Executive Summary Policies and Procedures for Quality Professional Services Committee From the Medical Executive Committee January 2018
Title of Policy Last BOT due Next review Policy Purpose Summary of History of Review Type Approved date date after Owner/Author/ Changes Committee Date from last BOT approval Reviewer approval Labor and Delivery New Policy N/A 3 Years Rachel Hogan (Asst Establish parameters Changes: • Clinical Practice Clinical Triage (HH Only) Nurse Manager), for obstetric triage, Council (3/2017), Theresa Cooper including admission, This policy was Patient Care (Director of transport and originally Leadership Nursing –MCH), discharge criteria, presented to MEC (3/2017) Sophie Shabel, MD acuity assignment in March 2017 • Medical Executive (Chair, MCH), Kinzi and standardization and not Committee Richholt (CNE) of nursing approved. (11/2017) documentation for Document all patients who Owner/ Writer present to Labor and was asked to Delivery. revise policy and re-submit to MEC for approval. Medical Record New Policy N/A 3 Years Bernice Zander To describe the Changes: • Ambulatory Admin Delinquency and (Dir., HIM), Steve process for Operations Council Medical Staff Kilgore (DON- suspension of New Policy (8/2017) Suspension: Ambulatory), Palav provider privileges for • Medical Records 1
Title of Policy Last BOT due Next review Policy Purpose Summary of History of Review Type Approved date date after Owner/Author/ Changes Committee Date from last BOT approval Reviewer approval Ambulatory Babaria, MD (CAO- delinquent medical Committee Ambulatory), Dave records. Timely (8/2017) Cox (CFO) completion of • Medical Executive ambulatory medical Committee records is essential (10/2017) for ensuring patient safety, continuity of care and appropriate clinical care, especially when outpatients are seen in other locations subsequent to their outpatient visits. Medication Kit/ New Policy N/A 3 Years Doug Del Paggio Different Changes: • Pharmacy and Dept Transport Boxes for (Director, departments/division Therapeutics Specific Departments Pharmacy), Diana s store boxes or kits New Policy (10/2017) and Divisions (HH Thamrin (System to get access to Only) Director, mediations in their Pharmacy), John specific areas, where Chapman (CAO) Automated Dispensing Machines (ADM, e.g. Pyxis) are not accessible and/or certain specific drugs are not included in crash cart. These departments/ divisions include Allergy Clinic, Anesthesiology, Cardiology, Diagnostics, Oral Surgery, Operating Room and Radiology. Medications: Look- New Policy N/A 3 Years Priya Patel To ensure Alameda Changes: • Pharmacy and Clinical Alike, Sound-Alike (Medication Safety Health System (AHS) Therapeutics (AHS 2
Title of Policy Last BOT due Next review Policy Purpose Summary of History of Review Type Approved date date after Owner/Author/ Changes Committee Date from last BOT approval Reviewer approval (System) Officer), Diana has a system in place New System-Wide Core, 2/2017, AH Thamrin (System to eliminate Policy 4/2017, SLH Director, medication errors 3/2017) Pharmacy), John caused by the • Clinical Practice Chapman (CAO) procurement, storage, Council (6/2017) dispensing and • PCLT (7/2017) administration of look alike, sound alike medications. Medications: 2/2011 2/2017 3 Years Doug Del Paggio The formulary Changes: • Pharmacy and Dept Prescribing and (Director, system improves Therapeutics Ordering (AHS Core) Pharmacy), Priya patient care by Minor revisions (3/2017) Patel (Medication promoting rational Safety Officer), and discriminate Diana Thamrin drug therapy, (System Director, providing Pharmacy), John medications in a Chapman (CAO) timely manner and generally at a lower cost to the patient because of the contractual prices. Scope of Service – 7/2014 7/2017 3 Years Bernice Zander To ensure adequate Changes: • Health Information Health Information (Director, HIM), information is Management ( Management (System) Dave Cox (CFO) available to the Minor revisions members of the healthcare team and other health care providers and when necessary to provide effective patient treatment. To process and maintain patient care information for the continuity of patient care research, legal 3
Title of Policy Last BOT due Next review Policy Purpose Summary of History of Review Type Approved date date after Owner/Author/ Changes Committee Date from last BOT approval Reviewer approval purposes, and justification for reimbursement, service utilization and other administrative purposes. Vancomycin Pharmacy 9/2014 9/2017 3 Years Matt Labreche To enhance the safe Changes: • Pharmacy and Dept Dosing Protocol (HH (Clinical Pharmacy and effective use of Therapeutics Only) Specialist) (Doug vancomycin and to Minor revisions Committee Del Paggio increase antibiotic (11/2017) (Director, stewardship for this Pharmacy), Diana medication with a Thamrin (System pharmacist dosing Director, and monitoring Pharmacy), John protocol. Chapman (CAO) PLANS Infection Prevention 9/2016 9/2017 Annually Deborah Ellis This document is a Changes: • Infection Control Admin and Control Annual (Interim System comprehensive Committee Plan: 2016 Assessment Director, Infection evaluation, risk Annual Plan (8/2017) 2017 Plan (AHS Core) Prevention and assessment, • Quality and Safety Control), Adrian prevention and Committee Smith (Interim VP, control plan (11/2017) Quality) completed annually. This document may be revised at any time based on significant changes in the healthcare setting and infection control field.
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Alameda Health System
LABOR AND DELIVERY TRIAGE
Department Maternal Child Heath Effective Date New Policy Campus Highland Date Revised 2/2017 Unit Labor and Delivery Next Scheduled Review 2/2020 Manual Maternal Child Health Author Director of Nursing – MCH Replaces the following Policies: Responsible Person Chief Nurse Executive Chair, Maternal Child Health Printed copies are for reference only. Please refer to electronic copy for the latest version.
Purpose
Establish parameters for obstetric triage, including admission, transport and discharge criteria, acuity assignment and standardization of nursing documentation for all patients who present to Labor and Delivery.
Policy
Alameda Health System Family Birthing Center will provide comprehensive professional nursing care to all patients presenting to Labor and Delivery under the guidelines of the Emergency Medical Treatment and Active Labor Act (EMTALA) and the AHS EMTALA policy. Use of a maternal fetal triage index and standardized criteria for ongoing assessment and dispensation will facilitate the highest quality care delivery.
Admission to Labor and Delivery Triage
1. Labor and Delivery (L & D) triage services will be available 24 hours per day, seven days per week.
2. Patients less than 20 weeks gestation or with a non-obstetric emergency will be triaged in the Emergency Department. If patient’s condition warrants, fetal monitoring or obstetric clearance may be provided in the Emergency Department by Labor and Delivery RN and/or OB physician.
3. Obstetric patients at 20 weeks of gestation or greater will be evaluated on the labor and delivery unit. Patients may present to L & D Triage in the following ways: self present, brought in by ambulance, referred or brought in from an outpatient setting, brought from the Emergency Department, transported from another medical facility or from an out-of-hospital birth attendant.
4. Patient with the following conditions will bypass L & D Triage and be either directly admitted or placed in observation status: a. Patients scheduled for cesarean delivery, induction of labor, cerclage placement, external cephalic version, or other conditions as determined by provider. b. Patients directly admitted to the postpartum or antepartum unit. Page 2 of 7
c. Patients who present as born out of asepsis. d. Patients with imminent delivery.
5. All patients will be interviewed in a private location by an RN to determine evaluation priority. Patient acuity will be categorized according to the Maternal Fetal Triage Index (Appendix A).
6. Initial and ongoing assessment and documentation will occur per Labor and Delivery RN Triage Protocol (Appendix B).
7. An in-house OB provider will be notified of each patient’s chief complaint and acuity index on patient arrival depending on assigned acuity level.
Ongoing Evaluation
Following Medical Screening Exam by Qualified Medical Personnel (QMP):
1. Orient patient to nurse call light, restroom and fetal surveillance.
2. Re-assess vital signs per protocol or as ordered.
3. Document all interventions including start and stop times of infusions and injections.
4. Complete triage re-evaluation within 2 hours to determine if patient will be discharged, admitted or placed on observation status.
5. When it is determined that the pregnant patient is not in labor and does not have an emergency medical condition, the woman may be transferred to another health care facility, be referred for outpatient services, be discharged, or be seen in the Emergency Department as determined clinically appropriate by a physician or Certified Nurse Midwife (CNM) or other Qualified Medical Personnel (QMP). The medical record will reflect the basis of the determination.
Acceptance of Maternal Transports to Labor & Delivery
1. Requests for maternal transport should be from the attending physician at the referring hospital to the triage attending and/or perinatologist at the transport hospital to assess medical need.
2. Request for maternal transport from an out of hospital birth site may be made directly from out of hospital birth attendant to on- duty Certified Nurse Midwife or OB Attending.
3. Triage attending physician, CNM, or their designees should notify the charge nurse or unit manager that they have accepted the transport.
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4. Referring hospital should call with a nurse-to-nurse report. The nurse receiving the referral call will complete the Obstetric Evaluation database form, including patient information, referring physician’s name and relevant contact numbers.
5. The patient being transported should go directly to the triage area, unless previously accepted for direct admission. Patient acuity level will be assigned and she will be cared for accordingly.
Transfer out of Labor & Delivery
1. Requests for maternal transport to another facility should be from the AHS attending physician to the OB attending or perinatologist at the receiving hospital to assess medical need.
2. Triage attending physician or their designees should notify the AHS L&D charge nurse or unit manager that they are planning to transport the patient to another facility.
3. The OB Attending will order the type of transport and level of support required (BLS, ACLS) during transport as well as the destination facility and indication for transfer.
4. The charge nurse will contact the House Supervisor and arrange for transfer via ambulance.
5. The Triage/designated nurse will contact the receiving hospital via telephone to complete a nurse-to-nurse report.
6. The charge nurse or delegate will ensure that copies of all medical records have been completed and prepared for ambulance pick up.
