, but is relatively safer than anesthesia and speeds recovery when compared to anesthesia.

The Depth of Sedation Continuum Awake  Minimal Sedation  Moderate Sedation  Deep Sedation  Anesthesia (From AACN Sedation Guideline, March 2002)

Minimal sedation (anxiolysis) A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.

Moderate sedation/analgesia ("conscious sedation") A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to

Annual Mandatory Education—Professional Nurse

maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

Deep sedation/analgesia A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function maybe impaired. Patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

Anesthesia Consists of general anesthesia and spinal or major regional anesthesia. It does not include local anesthesia. General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.”

For convenience, the following chart summarizes the above information: (Based on American Society of Anesthesiologists Practice Guidelines, 2002) System Minimal Sedation Moderate Sedation Deep Sedation Anesthesia Response to Normal response to Purposeful response to Purposeful response to Unarousable stimulation verbal stimulation verbal or tactile repeated or painful stimulation stimulation Airway Unaffected Adequate May require Intervention required intervention Spontaneous Unaffected Adequate May require Intervention required ventilations intervention Cardiac Unaffected Usually adequate Usually adequate Intervention may be required

Positive and Negative Patient Responses to Procedural Sedation Positive The patient is: Relaxed and cooperative Experiencing reduced pain Conscience or arousable Maintaining stable vital signs Maintaining protective reflexes such as gag, cough, and swallow

Negative The patient is: Unarousable Unable to maintain protective reflexes Exhibiting respiratory and/or cardiovascular compromise Copyright 2015, Cross Country University Page 247 of 284, Procedural Sedation

Annual Mandatory Education—Professional Nurse

Anxious, agitated, or combative In pain

The RN Role in Procedural Sedation Most of the specifics of the RN role regarding Procedural Sedation are state and facility specific and guided by each healthcare entity’s policies and procedures and state practice acts. These site-specific factors about which the RN must be knowledgeable include: The diagnostic and therapeutic procedures for which procedural sedation is employed Emergency equipment and procedures Protocols for oxygen therapy and reversal agents such as Narcan Role and responsibility definitions, competencies, and training for personnel assigned to monitor patients undergoing procedural sedation. Standards for monitoring and documentation

As you might expect, despite the above site-specific examples, there are also broad commonalities to the RN role that are addressed here.

Pre-procedure risk assessment and the ASA The risk assessment generally includes a recent physical exam and medical history that includes the patient’s reactions to any previous experience with sedation. A near-universally accepted risk assessment tool is the American Society of Anesthesiologists (ASA) Classification of Physical Status.

Patients are classified according to their health status as follows: Class I: Healthy, no activity restrictions, not extremely young or extremely old, little to no danger of death

Class II: Mild systemic disease of one body system that is well controlled, some limitations on activity, little to no danger of death

Class III: Severe systemic disease of more than one body system or one major body system that is under control, some limitations of activity, no immediate danger of death

Class IV: Severe systemic disease that is poorly controlled and a constant threat to life, severe activity restrictions, some danger of death

Class V: Not expected to survive 24 hours, patient is incapacitated, death is imminent Patients with an ASA Classification of III or higher are monitored more closely throughout the procedure. In many states, care of these high risk patients must be directed by Physicians and LIPs with certain relevant credentials such as airway management. In addition, the risk threshold is lower for patients at both ends of the age spectrum. There may be additional state practice requirements addressing pediatric and geriatric patients identified as ASA Class III. Copyright 2015, Cross Country University Page 248 of 284, Procedural Sedation

Annual Mandatory Education—Professional Nurse

History and morbidity risk indicators A variety of conditions can complicate procedural sedation, and may involve additional consultation and precautions. These include: Obesity History of difficulties/complications during anesthesia or procedural sedation Sleep apnea and/or airway issues Respiratory or hemodynamic instability Drug allergies Medications with potential for drug interaction with sedatives Current history of substance abuse

Pre-sedation Nursing Assessment Prior to administration of sedation, the RN will likely be the healthcare professional to perform the baseline assessment. Parameters typically include: Vital signs Lung sounds, depth and quality of respirations

O2 Saturation EKG Skin color and warmth, pulses Level of consciousness

Informed consent The RN ensures that informed consent has been obtained. The physician/LIP must obtain the consent. Informed consent must include the name of the procedure, risks, benefits, and potential alternatives.

History and physical The history and physical includes several components relevant to procedural sedation risk. These include:

Cardiovascular status: sedation stresses this body system.

Respiratory status: Procedural sedation often depresses respiration, a serious consequence for patients with chronic lung conditions such as COPD. Oxygen administration is a risk in itself for COPD patients as it may depress respirations and must be carefully titrated. Asthma patients should have their medications available during procedural sedation.

A history of cardiovascular and/or respiratory problems is cause for concern and additional safeguards in monitoring procedural sedation.

Annual Mandatory Education—Professional Nurse

Benzodiazepene use for seizure disorder: Long-term benzodiazepine treatment or abuse is generally a contraindication for procedural sedation. Fumazenil, a reversal agent, could cause seizures.

Liver problems: Since most procedural sedation medications are metabolized in the liver, patients with liver disease may experience resultant deeper and longer sedation.

Substance abuse: Some substance abusers, as a result of high levels of resistance to sedatives, may not respond as expected to typical medication administration protocols for procedural sedation.

Thyroid problems: Medications for hyper thyroidism and hypothyroidism can interfere with sedation medications. Other medications such as atropine and epinephrine may precipitate a thyroid crisis in at- risk patients.

Allergies: Asses the agents and type of severity of allergic reactions to those agents.

Current medications, including OTC and ‘Alternative’ medications: Be alert especially to cardiac meds, diuretics, insulin, and MAO inhibitors.

NPO status: Fasting or clear liquids is recommended at least 2 to 6 hours prior to procedural sedation.

Airway patency: Some patients, for anatomical reasons, are harder than usual to intubate. These include patients with bull necks and small mouths, those who have difficulty flexing and extending their necks, obese patients, and those with a particular anatomy that makes visualization of the pharynx difficult. One common diagnostic index for identifying individuals who may be hard to intubate is the Mallampati Score. Note that as the Class increases, the pharynx becomes increasingly hard to visualize.

Annual Mandatory Education—Professional Nurse

Mallampati Scoring Courtesy of Creative Commons Attribution-ShareAlike 3.0 Unported

Any Class greater than Class I could be cause for concern and for notifying the physician/LIP in responsible for the procedure.

Universal Protocol Rather than duplicate content in the UP module in this same course, please refer to that module for ensuring patient safety in regards, to proper site and procedure.

Equipment requirements IV Oxygen Suction Code cart Medications (drug antagonists and reversal agents, and emergency medications) Monitoring Protocols Generally accepted protocols for assessment which also conform to broader Joint Commission guidelines for care include: A pre-sedation assessment is conducted for each patient Each patient’s sedation care is planned Sedation options and risks are discussed with the patient and family prior to administration The patient’s physiological status is monitored during sedation. Generally accepted guidelines include a minimum of q5 (Deep Sedation) and q15 minutes (Moderate Sedation) to include, at minimum, vital signs, pulse oximetry, pulses, Sedation level, and cardiac monitoring if indicated.