Discharge From Labor & Delivery Triage
All patients will undergo fetal monitoring per MCH Fetal Monitoring policy before discharge . Patients with >28 weeks estimated gestational age should have Category I fetal heart rate tracing or a reactive NST medically indicated and ordered prior to discharge or other check for fetal wellbeing per provider discretion.
1. For patients who are to be sent home a. If the nurse has done the vaginal exam and reassessment, notify the obstetrician /CNM to evaluate the patient and discharge, if appropriate. b. Complete discharge vital signs for any patient without vital signs for more than 2 hours, or any patient who presented with abnormal vital signs. c. Provide the patient with information needed for self-care at home, including labor precautions, kick count instruction, medication teaching and other discharge instructions. d. Document all care and assessments provided in triage, including patient’s verbal understanding of instructions. e. Patients discharged home may walk unaccompanied by hospital personnel. Page 4 of 7
2. For patients who are to be admitted or place in observation status a. Notify the primary nurse who will be accepting the patient, arrange for warm transfer of patient to the assigned room and provide report to the assigned RN. b. Transfer the patient in the central fetal monitoring system to the appropriate labor room. c. Obtain and implement diet orders. d. Observation beds may be provided for patients who do not yet meet criteria for inpatient admission and who require a period of ongoing evaluation for further treatment and to determine dispensation. Reassess Observation patients in accordance with the RN Triage Protocol and patient acuity. Record start and stop times for all infusions and injections.
3. For patients leaving against medical advice (AMA): a. Notify provider immediately of any patient expressing intention to leave the unit AMA. b. Staff will take all reasonable steps to ensure patient (or legal representative) is informed by the OB Provider of the examination, stabilizing treatment and/or transfer to another facility that patient is refusing. Document patient status and attempts of OB Provider to counsel patient regarding care recommendations.
References
1. American College of Obstetricians and Gynecologists. (2016) Hospital-based triage of obstetric patients. Committee Opinion No. 667. Obstet Gynecol;128:e16–9. 2. Angelini A. and LaFontaine, D. (2013). Obstetric Triage and Emergency Care Protocols. New York, NY. Springer Publishing Company. 3. Caliendo, C et al. (2004). Obstetric Triage and EMTALA Regulations: Practice strategies for labor and delivery nursing units. AWHONN Lifelines, Volume 8, Issue 5, 442-448. 4. Ruhl, Catherine et al. (2015) Content Validity Testing of the Maternal Fetal Triage Index. Journal of Obstetric, Gynecologic & Neonatal Nursing, Volume 44, Issue 6, 701 – 709.
Approvals
Departmental Date: 2/2017 Clinical Practice Council Date: 2/2017 Patient Care Leadership Date: 3/2017 Medical Executive Committee Date: 11/2017 Board of Trustees Date:
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Appendix B—Labor and Delivery RN Triage Protocol
RN will assess each patient presenting to Triage according to the following parameters. RN will initiate care under the Labor and Delivery Triage Standing Orders and will document intake times, medications and fluids administered, interventions, ongoing vital signs and re-evaluation on the OB Triage Evaluation Form.
EMTALA requirements
1. Record time of patient entry, method of arrival, time of RN triage initiation, and time OB provider notified. 2. Assign and document priority level according to Maternal Fetal Triage Index (MFTI)— 1-Stat, 2-Urgent, 3-Prompt, 4-Non-urgent, 5- Scheduled 3. Notify OB provider of patient’s arrival in triage, chief complaint, and MFTI priority level within time frame indicated by acuity.
Maternal and Fetal Assessment
Maternal— obtain and record initial vital signs (BP, HR, T, RR, O2 sat, pain score), height and weight, including calculation of BMI; obtain urine sample (see below).
1. If SBP ≥ 135 or DBP ≥ 85, repeat BP q 30 min x 3.
2. If SBP ≥ 140 or DBP ≥ 90, repeat BP q 15 min x 3, then q 30 min and notify provider (see Preeclampsia Evaluation in Triage).
3. If SBP ≥ 160 or DBP ≥ 100 check BP & HR q 5 min x 3, then q 15 min x 3, then q 30 min, notify provider at first elevation. Draw and send preeclampsia panel.
4. If BP recurs above parameters restart monitoring at q 5 min and follow timing as above.
5. If BMI ≥ 40, pulse ox with vitals q 4 hours, notify provider if pulse ox <95% .
6. Temperature Q1 hour if febrile ≥ 100.0 or after rupture of membranes.
7. Ongoing VS assessment if patient is laboring: a. Q4 hours latent phase b. Q2 hours active phase
8. Urinalysis a. Obtain and send UA STAT, clean catch. b. If patient has signs or symptoms of preeclampsia or hypertension AND suspected ruptured membranes or vaginal bleeding then obtain instead: UA STAT, catheter.
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Fetal/Tocometry Monitoring-- Ensure patient entered into central monitoring system.
1. For estimated gestational age (EGA) less than 23 weeks, fetal heart rate by Doppler once. Assess for uterine contractions.
2. For EGA greater than or equal to 23 weeks, obtain an initial 20 minute fetal monitor tracing to evaluate for baseline rate and periodic patterns. Assess uterine contractions. If evaluation extends more than 40 minutes without appropriate fetal reassurance then treatment plan is per attending provider.
3. Continue monitoring, if indicated, as specified in Fetal Monitoring Policy. Patients with >28 weeks EGA should have a reactive nonstress test (NST) prior to discharge.
Rupture of Membranes Assessment
Assess for amniotic fluid leakage, including patient report and objective findings. If spontaneous rupture of membranes suspected, collect specimen of fluid and assess per protocol. Defer SVE unless signs of imminent delivery are present.
Labor Assessment
Vaginal exam to assess cervix and fetal presentation.
1. Defer if ruling out SROM, vaginal bleeding, known placenta previa, or GA < 35 weeks (unless requested by provider). 2. If suspected preterm labor, gestational age 23-34 weeks, obtain FFN specimen prior to vaginal exam. 3. Assess cervical dilation, effacement, station, presenting part, cervical consistency, position and membrane status. Document in the medical record and inform provider of exam results. Notify provider as necessary to repeat exam if unable to perform complete assessment.
Preeclampsia evaluation in Triage
1. If triage SBP confirmed ≥ 140 or DBP ≥ 90, draw and send Preeclampsia Panel STAT.
2. If BP ≥ 160/100, place IV & saline lock and order Type & Screen STAT. Ensure ABO re- check done.
Assess obstetrical hemorrhage risk.
1. Low Risk : Singleton pregnancy, no previous uterine incision, fewer than 4 previous vaginal deliveries, no known bleeding disorder, no hx postpartum hemorrhage a. Action: Verify prenatal blood type and antibody screen done.
2. Medium Risk: Prior C/S or uterine surgery, multiple gestation, greater than 4 vaginal deliveries, hx previous PPH, chorioamnionitis, large uterine fibroids, EFW > 4 kg, BMI > 35 Page 7 of 7
a. Action: Assess need for ABO recheck.
3. High Risk : Placenta previa or low-lying placenta, suspected placenta accreta or percreta, hematocrit < 30 AND other risk factors, platelets < 100,000, active bleeding on admit, known coagulopathy a. Action: If admitted for anticipated delivery, notify OB provider and anesthesia. Order type and cross match 2 units PRBCs.
Insert and Maintain peripheral IV with saline lock if clinically indicated.
Obtain prenatal care records, including prior obstetric triage and emergency room visits.
Diabetes Care in Triage: for patients with established diagnosis of DM or GDM.
1. Point of Care: Finger Stick Blood Glucose (FSBG) ONCE upon arrival. 2. Record current home diabetes medications in the medical record. 3. POC FSBG: q4 hrs if NPO or Clears. 4. POC FSBS: Fasting and 1hr after meals if has diet. 5. Call provider for BS≥ 160 or ≤ 65 or with symptoms of hypoglycemia
Limited or no prenatal care or Transfer of care:
1. If ≥ 36 weeks gestational age or with risk factors, a. collect and send new OB panel and GBS culture if not done this pregnancy. b. send urine toxicology screen after verbal consent obtained and documented
2. If < 36 weeks without risk factors with no presenting complaint, a. obtain 1 set of vital signs b. obtain medical and obstetric records, if available. c. establish and document fetal well-being and absence of uterine contractions, vaginal bleeding or rupture of membranes d. refer to clinic triage intake to establish ongoing prenatal care
Maternal Fetal Triage Index (MFTI) Implement appropriate infectious disease control processes for triage YES Is the woman presenting for a scheduled procedure and has no complaint? and evaluation.
NO Stat Abnormal Vital Signs 1 PRIORITY Maternal HR <40 or >130, apneic, Sp0 <93%, SBP ≥160 or Does the woman or fetus 2 DBP ≥110 or <60/palpable, No FHR detected by doppler have STAT/PRIORITY 1 vital (unless previously diagnosed fetal demise), FHR <110 bpm for >60 seconds signs? Immediate lifesaving intervention required, such as: OR YES YES Maternal STAT/ Does the woman or fetus • Cardiac compromise • Acute mental status change or PRIORITY 1 • Severe respiratory distress unresponsive (cannot follow verbal require immediate lifesaving • Seizing commands) intervention? • Hemorrhaging • Signs of placental abruption • Signs of uterine rupture OR Fetal Is birth imminent? • Prolapsed cord Imminent Birth • Fetal parts visible on the perineum • Active maternal bearing-down efforts
NO Urgent Abnormal Vital Signs 2 Maternal HR >120 or <501, PRIORITY 1 1 Temperature ≥101.0°F, 38.3°C, RR >26 or <12, Sp02 <95% , SBP ≥140 or DBP ≥90 symptomatic or <80/40, repeated; FHR >160 bpm for >60 seconds; decelerations Does the woman or fetus have URGENT/PRIORITY 2 Severe Pain: (unrelated to ctx) ≥7 on a 0–10 pain scale vital signs? Examples of High-Risk Situations OR • Unstable, high risk medical conditions • <34 wks c/o of SROM/leaking or Is the woman in severe pain • Difficulty breathing spotting without complaint of YES YES • Altered mental status • Active vaginal bleeding (not contractions? URGENT/ spotting or show) PRIORITY 2 • Suicidal or homicidal OR • c/o of decreased fetal movement • <34 wks c/o of, or detectable, 2 Is this a high-risk situation? uterine ctx • Recent trauma OR Will this woman and/or new- ≥34 wks with regular contractions or SROM/leaking with any of the following born require a higher level of • HIV+ • Multiple gestation care than institution provides? • Planned, medically-indicated cesarean • Placenta previa (maternal or fetal indications) • Breech or other malpresentation Transfer of Care Needed NO • Clinical needs of woman and/or newborn indicate transfer of care, per hospital policy
Prompt Abnormal Vital Signs 3 Does the woman or fetus PRIORITY Temperature >100.4°F, 38.0°C1, SBP ≥140 or DBP ≥90, asymptomatic1 have PROMPT/PRIORITY 3 YES YES Prompt Attention, such as: vital signs? PROMPT/ • Signs of active labor 34 weeks PRIORITY 3 ≥ OR • c/o early labor signs and/or c/o SROM/leaking 34–36 6/7 weeks Does the woman require • ≥34 weeks with regular contractions and HSV lesion prompt attention? • ≥34 weeks planned, elective, repeat cesarean with regular contractions • ≥34 weeks multiple gestation pregnancy with irregular contractions • Woman is not coping with labor per the Coping with Labor Algorithm V23
NO
Non-Urgent YES NON- YES Non-urgent Attention, such as: 4 Does the woman have a PRIORITY URGENT/ complaint that is non-urgent? • ≥37 weeks early labor signs and/or c/o SROM/leaking PRIORITY 4 • Non-urgent symptoms may include: common discomforts of pregnancy, vaginal discharge, constipation, ligament pain, nausea, anxiety. NO DRAFT Scheduled or Is the woman requesting Woman Requesting A Service, such as: Requesting 5 PRIORITY a service and she has no • Prescription refill YES YES • Outpatient service that was missed complaint? SCHEDULED/ OR REQUESTING Scheduled Procedure PRIORITY 5 Does the woman have a Any event or procedure scheduled formally or informally with the unit scheduled procedure with before the patient’s arrival, when the patient has no complaint. no complaint?
1High Risk and Critical Care Obstetrics, 2013 2Trauma may or may not include a direct assault on the abdomen. Examples are trauma from motor vehicle accidents, falls, and intimate partner violence. 3Coping with Labor Algorithm V2 used with permission The MFTI is exemplary and does not include all possible patient complaints or conditions. The MFTI is designed to guide clinical decision-making but does not replace clinical judgement. Vital signs in the MFTI are suggested values. Values appropriate for the population and geographic region should be determined by each clinical team, taking into account variables such as altitude. ©2015 Association of Women’s Health, Obstetric and Neonatal Nurses. For permission to use MFTI or integrate the MFTI into the Electronic Medical Record contact [email protected]. Page 1 of 2
Alameda Health System
MEDICAL RECORD DELINQUENCYAND MEDICAL STAFF SUSPENSION: AMBULATORY
Department Health Information Management Effective Date New Policy Campus All Ambulatory Clinics Date Revised 8/2017 Unit Ambulatory/HIM Next Scheduled Review 8/2020 Manual Health Information Management Author Director, Medical Records Replaces the following Policies: Responsible Person Chief Administrative Officer, Chief Information Officer (CIO) Printed copies are for reference only. Please refer to electronic copy for the latest version.
Purpose
To describe the process for suspension of provider privileges for delinquent medical records. Timely completion of ambulatory medical records is essential for ensuring patient safety, continuity of care and appropriate clinical care, especially when outpatients are seen in other locations subsequent to their outpatient visits.
Policy
All documentation for outpatient encounters (clinic visits and outpatient procedures) should be completed within 3 days of the clinic visit. Residents should complete documentation on the day of the encounter, and supervising attendings are expected to co-sign encounters within 3 days of the clinic visit.
Documentation will begin to appear on the ‘delinquent’ list at day 7.
Provider privileges shall be suspended when completion of the clinic or procedural progress note exceeds 21 days after the clinic encounter.
Procedure
1. The Medical Record Department will generate a weekly report that lists all documentation that is incomplete for more than 7 days after the clinic visit from the outpatient EHR (clinics not utilizing the EHR will be exempt from this policy until they are on the EHR). The Medical Record Department will distribute this list on a weekly basis to all individuals on the delinquent list and to Department/Clinic leaders.
2. Providers with incomplete documentation will be listed starting at day 7 on the weekly list of overdue missing documentation. The provider (s) to whom the incomplete medical record is assigned shall be notified ("D7 - first notice of impending suspension").
3. Seven days later, the missing documentation list will be e-mailed again. a. If the record has been completed, the provider shall be removed from the suspension list. Page 2 of 2
b. If the record remains incomplete, the provider shall be issued a second notice ("D14 - second notice of impending suspension").
4. Seven days after, the missing documentation list will be e-mailed again. a. If the record has been completed, the provider shall be removed from the suspension list. b. If the record remains incomplete, the provider shall be notified his/her privileges have been suspended effective immediately ("D21 - Suspension") and will not be allowed to practice at AHS clinics until privileges are re-instated i. Shall have this suspension noted in his/her provider privileging file ii. Shall have the suspension documented on his/her Ongoing Professional Performance Evaluation (OPPE), and iii. May trigger a Focused Professional Performance Evaluation (FPPE) for multiple occurrences
5. The suspension process shall be temporarily halted for provider vacation or illness. a. The provider and/or Department Chair or designee is responsible for informing HIM. b. The suspension process shall start in the next business day after the provider's return.
6. The Department Chairs and/or designees shall be notified weekly of all providers to whom suspension notices have been issued (D7, D14, D21).
7. Suspension shall be immediately rescinded once incomplete records have been completed.
Process map: [Needs to be created from above]
Approval
Departmental Date: 8/2017 Medical Records Committee Date: 8/2017 Medical Executive Committee Date: 10/2017 Board of Trustees Date:
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Alameda Health System
MEDICATION KITS/TRANSPORT BOXES FOR SPECIFIC DEPARTMENTS AND DIVISIONS
Department Pharmacy Effective Date New Policy Campus Highland Date Revised 10/2017 Unit Pharmacy Next Scheduled Review 10/2020 Manual Multidisciplinary Clinical Author Director, Pharmacy Services Replaces the following Policies: Responsible Person Chief Administrative Officer Printed copies are for reference only. Please refer to electronic copy for the latest version.
Purpose
Different departments/divisions store boxes or kits to get access to mediations in their specific areas, where Automated Dispensing Machines (ADM, e.g. Pyxis) are not accessible and/or certain specific drugs are not included in crash cart. These departments/divisions include Allergy Clinic, Anesthesiology, Cardiology, Diagnostics, Oral Surgery, Operating Room and Radiology.
Other medication kits are assembled and put in ADM by pharmacy for the ease of removal under specific situations.
Procedure
Preparation
1. Pharmacy staff fills medications listed in the boxes and kits. Non-medicinal supplies in oral surgery boxes are filled by the Oral Surgery division.
2. Pharmacy staff records expiration dates of mediations on the content list.
3. Pharmacy staff who prepares the box or kit will sign and date on the content list.
4. Pharmacist will check all medications against the content list for correct quantity and expiration.
5. Pharmacist will sign and date the content list after checking the box or kit.
6. The signed and dated content list will be put inside the box or kit.
7. A copy of this content list can be put outside the box or kit. Or a sticker with the name of earliest expired drug and expiration date will be put outside the box or kit. This is to identify when to replace the content of the box or kit.
8. Pharmacy will put a tamper resistance lock on the checked box or kit to ensure the box or kit is secured before being dispensed. Page 2 of 3
Dispensing
1. When a box or kit is needed for a procedure by a department/division, the department/division staff will come to pharmacy to pick up the specific box or kit.
2. Pharmacy staff, before dispensing the box or kit, will make sure the lock is secured and medications are not expired.
3. Pharmacy staff fills out the dispensing log to indicate when and where the box/kit is dispensed.
Storage
1. Each department/division is responsible to store the box/kit in an area where direct supervision of its usage is allowed until the procedure is complete.
2. Anesthesia department, oral surgery division and radiology department will store the boxes/kits in their areas until replacement.
3. Such storage area should be easily monitored by the department or division staff to prevent unauthorized usage.
Administering and Returning
1. When a medication is needed, the department staff will break the lock to open the box or kit.
2. The department/division staff will put the patient addressograph sticker on the content list for subsequent billing by pharmacy.
3. The department/division staff will return the used box or kit with the patient stamped content list to pharmacy for replacement.
4. In the situation where the lock is found broken in the department/division but medications are not used, the box or kit should be returned to pharmacy for checking.
Replacement
1. Pharmacy will follow the procedures under “Preparation” in this policy to replace and refill any medications used in the box or kit that is returned from the department/division.
2. When the box or kit is pending to expire, the department/division staff is responsible to inform pharmacy and bring the box or kit to pharmacy for replacement.