Annual Mandatory Education—Professional Nurse

The RN monitoring the patient must have no other responsibilities (that could impede that monitoring) from the time the 1st dose of sedative is administered until the procedure is complete the patient has returned to baseline.

With geriatric patients, special attention is paid to dosages, evidence of sedation and respiratory depression, and probable increased circulatory time and decreased metabolism of medications.

All healthcare professionals caring for patients during procedural sedation must be appropriately trained/credentialed as required by state law and relevant practice acts.

Pharmacology Drugs used in procedural sedation ideally meet the requirements that they decrease anxiety and/or reduce pain with minimal side effects, as well as have a fast onset and short duration of action. The most common agents are propofol, bendiazepenes, ketamine, opioids, and etomidate. These drugs are most commonly administered as a bolus plus continuous infusion. Patient monitoring during administration is primarily focused on minimizing/managing the adverse hemodynamic and respiratory effects of these drugs.

Propofol Propofol is an effective sedative and amnesiac agent. Because it is not an analgesic, it is given in combination with other drugs when pain control is needed. Hypotension and respiratory depression are common side effects, and cardiopulmonary side effects are sometimes seen when coadministered with sedatives and/or analgesics. The drug is usually administered in an initial IV bolus and additional boluses if needed. To minimize hypotension, the bolus is administered in small increments.

Benzodiazepenes Midazolam is the most commonly administered benzodiazepine in procedural sedation due to its fast onset and short duration. Benzodiazepenes reduce anxiety and can cause sedation and retrograde amnesia. As with propofol, midazolam is given in combination with other drugs when pain control is needed. Hypotension and respiratory depression are common side effects, and cardiopulmonary side effects are sometimes seen when coadministered with sedatives and/or analgesics. In as many as 15% of patients—most commonly children and older adults, the drug can cause symptoms of paradoxical excitement including agitation, anxiety, and aggression. Flumazenil is an effective reversing agent recommended for acute benzodiazepine overdose, but is contraindicated in patients who are chronic users of benzodiazepines because reversal can lead to withdrawal symptoms and seizures in that population.

Etomidate Primarily a sedative, this drug is often coadministered with analgesics. It is generally used for shorter procedures due to its rapid onset and short duration of action. Unlike many sedatives, etomidate has

Annual Mandatory Education—Professional Nurse

minimal hemodynamic effects and is useful for patients who may be at risk for such problems. Sometimes, muscle twitching is seen after administration,

Opioids Fentanyl is the most common of drug of this class used for procedural sedation because is has fewer hemodynamic side effects. Onset and recovery are fast. Respiratory depression is not uncommon, and all opioids have the potential to cause hypotension.

Ketamine Ketamine is a dissociative agent that creates a trance state as well as amnesia. It is a sedative and an analgesic. Onset is rapid, but duration of action is longer which can be an advantage for longer procedures. Heartrate and blood pressure generally increase as well as myocardial oxygen demand. Respirations are generally not affected. Sometimes hallucinations can occur but can be managed with benzodiazepenes. Adverse psychological reactions can be minimized by positive ideation prior to administration and reduced sensory stimuli.

End of Procedural Sedation Lesson

Quality Improvement

The concept of quality improvement An organization is a system made up of many parts, and each part has a specific role to play within the organization. Processes, such as admitting patients or providing meals to patients, are things that help the organization accomplish its goals.

A Process is all of the steps involved in doing a particular procedure or task, and it may involve more than one department. For example, the process of admitting a patient is all of the steps that go into admitting the patient. 1. The patient gets the admission order from the physician office and walks into an Admitting Department. 2. The volunteer has them sign in and wait. 3. An admitting clerk calls them into the admitting area and has them answer questions and sign papers. 4. Someone from Transportation takes them up to their room and gives the paperwork to a staff person.

Quality improvement ensures that an organization's processes are designed to fulfil its goals. It entails looking at the mission, values and goals of the organization to determine whether its processes could be improved.

Annual Mandatory Education—Professional Nurse

Mission An organization's mission is its purpose. It is usually written as a vision statement. For example: "It is our mission to be a leader in healthcare, providing quality care for the community."

Values An organization's values are qualities the organization considers important to its operation. For example: "We take pride in providing courteous, prompt service to our clients."

Goals An organization's goals state specific actions to be taken by the organization. For example: "Goal #1: To expand services to the community during evening hours" "Goal #2: To develop a cardiac care center for the community" "Goal #3: To decrease the number of days patients remain in hospital."

All departments contribute to an organization's mission and goals. The organization's values should be reflected in each department.

Quality improvement, sometimes called performance improvement, is the study and improvement of processes to help an organization achieve desired outcomes to better meet the needs of its clients.

A Process is all of the steps involved in doing a particular procedure or task (such as admitting a patient). It is a series of actions that leads to a particular result.

Desired outcomes must be MEASURABLE to determine what processes need to be improved. Examples of measurable outcomes are: "To reduce the length of waiting time in the clinic" "To reduce the length of time it takes to admit a patient" "To assure correct meals are delivered to patients" "To reduce the number of hospital acquired infections."

Annual Mandatory Education—Professional Nurse

Outcomes must be measurable to determine what processes need to be improved.

The focus of quality improvement is not on the people, but on the process. It is designed to determine what areas of service must be improved. Quality improvement involves gathering and analyzing data to see if outcomes are consistent with the mission, values and goals of the organization. It also determines whether outcomes are in line with established benchmarks for the industry. Benchmarks are industry standards by which an organization's outcomes are measured.

For example: "Are waiting times in the emergency department of your organization comparable to the waiting times set as standards within the healthcare system?"

Implementation of Quality Improvement

The Joint Commission mandate to healthcare organizations The Joint Commission mandates that healthcare organizations systematically: Monitor and evaluate the quality and appropriateness of care Pursue opportunities to improve patient care Resolve identified problems.

Organizations must have a written plan that describes the program's objectives, organization, scope, and mechanisms for overseeing the effectiveness of monitoring, evaluating, and problem-solving activities.

Organizations have adopted various methods and plans to monitor processes, improve processes, and solve problems. Terms referring to these plans include Continuous Quality Improvement (CQI), Total Quality Management (TQM), and Performance Improvement (PI). Copyright 2015, Cross Country University Page 255 of 284, Quality Improvement

Annual Mandatory Education—Professional Nurse

Planning for quality improvement implementation To implement a quality improvement plan, an organization must design processes, monitor performance through data collection, analyze current performance, and improve or sustain improved performance.

Organizational leaders establish priorities to determine what processes should be reviewed and improved. Each organization has its own policies and procedures for conducting reviews and setting priorities. Priorities may be based on: Mission, values and goals of the organization Patient satisfaction surveys Data collection (infection control reports, autopsy results, etc.) Risk management (events that became risks, such as safety concerns, medication or treatment errors, etc.) Patient demographics/diagnoses (analyze top diagnoses and patient outcomes) Pain management methods (appropriateness and effectiveness) Employee opinion/needs surveys Quality control.

Once problems have been identified, organizations use teams made up of staff members from each involved department to study the problems and formulate plans for improvement. The focus is on the process, NOT on people.

An implementation model

Quality improvement should entail a constant cycle of continuous improvement. One model is PDCA: Plan, Do, Check and Act.

Annual Mandatory Education—Professional Nurse

Quality improvement should entail a constant cycle of continuous improvement. There are many different models on which to base the implementation of a quality improvement program. A model often used is "PDCA," which stands for: Plan Do Check Act.

Plan Once a problem has been identified, look at the processes involved. If the processes involve more than one department, employees representing each of the involved departments should be members of the quality improvement team. They should collect data, determine where, how, and why the problem is occurring, and develop a plan to correct the current processes. Desired outcomes must be measurable. Outcomes after implementation of quality improvement must be compared with the initial data collected to determine if desired outcomes have been achieved.

Planning also includes training people to use the solution, determining when the solution will be implemented, acquiring necessary equipment, forms or other supplies, and possibly organizing a pilot program and analyzing results.

Do Once the plan is complete, carry it out.

Check Collect data to determine if outcomes have improved. For accurate comparison, data should be collected from the same sources using the same collecting and analyzing methods used during the initial data collection.

Act If the new processes generate an improvement, implement them. If results of the new processes are not meeting the desired outcomes, the "PDCA" cycle must be repeated with a modified plan.

Example: Problem: Lab tests are not being performed at the ordered time. Program: Identify specific problem and assemble team. Plan: Collect data to determine how often it occurs, which nursing units are involved, which (if any) specific tests are involved, when tests were ordered, how tests were ordered, how tests are scheduled in the lab, and how tests are performed on the patient. Include how the problem affects mission, values, and goals; barriers to solving the problem; and impact on patients. Do: Train staff, change the process, do a pilot study or run on a trial basis. Check: Collect data in same manner as initial collection and compare results. Copyright 2015, Cross Country University Page 257 of 284, Quality Improvement

Annual Mandatory Education—Professional Nurse

Act: If process works, implement overall change. If process does not work, begin again with a modified "Plan."

End of Quality Improvement Lesson

Radiation Safety

Dangers of Radiation Radiation is energy traveling through space. Sunshine is one form of radiation. It provides heat, light, and tans our bodies. Too much sunshine may be harmful so we control our exposure to it with sunglasses, sunscreen, clothing, and shade.

Other types of radiation are infrared and ultraviolet. Some kinds of radiation are known as ionizing radiation and they can be harmful to living tissues. Just as we protect ourselves from sunshine, we also must protect ourselves from ionizing radiation.

Controlled amounts of ionizing radiation are used in health care to visualize organs, bones, teeth, etc. These types of ionizing radiation include X-rays, gamma rays, and radiation emitted by radioactive materials. Different types allow us to either see body structures and diagnose disease. Some ionizing radiation is used to treat disease by destroying damaged tissues.

Radiation occurs naturally and is also artificially produced.

Naturally occurring ionizing radiation provides light and heat and supports life. Artificially produced and controlled radiation can be used to promote health and save lives. Radiation of any kind can cause damage to living tissue so, it is necessary to control the amount of exposure.

Annual Mandatory Education—Professional Nurse

Ionizing radiation in healthcare facilities

Warning signs should be visible in all areas of the hospital where exposure to radiation is possible.

Ionizing radiation in hospitals is used for diagnosing and treating patients. Warning signs should be visible in all areas of the hospital where exposure to radiation is possible. Major uses are of ionizing radiation include: Medical and dental x-rays Nuclear medicine testing Radiation treatments.

Medical and dental x-rays Medical and dental x-rays are used to diagnose patient's conditions. X-rays enable specialists to distinguish bones and dense organs like the lungs and heart, from less dense parts of the body such as skin, muscle, and fat. X-rays, along with a "contrast medium" such as a "barium meal," is used to see organs that cannot be seen by x-ray alone, and to see the shape, action, and state of disease or wellness of these organs.

Nuclear medicine Nuclear medicine may be used to diagnose patients' conditions. In nuclear medicine, radioactive materials are inserted into the body. The radioactive materials emit radiation and a pattern outside the body is captured as an image on a computer screen. The image along with mathematical imaging techniques, is used to detect disease very early on in the disease.

Radiation treatment Radiation treatment, or radiation therapy, is used to kill certain types of cancer cells. Radiation is most

Annual Mandatory Education—Professional Nurse

harmful to rapidly growing cells, which is what cancer cells are. However, radiation can also be harmful to non-cancer cells. Radiation therapy involves the placement of radioactive implants in the body to kill cancer cells. These implants, sometimes in the form of seeds in a container, may be implanted into a tumor or into a body cavity close to a tumor.

Because of the high energies of different types of ionizing radiation used for medical imaging and radiation therapy, these tests and treatments present risks for patients and healthcare professionals. Knowing the dangers of radiation can help you to avoid them and to minimize your risks.

There are various different ways radiation can be dangerous: Radiation can cause cell changes and cancer. Radiation can cause birth defects in the fetus of pregnant women. Radiation effects are cumulative - they build up in the body with each exposure.

Three ways to minimize exposure and avoid the dangers of radiation: Lead shielding, which absorbs most forms of radiation, is built into walls, screens, and patients' gowns. Radiation counters monitor the amount of radiation exposure someone experiences, and enable workers to stay within a safety threshold. The dose, number of exposures, and a treatment plan must be calculated to insure the patient's risk stays within a suitable safety threshold.

Pause for review Radiation is energy traveling through space. Radiation may be naturally-occurring (such as sunshine) or artificial (such as x-rays used for diagnostic imaging). Natural and artificial radiation have both benefits and risks. Ionizing radiation can damage living tissue, but is very useful for the diagnosis and treatment of certain diseases. The use of medical x-rays is carefully monitored so that exposure is within acceptable and safe ranges. The best safety approach for radiation is to minimize exposure. People exposed to radiation in their workplace wear counters to measure the amount of exposure they experience. Lead shielding provides protection by absorbing most forms of radiation, so it is built into walls, screens, and gowns worn by workers.

Radiation Safety Procedures

Annual Mandatory Education—Professional Nurse

Stand close to the machine without shielding when an x-ray is taken Stand close to someone who has radioactive implants.

Be alert for warning signs in radiology and nuclear medicine departments.

People are NOT exposed to radiation when they: Visit radiology and nuclear medicine departments. However, employees who work in radiology and nuclear medicine departments expect exposure during their work time and must wear radiation counters that will record their exposure. Are in an area where warning signs about radiation are posted. However, all staff must be alert for warning signs and directions, and follow the instructions given in these departments. Are near an x-ray machine that is OFF. However, people are exposed to radiation when the x-ray is actually being taken. Are near people after those people have received diagnostic x-rays.