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Medication kits stored in Automated Dispensing Machine (ADM, e.g. Pyxis)
1. These kits are assembled in pharmacy and checked by pharmacist before putting in ADM.
2. Kits are removed from ADM according to the ADM procedure.
3. A refill or stock out report will be printed in pharmacy to prompt for replacement.
4. Used kits should be placed in the “return to pharmacy” bin for pick up and return to pharmacy.
List of Specific-Medication Boxes or Kits (See Attachment A)
Department/Divisions Name of Emergency Box/Kit Allergy Clinic Allergy Emergency Kit Anesthesiology Anesthesia Intubation Box Anesthesiology Anesthesia Intubation Kit (to be put in the transport bag) Cardiology/Radiology Cardiac CT Scan/Nuclear Medicine Box Maternal Child Health OB Code Stork Bag – Medication Box Oral Surgery Oral Surgery Box Radiology Radiology Contrast Allergic Reaction Kit
List of Medication Kits Stored in Automated Dispensing Machines (Pyxis) (See Attachment B)
Locations Name of Medication Kit ACT-7th floor, Infusion Center Chemotherapy Agent Extravasation Kit Emergency Department, Cath Lab Heart Alert (STEMI) Kit Operating Room OR Emergency Kit (Anesthesia Pyxis) Emergency Department, Floor Units, Rapid Response Intubation (RSI) Kit Cath Lab, GI Lab/Pulmonary Emergency Department Calcium Gluconate Kit, Tranexamic Acid (TXA) Kit-- ED Operating Room Anesthesia Support Kit Operating Room Tranexamic Acid (TXA) Kit -- OR Highland Care Pavilion-Diagnostics Electrocardiography (EKG) Medication Kit
STEMI = ST-Elevation Myocardial Infarction; GI= Gastrointestinal; ED = Emergency Department; OR = Operating Room
Approvals
Departmental Date: 10/2017 Pharmacy and Therapeutics Committee Date: 10/2017 Medical Executive Committee Date: 11/2017 Board of Trustees Date:
Attachment A: List of Specific-Medication Boxes or Kits
Allergy Clinic Kit
Drug Quantity Expiration Albuterol Inh. 90 mcg/puff HFA Inhaler 1 Diphenhydramine Inj. 50mg/mL 1mL vial 1 Epinephrine 0.3mg auto-injector (Epi-Pen) 2 Methylprednisolone Inj. 125mg vial 1 Opti-haler 1 Syringe for Injection, 3mL 4 Needle, 25G 1½ inches 4 Alcohol Swab 4
Prepared By: ______Checked By: ______
Date: ______Date: ______
Revised 11.6.2017
Anesthesia Intubation Box
Drug Quantity Expiration 0.9% Normal Saline Inj. 10 ml vial 4 Atropine Inj. 0.1 mg/ml 10 ml syringe 1 Calcium Chloride Inj. 10% 100 mg/ml 10 ml syringe 1 Chloraseptic Topical Spray (Phenol 1.4%) 177 ml bottle 1 Ephedrine Inj. 50 mg/ml 1 ml ampule 1 Epinephrine Inj. 0.1 mg/ml (1:10,000) 10 ml syringe 1 Esmolol Inj. 10 mg/ml 10 ml vial 1 Etomidate Inj. 2 mg/ml 20 ml vial 1 Flumazenil Inj. 0.1 mg/ml 5 ml vial 1 Labetalol Inj. 5 mg/ml 20 ml vial 1 Lidocaine Inj. 2% 20 mg/ml 5 ml syringe 2 Lidocaine Topical Jelly 2% 5 ml tube 2 Naloxone Inj. 0.4 mg/ml 1 ml vial 2 Phenylephrine Inj. 10 mg/ml 1 ml vial 2 Propofol 1% 10 mg/ml 20 ml vial 1 Rocuronium Inj. 10 mg/ml 10 ml vial 1 Succinylcholine Inj. 20 mg/ml 5 ml syringe 2 Sodium Citrate/Citric Acid (Bicitra) Oral Solution 15 ml UD cup 2
Prepared By: ______Checked By: ______
Date: ______Date: ______
Revised 11.6.2017
Anesthesia Intubation Kit (to be put in Anesthesia Airway Backpack)
Drug Quantity Expiration Atropine Inj. 0.1 mg/ml 10 ml syringe 1 Ephedrine Inj. 5 mg/ml 5 ml syringe 1 Epinephrine Inj. 0.1 mg/ml (1:10,000) 10 ml syringe 1 Etomidate Inj. 2 mg/ml 10 ml vial 1 Phenylephrine Inj. 100 mcg/ml 10 ml syringe 1 Propofol Inj. 10 mg/ml 20 ml vial 2 Rocuronium Inj. 10 mg/ml 10 ml vial 1 Succinylcholine Inj. 20 mg/ml 5 ml syringe 2 Sugammadex 100 mg/ml 2 ml vials 7
Prepared By: ______Checked By: ______
Date: ______Date: ______
Revised 11.6.2017
Cardiac CT Scan/Nuclear Medicine Box
Drug Quantity Expiration Albuterol Inhaler 90 mcg/puff 8 gm inhaler 1 Aminophylline Inj. 25 mg/ml 10 ml vial 2 Atropine Inj. 0.1 mg/ml 10 ml syringe 2 Digoxin Inj. 0.25 mg/ml 2 ml ampule 4 Diphenhydramine Inj. 50 mg/ml 1 ml vial 4 Epinephrine Inj. 0.1 mg/ml (1:10,000) 10 ml syringe 2 Esmolol Inj. 10 mg/ml 10 ml vial 2 Furosemide Inj. 10 mg/ml 4 ml vial 4 Glucagon Inj. 1 mg vial 2 Methylprednisolone Succinate Inj. 125 mg vial 1 Metoprolol 100 mg oral tablet 6 Metoprolol Inj. 1 mg/ml 5 ml vial 6 Nitroglycerin Inj. 5 mg/ml 10 ml vial 4 Nitroglycerin Spray 400 mcg/spray aerosol solution bottle 1 Nitroglycerin Sublingual 0.4 mg tab 25 tabs bottle 1 Ondansetron Inj. 2 mg/ml 2 ml vial 2 Phenylephrine Inj. 10 mg/ml 1 ml vial 2 Sterile Water Inj. 10 ml vial 2
Prepared By: ______Checked By: ______
Date: ______Date: ______
Revised 11.6.2017
OB CODE STORK BAG – MEDICATION BOX
Quantity Drug Expiration Date 2 Oxytocin (Pitocin) 10 units/ml 1 ml vial
5 Misoprostol (Cytotec) 100 mcg tablet
Prepared by: ______Date: ______
Checked by: ______Date: ______
Revised 11.6.2017
Oral Surgery Box
Drugs Qty. Expiration Date
Atropine Inj. 0.4 mg/ml 1 ml Vial 2 Supplies Qty. Dextrose 50% Inj. 0.5 gm/ml 50 ml Syringe 1 Diphenhydramine Inj. 50 mg/ml 1 ml Vial 1 Alcohol Pads 8 Ephedrine Inj. 50 mg/ml 1 ml Ampule w/ Filter needle 1 BD 10ml Syringe w/ Luer Lock Tip 2 Blunt Fill Needles Epinephrine 1:10,000 Inj. 0.1mg/ml 10 ml Syringe 2 BD 5 ml Syringe 3 Epinephrine 1:1000 Inj. 1 mg/ml 1 ml Ampule 1 BD Eclipse 18G x1½” Needles 4 Flumazenil Inj. 0.1 mg/ml 5 ml Vial 1 Labetalol Inj. 5 mg/ml 20 ml vial 1 BD Eclipse 3 ml Syringe w/ 21G x1½” Needle 3 Lidocaine 2% Inj. 20 mg/ml 5 ml Syringe 3 CPR Mask 1 Lidocaine Gel 2% 5 ml Tube 2 Extension Set w/ y-site 1 Methylprednisolone Inj. 125 mg Vial 1 IV Catheter 18G x1¼” 2 Naloxone Inj. 0.4 mg/ml 1 ml Vial 2 IV Catheter 20G x1¼” 2 Nitroglycerin SL Tablet 0.4 mg/tab #25 tab Bottle 1 IV Catheter 22G x1” 2 Normal Saline 250 ml Bag 1 IV Start Kit w/Chloral Prep 2 Sterile Water Inj. 10 ml Vial 2 Oxygen Mask 1 Succinylcholine Inj. 20 mg/ml 5 ml Syringe 2 Regular IV Set 1 Terbutaline Inj. 1 mg/ml 1 ml Vial 2 Verapamil Inj. 2.5 mg/ml 2 ml Vial 2
Prepared By: ______Checked By: ______
Date: ______Date: ______
Drugs are replaced by pharmacy. Supplies are replaced by dental dept. oral surgery staff.
Revised 11.6.2017
Kit #: ______
Radiology Contrast Allergic Reaction Kit
Medication Quantity Expiration Diphenhydramine Inj. 50 mg/ml 1 ml Vial 1 Epinephrine Inj. 1 mg/ml (1:1000) 1 ml Vial 2 Methylprednisolone Inj.125 mg Vial 1
Prepared By: ______Checked By: ______
Date: ______Date: ______
Epinephrine Dosing: Hypersensitivity Reaction (e.g. anaphylaxis): IM administration in the anterolateral aspect of the middle third of the thigh is preferred in the setting of anaphylaxis. Subcutaneous administration results in slower absorption and is less reliable.
IM (preferred): Adults: 0.2 to 0.5 mg (0.2 to 0.5 ml) of 1 mg/ml solution every 5 to 15 minutes. Peds: 0.01 mg/kg (Max 0.3 mg) of 1 mg/ml solution (AAAAI [Lieberman 2015]; AHA [Vanden Hoek 2010]; WAO [Kemp 2008])
Revised 11.6.2017
Attachment B: List of Medication Kits Stored in Automated Dispensing Machines (Pyxis)
CHEMOTHERAPY AGENT EXTRAVASATION KIT
Quantity Medication Expiration date
1 Sodium Bicarbonate 8.4% - 50mEq/50ml Vial
1 Sodium Thiosulfate 25% - 12.5 gm/50ml vial
1 Hyaluronidase 150 units/1 ml vial (Amphadase) ***(Stored in Refrigerator)***
1 Topical DMSO 50% -- 50 ml vial (RIMSO-50)
4 0.9 % Sodium chloride inj. USP- 10 ml vials
2 Dexrazoxane 500mg vial
Hyaluronidase inj (Amphadase) is good for up to 30 days at room temperature.