Minimize your exposure to radiation Everyone must keep exposure to radiation As Low as Reasonably Achievable ("ALARA").

To keep your exposure ALARA, remember the following three things: Time Distance Shielding Time The less time you are in an area where radiation is present, the less exposure you receive. Minimizing exposure time is especially important when caring for someone who has recently received radioactive implants.

Annual Mandatory Education—Professional Nurse

Spend as little time as possible close to the patient, but be careful not to make the patient feel isolated. Talk to the patient from a safe distance. Organize your patient care tasks so you minimize the time spent in close proximity with the patient. Distance The further away you are from the radiation source, the less exposure you have. Leave the room, or stand behind a shielded wall, when x-rays are being taken (including portable x-ray equipment). If you must stay in the room, wear a lead apron if one is available. If you must stay in the room, stand at least 6 feet away. If distance is not possible try to minimize the length of time you are in contact.

Shielding Shielding refers to a barrier between the radiation source and yourself or others. Shielding can be furniture, a wall, or even other people who have not been exposed as much as you have. The purpose of lead walls in x-ray rooms is to separate the technician from the patient being x- rayed. Technicians and others who need to be close to the patient being x-rayed wear lead aprons. Patients should wear lead aprons or other clothing to protect certain areas of the body when another area is being x-rayed. Safety features, such as built in lead, are used in the walls of rooms where radioactive implants are given.

Pause for review Identify potential risk situations and be alert and responsive to signs and directions in radiology and nuclear medicine areas so you can minimize your exposure to radiation. Exposure to radiation does occur if you have an x-ray, are close to others when they have an x- ray, if you receive radiation treatment, or if you are close to people who have radiation implants. Exposure to radiation does NOT occur just because you are in a radiology or nuclear medicine department, near an x-ray machine that is off or not being used, or because you are near people after they have had diagnostic radiation tests. To keep exposure to radiation As Low As Reasonably Achievable (ALARA), remember three things: the less time you are in an area where radiation is present, the less your exposure you have; the greater your distance from the radiation source, the less exposure you have; and lead shielding (between the radiation source and yourself or others) minimizes exposure.

Annual Mandatory Education—Professional Nurse

End of Radiation Safety Lesson

Restraints/Restrictive Practices A Philosophy for Using Restraints

What are restraints? A restraint can be any mechanical device (physical restraint) or drug (chemical restraint) used to limit the normal movements of a patient.

Physical restraints Physical restraints include any device used for the purpose of restricting the movement of a patient or denying the patient access to parts of the body. Examples of physical restraints: Mittens Vests Limb restraints Chest restraints Roll belts

A siderail, when used for the SOLE PURPOSE of keeping a patient in bed, is also a restraint. However, half-rails that still allow a patient to get out of bed, or that are raised to assist a patient in turning or for some other purpose are NOT considered restraints. Similarly, supportive devices, such as a sling for a sprained wrist, are not restraints even though they may restrict movement.

Soft (cloth) restraints may have to be replaced by stronger restraints (4-point leather) for extremely agitated or combative patients. Leather restraints, used to secure ankles and/or wrists, are buckled into place and may be locked.

Annual Mandatory Education—Professional Nurse

A restraint is a physical device or a drug used to restrict or limit the normal movements of a patient.

Chemical restraints Chemical restraints include any drug given for the sole purpose of restricting the movements of a patient. Examples of chemical restraints: Sedatives Tranquilizers

Dangers of using restraints There is always danger involved in restraining patients. In the US, approximately 100 deaths every year are blamed on the use of patient restraints.

The use of restraints has been shown to: Increase the number of falls (rails used to keep patients from falling sometimes cause more injury because of patients crawling over them and falling from a greater height) Increase the patient's length of stay in hospital (this can happen as a result of injuries acquired when patients try to free themselves from restraints) Increase mortality rates (patients are occasionally strangled by ties used to secure them to the bedrail, or they may die from cardiac arrest due to the increased agitation of being restrained).

Annual Mandatory Education—Professional Nurse

The use of restraints increases the number of patient falls, the length of stays in hospital, and mortality rates.

Patients escaping physical injury from restraints may still suffer emotional injury. Patients have reported: Feeling humiliation and shame Being increasingly confused Not understanding why they were being restrained

Restraints are to be used ONLY as a last resort. They are used when other measures are not effective and the patient could injure himself or others if his movement is not restricted. At times, combative and confused patients who are potentially violent need to be restrained during an acute outburst. Patients who are simply confused, but not violent, should ONLY to be restrained if they are endangering themselves or others AND other methods are not working. The least restrictive type of restraint must always be chosen.

Your facility may have policies that determine when restraints can be applied. Follow all policies of your facility. Before taking any action, you must document (in writing) the reasons why restraints are necessary (for example, "the patient is not able to understand the reason for having an IV line and persists in removing it") and the reasons for choosing the particular type(s) of restraints (for example, "a soft wrist restraint is being used to prevent the patient from pulling out the IV line").

In the above example, a patient, unable to understand the reason for using an IV line, may try to remove it. That patient would have to be placed in a soft wrist restraint for ONLY as long as he or she is still not able to understand the reason for the IV being in place. The restraint would be removed immediately once it has been determined that the patient is able to understand the necessity of having the IV line in place. Copyright 2015, Cross Country University Page 265 of 284, Restraints/Restrictive Practices

Annual Mandatory Education—Professional Nurse

When not to use restraints Traditionally, restraints have been used when there were concerns about patients falling. However, research has shown that although the use of restraints has decreased, the number of injuries from falls has NOT increased. That research would suggest that restraints do not help to prevent falls.

Sometimes restraints are applied for convenience, because of staff shortages. It may seem easier to put patients in restraints when staffing is "short," so that patients do not fall with fewer staff to watch them. However, studies have shown that dramatically decreasing restraint use actually decreases the number of falls and other injuries, even when staffing is "short."

There are important factors to consider before deciding to use restraints: The policies of your particular facility must be followed. There must be a very good reason for applying restraints of any kind. Except in an extreme emergency, other methods of handling the patient must be tried first. Restraints MUST NOT be used for the convenience of the staff.

Alternatives to Restraints

The confused patient and restraints Confusion by itself is not a reason to use restraints. Restraints can further confuse patients and cause increased agitation. Alternatives to restraints should be used whenever possible with ALL patients, including confused patients.

Some measures to help minimize the use of restraints include: Analyzing medications that could be causing confusion or restlessness Analyzing treatments that may be particularly bothersome to the patient Avoiding the use of tubes, if at all possible (they can be a source of aggravation and give a confused patient something to pull at) Removing nasogastric tubes as soon as possible Offering assistance with oral intake Keeping IV lines and other solution bags out of sight Using adult diapers with foley catheters to prevent patients from pulling catheter out Offering opportunities for frequent toileting Using larger than needed dressings so patients can't pick at wounds.

Environmental interventions A patient's environment can contribute to disorientation and falls. Some changes can often be made in the patient's room to decrease the chance of falls and to help him to stay oriented. These "environmental interventions," which reduce the need for restraints, include: Keeping the bed at the lowest level possible, or placing the mattress on the floor. Copyright 2015, Cross Country University Page 266 of 284, Restraints/Restrictive Practices

Annual Mandatory Education—Professional Nurse

Installing a bed alarm that detects patient movement and alerts staff. Keeping the path to the bathroom free of obstacles such as tables or chairs Using a nightlight or lamp so the patient is able to see where he or she is going Keeping lights lowered if they are too stimulating or disturb the patient Making sure the emergency call button or light is within reach of the patient and that the patient knows how to use it Placing a commode near the patient so trips to the bathroom won't be necessary Reducing noise level wherever possible so as not to disturb the patient (for example, by keeping voices down, turning down ringers on phones or lowering volumes on nearby TVs) Drawing the curtains (around the bed or on the windows) to eliminate distractions.

Psychosocial interventions Patients' fears, as well as other feelings, play a large part in determining how they behave. The psychosocial aspect involved in providing patient care cannot be overlooked when trying to avoid the use of restraints.

Annual Mandatory Education—Professional Nurse

Psychosocial elements for avoiding the use of restraints include: Assigning consistent caregivers to promote feelings of familiarity and security Incorporating a schedule similar to the patient's normal home schedule for eating, sleeping, toileting, and relaxing Providing reassurance to the patient by keeping all personal aids, such as eyeglasses, hearing aid, cane, walker, dentures, prosthesis, etc., close at hand Asking family members to bring in favorite pillows, photos, blankets, etc. Having a family member (or sitter) stay with the patient, if necessary Reminding the patient of where he or she is and why Reminding the patient of the date, day, and time Keeping a clock in view of the patient for awareness of the time Explaining actions or treatments and reinforcing them (over and over, if necessary) Providing favorite TV or radio programs and newspapers Talking to the patient Listening to the patient.

When behavior is disruptive or inappropriate, try to determine why the patient is behaving in that manner. Reasons could include: Type or strength of medication Lack of exercise throughout the day (which makes sleep difficult at night) Worry about issues at home Fear of medical procedures to be faced.

Types of Restraints

Side rails A side rail on a bed is a restraint if it is intended to restrict movement of the patient. Currently, the emphasis is on restraint reduction and the traditional use of side rails as restraints should be avoided whenever possible. An effective alternative in many cases is to install a bed alarm that detects patient movement and alerts staff.

If there is no alternative to using side rails as a restraint, observe the following guidelines.

DO: Check the patient frequently. Remember that patients sometimes try to climb over a side rail. Place the call button within easy reach of the patient. Make sure the patient knows how to use the call button. Tell the patient and family members why the restraint is being used and when it can be removed.

Annual Mandatory Education—Professional Nurse

Follow the policies of your facility. Document the use of the restraint.

NEVER restrain an agitated patient by raising the side rail.

A side rail may be an appropriate device for a patient who is sedated because it will help to remind the patient that help is required before getting out of bed. If the patient can use the side rail as a turning aid or to access bed controls, it is not considered a restraining device.

Limb restraints Limb restraints are usually made from cloth and have padding to protect the skin at contact points. Examples include wrist restraints, mittens and ankle restraints. One end of a limb restraint is wrapped around the patient's limb and the other end is secured (usually to the bed frame). Limb restraints and mittens may be secured with ties, buckles, or Velcro straps. Wrist restrains are used to keep patients from pulling out tubes or disturbing dressings or wounds. Mittens are sometimes used instead of wrist restraints because they are less restrictive and allow for more patient movement. Ankle restraints are used to prevent disturbing dressings or wounds and may also be necessary for patients who are kicking or trying to get out of bed.

Currently, with the emphasis on restraint reduction, traditional types of limb restraints are being replaced by positioning devices.

The guidelines listed below may be helpful when using limb restraints.

DO: Follow the directions of the manufacturer Use restraints of the appropriate size Attach limb restraints to the bed frame (so they move with the bed when raised or lowered) Use quick-release knots that can be untied easily in case of an emergency Check circulation and ensure that restraint is tight enough to limit movement WITHOUT impairing circulation Offer food and fluids frequently, and provide assistance Offer a bedpan frequently, and provide assistance Tell patients and their families why restraints are used and when they can be removed Document the use of all restraints, including times the patient was offered food, fluids, and opportunities for toileting Follow the policies of your facility Check the patient frequently.

Annual Mandatory Education—Professional Nurse

DO NOT: Attach limb restraints to the bedrail Tie restraints tight enough to impair circulation.

Every two hours: Remove the restraints Check the patient's circulation Inspect the skin for signs of injury Provide range-of-motion exercises to limbs released.

Belt restraints A belt restraint is sometimes used to keep patients in a chair or wheelchair. Their use should be avoided if at all possible. With the current emphasis on restraint reduction, wheelchairs are now being manufactured with self-release belts installed.

The guidelines listed below may be helpful when using belt restraints.

DO: Use a restraint of the correct size Follow the manufacturers directions for proper application Tell patients and their families why restraints are used and when they can be removed Check the belt, and the patient, frequently Follow the policies of your facility Document the use of all restraints.

DO NOT: Secure restraint too tightly Leave the patient unsupervised for any length of time.

Chest and vest restraints There are times when patients must be immobilized in a bed or chair. However, chest and vest restraints should ONLY be used as a last resort. They not only restrict patient movement, but they also pose a safety hazard to the patient.

The guidelines listed below may be helpful when using chest and vest restraints.

DO: Use a restraint of the correct size Follow the manufacturers directions for proper application Tell patients and their families why restraints are used and when they can be removed Attach chest/vest restraint to the bed frame (that will move as the bed is raised or lowered)

Annual Mandatory Education—Professional Nurse

Reposition the patient at least every 2 hours and adjust pillows for comfort Check the patient, frequently Follow the policies of your facility Document the use of all restraints.

DO NOT: Attach a chest/vest restraint to the bedrail Use a chest/vest restraint if a less restricting device would be adequate. Restraint Orders What are restraint orders? An order to restrain a patient MUST come through the proper authorities. It is usually issued by a licensed independent practitioner (LIP) such as a medical doctor (MD), a doctor of osteopathy (DO), or nurse practitioner (NP). Some hospitals might allow a physician assistant (PA) to give a restraint order, but this is not common and depends on privileges granted by the hospital.

A restraint order must contain: The type of restraint ordered The reason for the restraint (based on the behavior of the patient - NOT on a diagnosis) The time limit or duration of the restraint (NOT more than 24 hours) The signature of the practitioner who issued the restraint order.

Summary of Joint Commission Standards When to use restraint Restraint is used only when clinically justified or when warranted by patient behavior that threatens the physical safety of the patient, staff, or others. The least restrictive method of restraint should be used. Restraint is employed for the shortest time necessary.