EXPIRATION DATE: ______
CHECKED BY: ______(Pharmacist)
DATE: ______
***Please call Inpatient Pharmacy at 44223 or 44222 if you need the replacement of any medication in the extravasation kit.*** Revised 11.6.2017
CALCIUM GLUCONATE KIT
Quantity Content Expiration 1 D5W 100 ml Bag 1 Calcium Gluconate 1gm/10 ml vial 1 Syringe 10 ml 1 18G Needle Add 10 ml of calcium gluconate (1gm/10ml) to 100 ml D5W and infuse over 30 minutes.
For hyperkalemia, calcium gluconate 1 gm/D5W 100 ml bag can be infused over 5 minutes.
Beyond Use Date (BUD): Administer within 1 hour of mixing for immediate use. After starting administration, the bag is good for a total of 24 hours from time of mixing.
Please put a BUD sticker on bag.
Tech/RPh:______/______
Date:______
Revised 11.6.2017
Electrocardiography (EKG) Kit
Medication Strength Quantity Expiration Atropine inj. 1 mg/10 ml Syringe 1 Diphenhydramine inj. 50 mg/1 ml Vial 1 Dobutamine 500 mg/250 ml Bag 1 Metoprolol inj. 5 mg/5 ml Vial 1 Nitroglycerin SL tablet 0.4 mg 2 bottles (25 tabs/bottle)
Revised 11.6.2017
HEART ALERT (STEMI) Kit (STEMI = ST-Elevation Myocardial Infarction) Medication Name with Earliest Expiration: ______Expiration Date: ______
Medication Name Dose Time Route Documented in Quantity in Exp. Date Quantity Given MAR Kit Used Atropine Inj 1mg (0.1 mg/ml) 10 ml prefilled syringe Epinephrine Inj 1mg (1:10,000) 10 ml prefilled syringe Lidocaine Inj 2% (100mg/5ml)
5 ml prefilled syringe Amiodarone Inj 150mg (50mg/ml) 3 ml vial Diphenhydramine Inj 50mg/ml 1 ml vial
Heparin Inj 1000units/ml 10 ml vial Nitroglycerin Inj 50mg/250ml (200 mcg/ml) bottle Aspirin 81 mg chewable tablet
Clopidogrel 75 mg tablet
Metoprolol 25 mg tablet
Nitroglycerin 0.4 mg sublingual tablets
This kit is replaced by pharmacy. When it is removed from Pyxis, a refill or stock out report will prompt pharmacy to replace the used kit. Place the USED kit in the pharmacy pick up bin.
Prepared By: ______Checked By Pharmacist: ______Date Checked: ______
Revised 11.6.2017
Anesthesia Support Kit
Quantity Medication Expiration 1 Ephedrine 50 mg/ml (1 ml) vial/ampule 1 Etomidate 2 mg/ml (10 ml) vial 1 Norepinephrine 1 mg/ml (4 ml) ampule 1 Propofol 10 mg/ml (20 ml) vial 1 Rocuronium 10 mg/ml (10 ml) vial 1 Succinylcholine 20 mg/ml (5 ml) syringe
Back up medications for situations like power outage and Pyxis failure. The kit is stored in a locked box.
Revised 11.6.2017
Rapid Sequence Intubation (RSI) Kit
Quantity Medication Expiration 1 Etomidate 2 mg/ml (20 mg/10 ml) vial
1 Rocuronium 10 mg/ml (100 mg/10 ml) vial
2 Succinylcholine 20 mg/ml (100 mg/5 ml) syringes
Prep by: ______Checked by: ______
Date: ______Date: ______
Revised 11.6.2017
Tranexamic Acid (TXA) Kit – ED Massive Transfusion Protocol (MTP)
Quantity Content Expiration 2 Tranexamic Acid 1000 mg/10 ml 1 Normal Saline (NS) 100 ml Bag 1 Normal Saline (NS) 500mL Bag 1 Filter Needle* (only if ampoules are used) *Draw up drug with filter needle from ampoule
Indication: MTP activated patient within 3 hours of his/her injury
Loading dose: 1000 mg in 100 ml NS infuse over 10 minutes Second dose: 1000 mg in 500 ml NS infuse over 8 hours
Beyond Use Date (BUD): Administer within 1 hour of mixing for immediate use. After starting administration, the bag is good for a total of 24 hours from time of mixing.
Please put a BUD sticker on bag.
Prep by: ______Checked by: ______
Date: ______Date: ______
Revised 11.6.2017
Tranexamic Acid (TXA) Kit -- OR Massive Transfusion Protocol (MTP)
Quantity Content Expiration 1 Tranexamic Acid 1000 mg/10 ml 1 Normal Saline (NS) 500 ml Bag 1 Filter Needle* (only if ampoules are used) *Draw up drug with filter needle from ampoule
Indication: MTP activated patient within 3 hours of his/her injury
Second dose: 1000 mg in 500 ml NS infuse over 8 hours
Beyond Use Date (BUD): Administer within 1 hour of mixing for immediate use. After starting administration, the bag is good for a total of 24 hours from time of mixing.
Please put a BUD sticker on bag.
Prep by: ______Checked by: ______
Date: ______Date: ______
Revised 11.6.2017
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Alameda Health System
MEDICATIONS: LOOK-ALIKE, SOUND-ALIKE
Department Pharmacy, Nursing, Medical Staff Effective Date New Policy Campus AHS System Date Revised 5/2017 Unit Pharmacy Next Scheduled Review 5/2020 Manual Multidisciplinary, Clinical Author Director, Pharmacy Replaces the following Policies: Responsible Person CNE, CMO, CAO Printed copies are for reference only. Please refer to electronic copy for the latest version.
Purpose
To ensure Alameda Health System (AHS) has a system in place to eliminate medication errors caused by the procurement, storage, dispensing and administration of look alike, sound alike medications.
Policy
1. The Institute of Safe Medication Practices will be reviewed to identify those medications to add to AHS Sound Alike Look Alike List.
2. At least annually, AHS Pharmacy and Therapeutics Committee will review and update (if needed) the list of look-alike/sound alike drugs used by the organization
3. AHS will regularly provide information to professional staff on drugs that have been determined be problematic through published reports or internal issues.
4. To assist with the reducing the likelihood of medication events associated with Look Alike/Sound Alike medications, AHS will make every effort to comply with the following risk reduction strategies: a. Pre-printed order forms or order sets will be used whenever possible. b. Prescribers will give verbal or telephone orders only when truly necessary, and never for chemotherapeutics. Staff to read back all orders, spell the product name, and state its indication. c. Computer screen selection and automatic dispensing machine screens (ADM’s) will use Tallman Lettering to display easily confused medications whenever possible. d. Medications labels will include both generic and trade names to make them easier to distinguish whenever possible. e. Separate look-alike or sound-alike medications in the pharmacy and in the automated dispensing machine in the units.
5. Problematic medications and safety strategies identified by the Medical Staff and Pharmacy will be instituted per the guidelines referenced below.
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ACUTE CARE HOSPITALS
MEDICATIONS SAFETY STRATEGY ALPRAZolam LORazepam • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label amanTADINE AmioDARONE • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label buPROPion BuSPIRone • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label carBAMazepine OXcarbazepine • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label CISplatin (Platinol) CARBOplatin (Paraplatin ) • Pre-printed order forms are used to clearly identify medication being ordered. • stored solely in the pharmacy. • Products are separated by at least one shelf and clearly marked. • No medication abbreviations are accepted. • Orders are double checked by two pharmacists and two nurses prior to administration. DOPamine DOBUTamine • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label glipiZIDE GlyBURIDE • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label Heparin HEPARIN (pediatric strength • Stored in limited supply in Automated Dispensing machines. versus adult) • Double checked by pharmacy before restocking Automatic Dispensing Machine (ADM) • Heparin drip requires double RN signature during medication administration and each dose titration hydrALAZINE hydrOXYzine • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label predniSONE prednisoLONE • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label levoFLOXacin levETIRAcetam • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label
Tdap Dtap • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label riFAMpin riFAXimin • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label
HYDROmorphone morphine • The PF morphine injection (Duramorph) is restricted to pharmacy for (Dilaudid) (Astramorph, Duramorph) compounding. • Dispensing of these medications are controlled and tracked through the Automated dispensing machines. • Stored in the ADM in different cubies and/or different drawers. • Tallman lettering. Insulin products HumuLIN • Only approved insulin products are stocked in the nursing unit to limit the variety. • Lantus and Lente HumaLOG • The removal of insulin doses are recorded and tracked through the automated NovoLOG dispensing machines. • Humalog and • All insulin short acting medications are available as vials while insulin long acting • Humulin NovoLIN medications are available as pens whenever possible. • Novolog and • All insulin medications are patient specific and clearly marked with auxiliary • labels to differentiate the products and are patient specific (except for the ED). Novolin • Tallman lettering • Humalog and • Novolog • Novolin 70/30 and • Novolog Mix • 70/30
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MEDICATIONS SAFETY STRATEGY DOXOrubicin DAUNOrubicin • Pre-printed order forms are used to clearly identify medication being ordered. • stored solely in the pharmacy. • Products are separated by at least one shelf and clearly marked. • No medication abbreviations are accepted. • Orders are double checked by two pharmacists and two nurses prior to administration. PACLitaxel (Taxol) DOCEtaxel (Taxotere) • Pre-printed order forms are used to clearly identify medication being ordered. • stored solely in the pharmacy. • Products are separated by at least one shelf and clearly marked. • No medication abbreviations are accepted. • Orders are double checked by two pharmacists and two nurses prior to administration. vinCRIStine (Oncovin) vinBLAStine (VELBAN) • Pre-printed order forms are used to clearly identify medication being ordered. • stored solely in the pharmacy. • Products are separated by at least one shelf and clearly marked. • No medication abbreviations are accepted. • Orders are double checked by two pharmacists and two nurses prior to administration. MetFORMIN metroNIDAZOLE • Store separately from each other in different cubies in the ADM. (GLUCOPHAGE) (FLAGYL) • Tallman lettering and Auxiliary label
FOSphenytoin (Cerebyx) PHENYtoin (Dilantin) • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label
HYDROcodone OxyCODONE (immediate • Store separately from each other in different cubies in the ADM. release) • Tallman lettering and Auxiliary label
MS Contin (morphine OxyCONTIN (extended • Store separately from each other in different cubies in the ADM. extended release) Release) • Tallman lettering and Auxiliary label
PHENYLephrine NOREPInephrine • Store separately from each other in different cubies in the ADM. (Neo-Synephrine) (Levophed) • Tallman lettering and Auxiliary label Levofloxacin (Levaquin) LevETIRAcetam (Keppra) • Store separately from each other in different cubies in the ADM. LevETIRAcetam (Keppra) LevOCARNitine • Tallman lettering and Auxiliary label LevOCARNitine methylene blue VisionBlue • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label soluCORTEF soluMEDROL • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label
Ambulatory Care, Behavioral Health, and Long Term Care
MEDICATIONS SAFETY STRATEGY buPROPion busPIRone • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label citalopram hydrobromide (CeleXA) Celecoxib (CeleBREX) • Prescribers will give verbal or telephone orders only when truly necessary.