Safe use Restraints are applied according to written policies and procedures and are in regulatory compliance Restraints are pain-free. Restraints are applied by trained staff.

Individualized use A prescriber (LIP) responsible for the patient’s ongoing care orders the restraint Within one hour of restraint initiation, an authorized licensed professional responsible for the patient’s care will evaluate the patient in person, and, as soon as possible, consults with the attending physician or LIP. No standing or PRN orders

Annual Mandatory Education—Professional Nurse

Renewal orders may be made (unless state laws are more restrictive): Q4 hours for adults at least 18 years old Q2 hours for children 9 to 17 Q1 hour for children less than 9 years old Every 24 hours (unless state law is more restrictive), an authorized prescriber may write a new order. Patients are continuously monitored for vital signs, circulation, and comfort by staff trained in restraint application and use.

Documentation Monitoring activities that must be documented include: Releasing the restraints at least every two hours Repositioning the patient Checking circulation and performing range-of-motion exercises Checking the patient's skin condition and noting skin care procedures Offering nutrition/fluids at least hourly, unless sleeping (note times and patient's responses) Providing toileting opportunities at least hourly, unless sleeping (note times and patient's responses) Assessing patient behavior at least hourly (to clarify the reason for continuing the restraint) Assessing patient response to being restrained Removing the restraints (when the criteria for the restraints no longer exist).

End of Restraints/Restrictive Practices Lesson

Risk Management and Event Reporting

Introduction Decreasing risk and future loss to the organization is the responsibility of the entire organization. Every department can do their part by performing their job appropriately and following all policies and procedures. When healthcare providers work together to provide the best patient care that they possibly can, risk is considerably lowered. Documentation can save a healthcare provider in a lawsuit or it can prove the plaintiff attorney's case. Every day is a new day that brings with it new patients, new problems, and several difficult situations to overcome. Face each day with a positive attitude and the knowledge that Risk Management is there for you every day behind the scenes helping to control losses to the organization.

This educational offering is intended neither to provide legal advice nor to serve as a professional standard. In addition, consideration of all state laws and statutes is beyond the scope of this publication. It is recommended that consultation with legal counsel be obtained for advice on particular issues or concerns.

Annual Mandatory Education—Professional Nurse

What is Risk Management? Risk Management is the identification of situations that could lead to claims against the organization, taking steps to minimize the adverse effects of loss due to litigation, and maintaining of an acceptable level of risk.

The Risk Management department will assist in the identification of high risk areas and monitor related trends, in order to plan and implement corrective actions that will improve future patient care.

Benchmarking is another trending tool that is used by Risk Management to develop, implement, or sustain quality improvements.

Additionally, the maintenance of safe and secure work environments and protection of the organization's assets are duties of the Risk Management department. Because the healthcare provider has the front line primary accountability of patient care, the Risk Management department is a resource for information, support, and guidance when a healthcare provider is in need of assistance.

Responsibilities of the Risk Management Department In order to appropriately monitor and decrease any possible risks and prevent losses to the organization, Risk Management must become involved in several key areas:

Policies and procedures When policies and procedures are being created or reviewed for possible revision, Risk Management must evaluate the final product for any possible future risk in relation to these policies. The goal of writing policies is that they must be consistently attainable for those that must follow the policies. The reason for this is that if you do not comply with your policies and procedures, you will then be in breach of policy. A breach of a standard of policy is one of the elements of negligence which can assist the plaintiff attorney (the patient's attorney) in proving negligence in any lawsuit filed against you.

Incident reporting Risk Management must maintain an Incident Reporting System. Incident reports are used: As a non-punitive tool used to identify potential liabilities and correct them before becoming a loss to the organization As a tracking tool for trending information to determine the frequency and severity of specific adverse occurrences To plan corrective actions to further the improvement of processes and promote safer patient care To give Risk Management a head start on claims prevention and claims management. In the Peer Review Committee meetings to determine remediation, counseling, education, and or discipline. Peer Review is a process whereby the quality of the services provided by the healthcare staff is evaluated by equivalently trained personnel. Copyright 2015, Cross Country University Page 273 of 284, Risk Management and Event Reporting

Annual Mandatory Education—Professional Nurse

To meet the requirement for annual reporting of incident reports to specific national regulatory associations

Depending on specific state law, the incident report is a confidential document that is protected from discovery in a lawsuit at all cost. The incident report should never be copied and never be placed in the patient chart. It should also never be referred to within the patient chart. Three examples that require an incident report are patient falls, medication errors, and wrong site surgery.

Regulatory and contract compliance The Risk Management department will assist in the compliance of current laws and regulations as well maintenance of current certifications of regulatory organizations such as Joint Commission. The Risk Manager will support human resources in their role of medical staff credentialing and reappointment as well as maintaining representation on several facility committees including Quality Improvement. The Risk Manager will additionally review all facility contracts and advertising for possible risk and appropriate verbiage.

Education Education of the staff is extremely important as a method of risk control because an educated staff will be more apt to follow policies and understand how to decrease liability in their daily practice.

Risk Financing This includes the selection of insurance coverage, the type of insurance, and the review of specific insurance carriers. The Risk Manager will assist executive management in these critical decisions as a vital member of the team.

Litigation and claims management Another crucial responsibility of the Risk Management department is litigation or claims management. When a lawsuit has been filed, the Risk Manager will be involved in all stages of this process from the initial notification of a claim, or formal "notice of intent" to the final settlement or jury award. This process may take years to proceed to completion. The Risk Manager will cooperate with the defense attorney and the insurance consultant, to determine case strategy, aid in the investigation, discuss reserving of monetary funds for expenses and indemnity, and manage the file to conclusion.

The Risk Management Process Risk Identification is the first step in the Risk Management process. Potential problems prior to a patient injury or actual problems that can result in a loss to the organization are identified through the use of many different systems.

Some of the risk identification systems will include occurrence or incident reports, patient complaints, performance improvement indicators, satisfaction survey reports, personal inspections, infection control, sentinel event tracking, failure mode and effect analysis (FEMA). In failure mode and effect

Annual Mandatory Education—Professional Nurse

analysis, processes associated with hazardous procedures, patient types, and other high risk processes are examined to identify weak points before a problem happens. A number of these processes can have serious ramifications if a failure occurs.

RCA Root Cause Analysis deals with incidents while FMEA deals with potential areas of risk. Failure Mode and Effect Analysis is a way of identifying potential risks. It is a tool that the Risk Manager can use to review the risk of possible solutions prior to the completion of the pilot stage. 1. Risk Identification Once collected, all of the above areas of identification are then documented.

2. Risk Analysis Risk Analysis is the second step of the process. It is now time to determine the potential severity of the loss associated with the identified risk, the probability that such a loss will occur, and the frequency of such a loss. Alternative risk techniques must be evaluated. Some techniques include a form of risk control, one of which is risk avoidance, where you never undertake the risk. This completely stops the loss from happening. Other risk controls, may lessen the severity of the loss. Risk financing consists of ways of paying for the loss after it has occurred.