• Staff to read back all orders, spell the product name, and state its indication.
• Whenever possible, prescribers will include brand and generic names when writing orders and use computer generated or typed prescriptions. cloNIDine (Catapress) ClonazePAM (Klonopin) • Prescribers will give verbal or telephone orders only when truly necessary.
• Staff to read back all orders, spell the product name, and state its indication. • Whenever possible, prescribers will include brand and generic names when writing orders and use computer generated or typed prescriptions. Concentrated: Conventional: • Concentrated oral morphine solutions are only dispensed upon receipt of an morphine oral liquid morphine oral liquid order for a specific patient (not as unit stock). Roxanal, MSIR • The concentrated solution is segregated from the other concentrations in the Page 4 of 5
Pyxis C2 Safe. • Concentrated solutions are purchased and dispensed in dropper bottles and dispensed as unit dose for inpatients. chlorproMAZINE chlordiazePOXIDE • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label DULoxetine FLUoxetine • Store separately from each other in different cubies in the ADM. PARoxetine • Tallman lettering and Auxiliary label Insulin products HumuLIN • Only approved insulin products are stocked in the nursing unit to limit the • Lantus and Lente HumaLOG variety. • Humalog and NovoLOG • The removal of insulin doses are recorded and tracked through the • Humulin NovoLIN automated dispensing machines. • Novolog and • All insulin short acting medications are available as vials while insulin long • Novolin acting medications are available as pens. • Humalog and • All insulin medications are patient specific and clearly marked with auxiliary • Novolog labels to differentiate the products and are patient specific (except for the • Novolin 70/30 and ED). • Novolog Mix • Tallman lettering • 70/30 • lamiVUDine lamoTRIgine • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label Terbinafine (LamISIL) Lamotrigine (LaMICtal) • Prescribers will give verbal or telephone orders only when truly necessary.
• Staff to read back all orders, spell the product name, and state its indication. • Whenever possible, prescribers will include brand and generic names when writing orders and use computer generated or typed prescriptions. ThioTHIXine thioRIDazine • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label traZODone traMADol • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label Nefazodone (Serzone ) Quietapine (SEROquel) • Prescribers will give verbal or telephone orders only when truly necessary.
• Staff to read back all orders, spell the product name, and state its indication. • Whenever possible, prescribers will include brand and generic names when writing orders and use computer generated or typed prescriptions. Olanzapine (ZyPREXA) Cetirizine (ZyrTEC) • Prescribers will give verbal or telephone orders only when truly necessary.
• Staff to read back all orders, spell the product name, and state its indication. • Whenever possible, prescribers will include brand and generic names when writing orders and use computer generated or typed prescriptions. Hep A Vaccine ADULT HAVRIX 1440 • For those campuses that carry both Adult and Pediatric doses, adult dosing syringes will be labeled “Adult” • ADULT dose syringes stored on separate shelf from pediatric dose syringes • Pharmacist to double check all syringes & dosage prior to loading in Pyxis • Nurses to confirm ADULT and dosage prior to administration
References
The Joint Commission Medication Management MM.01.02.01 Institute for Safe Medication Practices: ISMP’s List of Confused Drug Names https://www.ismp.org/tools/confuseddrugnames.pdf
Page 5 of 5
Approvals:
AHS Core Alameda Hospital San Leandro Hospital Pharmacy Department Date 12/2016 12/2016 12/2016 Pharmacy and Therapeutics Date 2/2017 4/2017 3/2017 Clinical Practice Council Date 6/2017 Patient Care Leadership Team Date 7/2017 Medical Executive Committee Date 11/2017 11/2017 11/2017 Board of Trustees Date:
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Alameda Health System
MEDICATIONS; PRESCRIBING AND ORDERING
Department Pharmacy Effective Date 10/06 Campus AHS Core Date Revised 10/06, 2/2011, 3/2017 Unit All Next Scheduled Review 3/2020 Manual Clinical Practice Author Director of Pharmacy Medication safety officer Replaces the following Policies: Responsible Person Chief Nurse Executive Printed copies are for reference only. Please refer to electronic copy for the latest version.
Purpose
1. The formulary system improves patient care by promoting rational and discriminate drug therapy, providing medications in a timely manner and generally at a lower cost to the patient because of the contractual prices.
2. Non-formulary medications may be required; therefore, an efficient mechanism to assist in expediting the procurement of those medications is necessary for optimal patient care.
3. To support safe prescribing or ordering of all medications.
Policy
Medications are prescribed or ordered in compliance with all applicable law, regulation, licensure, and professional standards of practice. The Pharmacy and Therapeutics (P&T) Committee develops and maintains a drug formulary based on need, effectiveness, risks, and cost criteria. There is also a mechanism in place to procure non-formulary medications that are prescribed. The hospital will also maintain appropriate policies and procedures that support prescribing or ordering practices.
Procedure
Hospital Formulary
1. The hospital formulary or drug list is available on the AHS Intranet. Requests for the addition of drugs to the formulary are presented to the P&T Committee by individual physicians following department or service review. Completion of the Formulary Requests is required. The P&T Committee reviews the medications based on: a. Need – based on the diseases and conditions treated by the medication b. Effectiveness – efficacy, toxicity, pharmacokinetics, bioequivalence, pharmaceutical equivalence, and therapeutic equivalence. c. Risk – incidence of adverse reactions and tendency to be problem prone d. Cost – cost impact on the organization.
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2. The P&T Committee will approve medications for formulary addition for a three month trial to assess the utilization. Medications that are not utilized during the trial period may be removed from the formulary. In addition, any medication which is not utilized for one year will be deleted from the formulary unless a special circumstance exists.
Non-Formulary Medications
1. Medications not on formulary may be requested and procured. However, the pharmacist receiving the order may suggest a therapeutically equivalent formulary approved medication if one exists. If the physician insists upon a non-formulary item, the medication will be procured in the smallest amount possible. Procuring a non-formulary item may result in a delay of treatment and a higher cost may be incurred by the patient (See Pharmacy Non- Formulary Medication procedure).
Medication Shortages and Outages
1. The hospital communicates when medication is unable to be procured. Pharmacy notifies appropriate physicians, nursing and staff by way of multiple avenues including interdepartmental memos, email, newsletters and appropriate committees.
2. In the event of a disaster, medications will be obtained in accordance with Emergency Preparedness plan.
Sample Medications
1. Medication samples from manufactures are not allowed to be brought into the hospital by physicians, patients, or pharmaceutical sales representatives to be stocked or dispensed to patients, except: a. In the case of special clinical circumstances deemed appropriate by the physician or, b. When the medication cannot be procured through regular means, in such cases, the patient or his/her physician can supply the medication (this may include sample medications). The medications must be sent to Pharmacy for appropriate identification and labeling prior to distribution to the patient.
Drug Order Renewal
1. See Clinical Practice policy Medications: Automatic Stop Order
STAT Orders
1. STAT orders entered in the Pharmacy computer system should be verified by Pharmacy within 30 minutes unless the order is in question and delivered to the requesting unit to assure administration to the patient within 1 hour of the order
“As Needed” (PRN) Orders
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1. Orders for PRN medications must be accompanied by an indication for which the use of the drug is intended and frequency of use.
“Hold” & “Restart” Orders
1. Medication orders for patients going to surgery are discontinued. Blanket reinstatement of previous medication orders is not acceptable.
Titrate Orders
1. Medication orders for patients that receive an IV medication admixed in an IV solution (per manufacturer’s recommendations) and administered at an increasing or decreasing dose/rate until a desired response is achieved per MD parameters.
Taper (“Wean”) Orders
1. Medication orders for patients that receive an IV medication admixed in an IV solution (per manufacturer’s recommendations) gradually reduce/discontinued per a physician’s order of discontinuance.
Resume and Range Orders are not accepted
Medication related devices require an order.
Orders for compounded drugs or drug mixtures not commercially available will be specified by the ordering prescriber.
Medication Prescribing
1. Physicians, Dentists, and Podiatrists with staff privileges may prescribe medications at AHS. Mid-level Practitioners may prescribe medications at AHS under the scope of practice as defined by the Interdisciplinary Practice Committee. Verbal/telephone orders for drugs shall be given only to licensed personnel within their scope of practice by a person lawfully authorized to prescribe and shall be recorded promptly in the patient’s medical record, noting the name of the person giving the order and the signature of the individual receiving the order and the Read Back completed. The use of verbal and telephone orders will only be utilized as deemed absolutely necessary. The prescriber shall countersign the order with 48 hours. For outpatient prescriptions, the following professionals may prescribe medications to be filled at AHS: physicians, dentists and podiatrists. Written and verbal/telephone orders shall include the name of the drug, the dosage and the frequency of administration, the route of administration, if other than oral, and the date, time and signature or the prescriber. Orders for drugs shall be clear by the prescriber. There is a documented diagnosis, condition, or indication-for-use for each medication ordered in the patient’s record. Medications may be ordered as generic or brand. Prescription pads will be kept in a secure place away from public access at all times.
Page 4 of 5
2. Patient specific information is readily accessible, utilizing the H&P, chart, MAR and computerized lab, registration and ED software.
3. Licensed practitioner involved in the management of the patients medications shall have the following accessible: a. Patient identifiers b. Age c. Sex d. Diagnosis, comorbidities or problems e. Allergies f. Height, weight, pregnancy and lactation status g. Laboratory information
4. All medication orders for pediatric patients must be ordered as a weight-based dose, i.e as “mg/kg” or “mcg/kg”, though total dose may be included in the order. The pharmacist will verify that total dosage amounts are correctly calculated.
5. Medication orders must contain: a. The name of the drug (generic and/or brand) b. The dose c. The route d. The frequency. e. Indication of use (if not found in the medical record) f. Indication or reason for use is required for ALL as needed (PRN) medications g. The name of the ordering prescriber. h. The date and time the order. i. If the order is a telephone order, the name and title of the person receiving and recording the order j. Source of authorization (e.g. Anti-Coagulation policy, per Vancomycin Protocol), Renal Dosing Protocol and Autosubstitution Policy if ordered on behalf of Medical Staff.
Medication Orders for Standardized Procedures
1. All standardized procedures that contain medication orders as specified by the Interdisciplinary Practice Committee must be reviewed and approved by the Pharmacy and Therapeutics Committee.
Standing/Pre-printed Medication Orders
1. Standing and/or Preprinted orders must: a. Be reviewed and approved by the P&T Workgroup for Pharmacy-related orders. b. Standing orders must be reviewed every three years? c. Preprinted orders must be reviewed every three years? d. Have a revision date indicated at the bottom of the order.
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Radiographic Contrast Media
See Clinical Practice policy Medications: Contrast Media
Radioactive Medications
See Clinical Practice policy Radioisotope Therapy
Dialysis Medications
See Dialysis policy and procedure manual
Respiratory Therapy
See Respiratory Therapy policy and procedure manual.
Environmental Services
See Environmental Services (EVS) policy and procedure manual on repackaging and relabeling of bulk cleaning agents, and disposal of hazardous waste materials.
Discharge Prescriptions
Clinical Practice policy Medications: Discharge Prescriptions
Reference
The Joint Commission MM.02.01.01, MM.04.01.01,
Approvals
Departmental Date: 2/2017 Pharmacy and Therapeutics Committee Date: 3/2017 Medical Executive Committee Date: 11/2017 Board of Trustees Date:
Alameda Health System
SCOPE OF SERVICE - HEALTH INFORMATION MANAGEMENT
Department Health Information Management Effective Date 5/03 Campus System-wide Date Revised 8/2017 Unit Health Information Management Next Scheduled Review 8/2020 Manual Health Information Management Author Director, HIM Replaces the following Policies: Responsible Person Chief Financial Officer (CFO) Printed copies are for reference only. Please refer to electronic copy for the latest version.
Purpose
To ensure adequate information is available to the members of the healthcare team and other health care providers and when necessary to provide effective patient treatment. To process and maintain patient care information for the continuity of patient care research, legal purposes, and justification for reimbursement, service utilization and other administrative purposes. Develop and coordinate medical record reviews, evaluate and make available to all employees the tools and supplies needed to efficiently perform their duties. Continue monitoring all of the chart requests to increase/maintain chart availability. Monitor unit expenses to avoid exceeding the approved budget.
The department is responsible for maintaining the patient’s hybrid medical record, as well as the accuracy of the computerized patient index. It maintains the indices required by the Joint Commission and the California Department of Public Health through accurate and timely abstracting and coding and secure storage. Provide and maintain a unit record, in a timely and efficient manner. Maintaining the confidentiality of protected health information. Assuring availability to patient requestors of the patient’s medical record information. Assuring accurate reporting is provided to OSHPD by coding and reporting data as required. Provide records or statistical information to hospital users for research, statistics, reimbursement, and related activities.
Policy
Retain, house and make reasonably accessible, all patient related information obtained during the course of inpatient and/or outpatient medical treatment for a period of not less than ten years (per CHA Retention Laws). Abstract and code data from inpatient admissions for both internal and external uses in a format that satisfies requirements of the Office of Statewide Health Planning and Development. Provide sub-registrar function for Office of Vital Record for fetal deaths and live births not occurring and occurring in the hospital. Ensure medical records compliance with governmental and hospital Medical Staff Bylaws regulations. Process and provide information in the medical record for all professional staff, patients and outside agencies as outlined in departmental and hospital policies and procedures. Handle physician requests for information for Peer Review, Statistical Data, etc. The department also provides patient information to other health care providers when valid and deemed necessary for adequate
patient treatment, maintaining legal criteria, which applies to HIPAA and the confidentiality of the patient’s record.
Future goals of the department are to achieve a level of adequate information systems in our department such as; a master patient index, chart locator, physicians’ statistical data reporting system and electronic medical record that are automated. Maintain an environment for the continuous education and training necessary for the compliance of the laws, governing the patient’s medical record. Comply with regulatory agencies’ policies. Remain survey ready. Continue staff development plans for each employee and correct all duplicate medical record numbers. The continuous goal is to provide quality and cost effective services with a continued emphasis on providing patient medical records for all patient care related activities and continue to code diagnosis and procedures for patients with accuracy and in a timely manner.
Procedure
I. ORGANIZATION OF THE DEPARTMENT
a. Hours of Operation: Health Information Management is open seven days a week, 8:00am – 4:30pm. The Release of Information unit’s business hours are from 8:00am– 4:30pm, Monday thru Friday. b. Location: Location of HIM Department varies by facility.
II. REQUIREMENTS FOR STAFF
a. Required certifications The Health Information Management Coders are credentialed by the American Health Information Management Association as a Certified Coding Specialist (CCS), or a Certified Coding Associate (CCA). The Director of Health Information Management must be credentialed through the American Health Information Management Association as either a Registered Health Information Administrators (RHIA), Registered Health Information Technologist (RHIT)
III. RECOGNIZED STANDARDS/GUIDELINES USED
The Health Information Management Department adheres to the Center of Medicare and Medicaid Services (CMS), California Department of Public Health (CDPH), The Joint Commission of Accredited Hospital Organization (TJC) rules and regulations. The Coders follow the coding guidelines as documented from Coding Clinic, American Medical Association, American Health Information Association and American Hospital Association. They also follow the coding and sequencing instructions in the ICD-9-CM Coding Manual as well as the Coding Clinic. The California Department of Public Health, Title 22 and the Conditions of Participation from the Center of Medicare and Medicaid Services (CMS) provide the regulations for the completion of medical records and suspension functions of the Health Information Management Department.
Approvals:
AHS Core Alameda Hospital San Leandro Hospital Pharmacy Department Date 8/2017 8/2017 8/2017 HIM Committee Date 8/2017 Medical Executive Committee Date 11/2017 11/2017 11/2017 Board of Trustees Date:
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Alameda Health System
VANCOMYCIN PHARMACY DOSING PROTOCOL
Department Pharmacy Effective Date 2/2011 Campus Highland Date Revised 10/2017 Unit Pharmacy Next Scheduled Review 10/2020 Manual Pharmacy Author Director, Pharmacy Services Replaces the following Policies: Responsible Person Chief Administrative Officer Printed copies are for reference only. Please refer to electronic copy for the latest version.
Purpose
To enhance the safe and effective use of vancomycin and to increase antibiotic stewardship for this medication with a pharmacist dosing and monitoring protocol.
Definitions/Equations
AdjBW Adjusted body weight = ) AUC Area under the curve = TDD/CLVa AUC:MIC Ratio of AUC to MIC = AUC/MIC Modified Cockroft-Gault equation (see number 1, part C).
BMP Basic metabolic panel CLCr Creatinine clearance (mL/min) Modified Cockroft-Gault equation to be used CLVa Vancomycin clearance (L/h) = CLCr (mL/min) 0.045 DBW Dosing Body Weight: If TBW ≤ (IBW x 120%), use TBW If TBW > (IBW x 120%), use AdjBW IBW Ideal Body Weight(kg) For FEMALES = 45.5 + (2.3 x [height(in) - 60]) For MALES = 50 + (2.3 x [height(in) - 60]) MIC minimum inhibitory concentration Scr serum creatinine TBW total body weight (kg) TDD Total Daily Dose of vancomycin (mg) Vd Vancomycin volume of distribution = 0.7 x DBW
Policy
All adult patients on intravenous vancomycin, excluding 24-hour pre-op/post-op prophylaxis orders, will be dosed by the pharmacy department.
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1. The prescriber will initiate vancomycin therapy by ordering “Vancomycin Dosing per Pharmacy.”