3. Risk Treatment In the third step, the severity of the loss and the possible risk techniques has been analyzed. A risk treatment and corrective action plan will now be implemented. Some corrective actions may include policy and procedure changes, process redesign, in-service education, or patient relations. If Risk Avoidance is chosen as the risk treatment, an example would be if a facility no longer maintains a Labor and Delivery department. In Risk Financing, the cost of the risk is transferred to an insurance company.

After you have implemented your risk treatment and corrective actions, you must perform the final step in the process. As in other familiar processes, the last step is evaluation.

4. Risk Evaluation In the final step, consists of monitoring your loss control and corrective action plan. Risk Management must evaluate and assess the effects of the implementation plan annually. If the corrective action plans and risk treatments are found to not be as successful as anticipated, the Risk Manager will repeat the complete Risk Management process.

Negligence Negligence is the failure to do what a reasonable prudent person exercising ordinary care would do under similar circumstances. This would include a failure to meet the standard of care or a breach in the standard of care. In order for the plaintiff attorney to prove his case of medical malpractice he must establish that he has proven all four elements of negligence.

Annual Mandatory Education—Professional Nurse

The four elements of negligence are: 1. Duty: The law implies that you have a duty to exercise reasonable care whenever a patient- provider relationship has been established. This relationship may be formed just with the exchange of communication with the patient. Applicable state laws must be consulted to determine the parameters of the relationship.

2. Breach: A breach of the duty occurs when there is a failure to conform to or meet the applicable standard of care. The standard of care may be determined by facility policies and procedures, national or professional association standards, state licensing regulations, or even your job description. It is important to know that the standard of care in a medical malpractice trial will be established by expert testimony. There will always be a testifying expert permitted to attest to the prevailing standard of care. A medical malpractice trial will also include an expert to attest to the causation of the injury which brings us to the third element of negligence, causation.

3. Proximate or direct cause: Causation will require the plaintiff to prove a reasonably close proximate causal connection between the alleged conduct and the resulting injury. Causation is the most difficult connection to prove. It must be proven that if not for the actions or inactions of the healthcare provider, the injury would not have occurred. The element of causation is also established by the expert witness testimony at trial. There is one injury that is under the exclusive control of the defendant and cannot occur without negligence. This is called "Res ipsa loquitor", which is Latin for "the thing speaks for itself". One common example is a retained foreign object left in during surgery.

4. Damage or Injury: The fourth element, damages related to the injury, consists of several different categories. There can be economic damages which consist of monetary losses caused by the alleged injury. Monetary losses may include loss of wages, medical bills, or future expenses of medical care, and possible hired help for household chores. Other damages can be those such as pain and suffering, loss of companionship, loss of consortium and many others that are intangible and do not include monetary losses. Punitive damages are less common. These are damages that are assessed on a defendant for possible gross negligence or wanton disregard in the care of the patient. Many feel that these are meant to punish the defendant.

Please remember that there is a recent trend to include your organization in a lawsuit by naming the corporation separately. Corporate negligence is the failure of a hospital or organization to fulfill its responsibilities to exercise safeguards that would protect against injuries to patients or staff. The organization owes the patient a duty to take reasonable care in making sure that its healthcare providers are qualified to provide proper treatment.

Strategies for reducing the risk of being named in a lawsuit The best way is to perform safe practice and follow the appropriate standard of care for all patients

Annual Mandatory Education—Professional Nurse

every day. In a perfect world, this would be a very easy feat to accomplish but as we all know, life is not perfect.

Documentation Documentation is the one most important factor that you must consider when attempting to decrease your risk. The patient chart is a multidisciplinary tool for the purpose of taking care of the patient. Documentation is a means of communication between healthcare providers.

The 5 C's of Risk Management rules of documentation are to be Correct, Complete, Concise, Consistent, and Cautious.

Do not be defensive or argumentative in the record. If you are not going to take an action, do not write that you are going to take action. Make sure all of your notes are legible. It can be construed as negligence if the record is not legible. Do not use unauthorized abbreviations. Use ink Never erase an entry; cross out the incorrect entry with a single line and initial it, provide the date and time for all entries, Do not leave blank lines on the medical record, Use a "late note" for matters charted out of sequence. Document what is seen, heard, felt and smelled, thought processes, and non-compliant behavior.

Documentation should be objective. Refrain from including opinions or personal comments. If done correctly and appropriately a nurse's charting in the medical record is the best defense in the event of a lawsuit. On the other hand, if a healthcare provider documents inappropriately or does not document at all, this can be the main focus of a plaintiff attorney's malpractice case.

Work within your scope of practice Many times in your practice you may be asked to float to another floor or unit. When you are asked to work in an area that is not within your scope of practice or in which you have never had any experience, you should contact your supervisor and request that you work in this area on a "Helping Hands" basis. In this capacity you will still provide the needed assistance to the unit, but will not be put in a position of direct patient care in a totally unfamiliar area of practice.

In many states, your license may be sanctioned if you accept an assignment that is outside your own scope of practice. Please refer to your own state licensing organization and your state specific Nurse Practice Act for appropriate information. In a medical malpractice trial, the primary responsibility for accepting the assignment in an unfamiliar area of practice will be yours. As a patient advocate, it is your responsibility to assure that you have the requisite skills to provide care to any patient to which you may be assigned. Copyright 2015, Cross Country University Page 277 of 284, Risk Management and Event Reporting

Annual Mandatory Education—Professional Nurse

With the current nursing shortage, more hospitals may ask nurses to take assignments outside of their scope. The hospital will then share a portion of the principal responsibility for sending the nurse to this unfamiliar area.

When an incident occurs When an incident occurs, there are several things that may happen. Initially, an incident report should be written. This should be a confidential document from Risk Management. As previously stated, it should never be copied, never be placed in the patient chart, and never be referred to within the patient chart.

After this, you should not write any statements, give any formal statements, or sign any statements. Your charting should be appropriate and complete as per the listed guidelines stated above. You should no longer discuss this situation with anyone without the expert guidance of your employer's Risk Management department. If you are ever contacted by an attorney or investigator in relation to any past or present incident, please contact your employer's Risk Management department immediately.

End of Risk Management Lesson

Security

General Security Precautions

Protecting property In every facility, it is important to follow security procedures. By taking simple security precautions, you can help to: Protect personal, patient, and institutional property Maintain a safe environment.

Personal Property There are a number of security precautions that you can take at your facility to help protect your own personal property: Lock car doors. Secure all valuables. Keep purses and wallets in a locked area or locker.

Remember that a locker is not secure unless it is locked.

Annual Mandatory Education—Professional Nurse

Keep purses and wallets in a locked area.

Patient Property Patients should be encouraged to leave their valuables at home. If patients choose to bring their valuables into the facility with them, you can help to keep them safe by: Securing patient valuables Educating patients about security.

Follow your facility policy for securing patient valuables. For example, valuables may be placed in the facility safe according to policy. You can educate patients by explaining the visitor policy, including who can visit, visiting hours, and any restrictions. You should also explain how patients can identify staff.

Institutional Property There are also things you can do to protect institutional property: Keep restricted areas locked Report missing or damaged equipment.

Following policy Some areas in your facility may be restricted or "security-sensitive." This means that only people who need to be in these areas should be there.

Annual Mandatory Education—Professional Nurse

Medical Information Systems Medical Records Billing.

If you work in a security-sensitive area, follow facility policies and procedures to keep them secure. Procedures that should be followed all the time, especially in security-sensitive areas may include: Wearing your ID badge Keeping doors locked Reporting missing or damaged equipment.

You should wear your ID badge according to facility policy. If you lose your badge, you should report it and have it replaced immediately. It is important for you to be properly identified. It is also important to insure no-one else uses your badge.

In addition to wearing your own ID badge, you should be suspicious of people who are not wearing proper identification. Remember, wearing a lab coat or scrubs does not mean someone is an employee.

You should also be sure to keep doors to security-sensitive areas locked. Do not prop doors open that are supposed to be secure. If you do see someone acting suspiciously, report it to your security personnel.

There are good reasons that some areas need to be secure. For example, the pharmacy must restrict access to drugs. In Obstetrics (particularly the Nursery), it is important to guard against infant abduction. Medical Records contains sensitive personal information. By following procedures, you can help keep these areas secure.

Ensuring personal safety In addition to protecting personal, patient, and institutional property, it is important to ensure your personal safety. Take the following simple precautions: Do not walk alone to your car at night. Park in well-lit areas. Do not keep valuables in your car. Report any potential security hazards.

Annual Mandatory Education—Professional Nurse

Park in a well lit area and keep your car locked. If you have to leave after dark, ask someone to accompany you to your car.

For your own safety, do not walk alone to your car at night or any time you feel uncomfortable. Follow your facility procedure to get an escort. Park in well-lit areas and do not keep valuables in your car, especially in plain sight. If you do have valuables in your car, lock them in the trunk.

Report anything that you feel might be a security hazard. This includes such things as burned out lights in a stairwell or garage. If you feel someone is acting suspiciously, notify security personnel immediately.

Special Security Precautions

Security-sensitive areas Some areas in your facility are "security-sensitive areas." These are areas with limited or restricted access.

Security-sensitive areas may include the following: Pediatrics and Obstetrics (especially the Nursery), because of the risk of infant or child abduction Pharmacy, because of access to drugs Medical Information Systems and Medical Records, because of access to confidential information. Billing

Annual Mandatory Education—Professional Nurse

Only people who need have access to security-sensitive areas are given access.

Your facility may have policies restricting access to these areas. There may also be security devices, such as alarms and video cameras. Restricted access to security areas applies to everyone, even staff. Only people who need to be in a restricted area should be there.

End of Security Lesson

Team Communication about Serious Events, the SBAR Model The Joint Commission, which accredits the majority of hospitals in the United States, analyzes the root causes of sentinel or critical events. Poor communication is the most common cause of patient injury or death in the clinical setting. SBAR (Pronounced S-Bar), developed by Kaiser Permanente of Colorado, is a formalized method of communicating with other healthcare providers that is being adopted by many hospitals.

SBAR promotes patient safety by helping physicians and nurses communicate with each other. Staff and physicians can use SBAR to share what information is important about a patient. It improves efficiency by way of a standardized form of communication that helps caregivers speak about patients in a concise and complete way. SBAR is an acronym for: Situation Background Assessment Recommendation

Annual Mandatory Education—Professional Nurse

SBAR is used to report to a healthcare provider a situation that requires immediate action, and to define the elements of a hand off of a patient from one caregiver to another (for example, during transfers from one unit to another or during shift report, and in quality improvement reports).

Liability issues may surround the communication that occurred in any clinical situation, particularly when unexpected changes in a patient’s condition occur. It is often difficult to determine what the healthcare prescriber (physician, physician assistant, nurse practitioner) was told. An inexperienced or fatigued nurse may omit specific important information. One of the goals of SBAR is to provide a structure for such communication. The elements of SBAR are explained below and applied to contacting a healthcare prescriber.

Consider the following scenario with regard to SBAR:

Situation: When calling a healthcare provider to report a change in the patient’s condition, the nurse identifies his or her name and unit, the name and room number of the patient, and the problem. The nurse describes what is happening at the present time that has warranted the SBAR communication.

Situation Example: “Dr. Jones, this is Jane Smith, RN, of 5-West. I am to notify you that your patient, Scott Kelly, in Room 4017-2, fell on the floor today while being transferred out of bed.”

Background: The nurse includes relevant background information specific to the situation. For example, this could include the patient’s diagnosis, his mental status, current vital signs, complaints, pain level, and physical assessment findings.

Background vignette: “As you know, Mr. Kelly had a laminectomy and bone fusion on January 17. His legs have been weak since surgery. He fell when our aide was helping him get up with a walker. His current vital signs are 145/90, pulse of 88 and respirations of 20. He is able to move all of his extremities, although he is complaining of pain at his incision of 7 on a scale from 1-10.”

Assessment: This step of the communication provides the nurse with the opportunity to offer an analysis of the problem. If the situation is unclear, the nurse tries to isolate the problem to the body system that might be involved and describes the seriousness of the problem.

Assessment vignette (continued): “I see no changes in his neurological status since he fell; neither of his legs is shortened and externally rotated. He is quite anxious now and also worried something in his neck has been injured.”

Recommendation: The nurse states what he or she thinks would help resolve the situation or what is the desired response. This might be phrased in the form of a question: “Do you think we should give him a medication, perform lab work, do an xray, perform cardiac monitoring, or transfer to another unit? Will you come to evaluate him?”

Annual Mandatory Education—Professional Nurse

Recommendation vignette (continued): “I believe it would reassure Mr. Kelly if you would examine him. When can we expect you to come?”

Here is another yet more concise example…

Dr. White, this is Sue Black, RN, I am calling from ABC Hospital about your patient Sophie Brown.

Situation: Here's the situation: Mrs. Brown is having increasing dyspnea and is complaining of chest pain.

Background: The supporting background information is that she had a total knee replacement two days ago. About two hours ago she began complaining of chest pain. Her pulse is 120 and her blood pressure is 128/54. She is restless and short of breath.

Assessment: My assessment of the situation is that she may be having a cardiac event or a pulmonary embolism.

Recommendation: I recommend that you see her immediately and that we start her on 02 stat.

The safe and effective care of patients depends on consistent, flawless communication between caregivers. End of shift report, hand-offs or the process of passing on specific information about patients from one caregiver team to another, is an area where the breakdown of communication between caregivers often leads to episodes of avoidable harm to a patient.

End of Team Communication about Serious Events, the SBAR Model Lesson

End of Course