2. The prescriber will include the indication for vancomycin use on the vancomycin order. If the indication is not readily apparent, the validating pharmacist will contact the prescriber to establish an indication. The pharmacist will determine the goal vancomycin trough level as per the ACMC Vancomycin Pharmacy Dosing Protocol (see Dosing Protocol below). a. Note: vancomycin therapy should not be withheld while awaiting an indication. If an indication cannot be established in a timely manner, the pharmacist will proceed with initial vancomycin dosing and assume an initial target trough of 15-20 mcg/mL. b. If a prescriber elects to order a specific vancomycin dosing regimen, the pharmacist may modify the initial regimen in accordance with the Dosing Protocol.
3. The pharmacist will use his/her clinical judgment in conjunction with the Dosing Protocol when writing orders for vancomycin.
4. Under the vancomycin dosing protocol the pharmacist will have authority to a. Order sCr and/or BMP as needed b. Order vancomycin trough and/or random levels as needed c. Adjust vancomycin dosing regimen as needed d. These orders will be designated “per vancomycin protocol.”
5. If the pharmacist determines that vancomycin cannot be safely and effectively dosed for a particular patient and indication (e.g. vancomycin MIC ≥ 2 mcg/mL in Staphylococcus aureus infection), the pharmacist will contact the physician to recommend an alternative agent and/or consultation with the Infectious Disease service.
Dosing Protocol
1. Pharmacokinetic parameters a. Vancomycin will be dosed to target steady-state trough values based on indication.
Indication Trough (mcg/mL)
• Brain/Epidural Abscess • Endocarditis • Meningitis 15-20 • Osteomyelitis • Pneumonia • Prosthetic joint infection • Sepsis • Cellulitis, Skin and Soft tissue infection • Cystitis 10-15 • Neutropenic fever • Prophylaxis (i.e. drains, shunts) Page 3 of 8
Indication Trough (mcg/mL)
*Note: these targets are applicable only to adult patients, and only for empiric therapy or directed therapy with vancomycin MIC ≤ 1 mcg/mL
*Note: the pharmacist, in collaboration with the prescriber and the Infectious Disease service, may elect instead to dose vancomycin to a targeted AUC:MIC. This decision must be a consensus among the three listed parties, and must be clearly documented in the patient chart.
b. Vancomycin dosing body weight (DBW) will be used for all initial dosing. c. Vancomycin clearance (CLVa) will be calculated using creatinine clearance. Creatinine Clearance (CLCr) will be calculated using the Cockroft-Gault equation, whenever appropriate, with the following adjustments: i. For patients with TBW < IBW and sCr < 0.8 mg/dL, round sCr to 0.8 mg/dL. ii. For patients aged ≥ 65 yrs with sCr < 1 mg/dL, round sCr to 1 mg/dL. d. Doses will preferentially be rounded to the nearest 250 mg increment.
2. Loading Dose a. Patients with acute infection and/or with impaired renal function (including dialysis) should receive a loading dose of 20-25 mg/kg (using DBW) to a maximum of 2000mg. b. In the event that a first vancomycin dose of less than 20-25 mg/kg is administered to the patient, the pharmacist will use clinical judgment to adjust dosing, e.g.: i. Ordering a supplemental dose to achieve a full loading dose. ii. Retiming subsequent doses to achieve desired steady-state concentrations.
3. Initial Maintenance Dose a. Initial maintenance dosing will be calculated based on patient-specific pharmacokinetic factors, e.g. Vd, CLVa, targeted vancomycin trough. b. The pharmacokinetic software T.D.M.S. 2000Precise PK should be used as an approved aid to clinical judgment in creating vancomycin regimens (see Appendix A: T.D.M.SPrecise PK.). If the T.D.M.S.Precise PK software is unavailable for any reason, a dosing nomogram based on recommendations from T.D.M.S. 2000 Precise PKmay also be used (see Appendix B: Vancomycin Dosing Nomogram). c. The initial maintenance dose should not exceed a 4000mg/24 hour period, unless patient history warrants otherwise. Doses will be rounded to the nearest 250mg. d. In patients with severe renal impairment (i.e. CLCr < 20 ml/min) subsequent dosing status post the loading dose will be based on interpretation of vancomycin levels.
4. Monitoring a. Serum creatinine levels (Scr) are recommended: i. At initiation of the vancomycin maintenance dosing regimen. Loading doses should be administered regardless of serum creatinine availability. Page 4 of 8
ii. Every 48-72 hours during vancomycin therapy if not already ordered by prescriber. iii. Additionally as deemed appropriate by the pharmacist b. Vancomycin trough levels are recommended for patients who: i. Receive dosing to target trough levels of 10-20 mcg/mL. ii. Receive dialysis. iii. Are at heightened risk of nephrotoxicity (i.e. receiving concurrent IV contrast, loop diuretics, NSAIDs, aminoglycosides, amphotericin, cyclosporine, tacrolimus, vasopressors, or chemotherapy.) iv. Have changing renal status. Significant change in renal function is defined as: • Abrupt change in Scr by ≥ 0.3mg/dL (within 48h), or • A percentage change in Scr by ≥ 50% from baseline, or • A reduction in UOP (documented oliguria of < 0.5mL/kg/h for > 6h) v. Have atypical or dynamic Vd (e.g. morbid obesity, burns, dialysis). c. Vancomycin trough levels should be obtained as deemed appropriate per the pharmacist: i. Within the first three days of therapy. • It is recommended to obtain levels near steady state (e.g. fourth or fifth dose of regimen, including loading doses where applicable). If level obtained prior to steady state, interpretation of levels is warranted. ii. Once patient is stable on a regimen; it is recommended to obtain weekly levels thereafter pending patient has stable renal function with an appropriate clinical response. d. Vancomycin “random” levels may be obtained at the discretion of the pharmacist, and may be appropriate for patients who: i. Have severe renal impairment (e.g. CLCr < 20 ml/min) ii. Have atypical or dynamic Vd (e.g. morbid obesity, burns, dialysis)
5. Instructions for drug administration around trough levels: a. All vancomycin doses should be administered to patients as scheduled. b. If appropriate, a pharmacist may elect to defer vancomycin administration until a satisfactory vancomycin level has been achieved. The choice to hold a vancomycin dose while awaiting a level must be communicated to the responsible nurse through either oral or electronic communication by the pharmacist or the prescriber. i. In this situation, the pharmacist will discontinue the discrete vancomycin regimen, adding and just keep the “Vancomycin per pharmacy” placeholder on the patients MAR/MAK. The pharmacist will enter a replacement vancomycin regimen when supported by pharmacokinetic and clinical data.
6. Maintenance Dose Adjustment: a. The pharmacist will assess all vancomycin levels for accuracy and validity, and adjust vancomycin accordingly to achieve intended pharmacokinetic parameters based on pharmacokinetic and clinical interpretation of patient- and lab-data. b. The pharmacokinetic software T.D.M.S. 2000Precise PK should be used as an approved aid to clinical judgment in adjusting vancomycin regimens. Round dose to the nearest 250mg. Page 5 of 8
7. Maintenance Dose Adjustment in Special populations: a. The “Vancomycin Dosing per Pharmacy” order will remain active on the MAR/MAK for the duration of vancomycin therapy for the below patient populations. b. Patients on Chronic Intermittent Hemodialysis: i. An initial level prior to 1st hemodialysis session will be obtained (e.g. just prior to dialysis by the hemodialysis nurse). If a level cannot be obtained prior to dialysis, it may be obtained at a minimum of four hours after dialysis (to allow for drug redistribution). ii. Assume an approximate of 25% drug removal by standard high-flux hemodialysis at Highland Hospital. iii. If the pre-dialysis level is > 23mcg/mL hold post-dialysis dose and obtain another random level prior to next dialysis session. iv. If pre-dialysis level is between 18-23 mcg/mL, give the below maintenance dose post-dialysis: Patient’s DBW ≤ 49kg = 250 mg Patient’s DBW = 50-90kg = 500 mg Patient’s DBW ≥ 91kg = 750 mg v. If pre-dialysis level is < 18 mcg/mL, add an additional 250mg to current post-dialysis maintenance dose. Obtain another random level prior to next dialysis session. vi. If level was obtained post dialysis, extrapolate pre-dialysis level by multiplying obtained level by 1.25 and adjust dosing as per above for pre- dialysis levels. v. Once patient has had two levels within range on the same regimen, levels should be drawn at least weekly thereafter. c. Patients receiving pulse hemodialysis (not chronic): i. Hemodialysis schedule will be followed on a daily basis via: nephrology team, hemodialysis nurse, bedside nurse and/or primary team. ii. Subsequent dosing status post the loading dose will be based on interpretation of vancomycin levels. A pulse dose should be given once a random vancomycin level falls below the desired the goal. iii. Refer to chronic hemodialysis section for pulse dose recommendation.
8. Storage and Documentation a. Patient information and dosing history will be securely stored in the T.D.M.S. 2000Precise PK database located on the central hospital server and on the paper vancomycin daily monitoring sheets. Pharmacists will update patient information for monitoring safety and efficacy of vancomycin for the duration of vancomycin therapy. b. The pharmacist will complete a pharmacokinetic progress note at minimum on initiation of therapy and with each vancomycin level interpretation. The progress note will be included in the “consultations” section of the patient chart.
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Protocol Review:
The vancomycin protocol will be assessed annually by pharmacy to ensure optimized dosing and clinical outcomes, and to seek opportunities for improvement.
References
1. Centers for Disease Control and Prevention. Recommendations for preventing the spread of vancomycin resistance: recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR Morb Mortal Wkly Rep. 1995; 44(No. RR-12):1- 13. 2. Rybak M, Lomaestro B, Rotschafer JC, et al. Therapeutic monitoring of vancomycin in adult patients: a consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm. 2009; 1:82–98. 3. Ariano RE, Fine A, Sitar DS, Rexrode S, Zelenitsky SA. Adequacy of a vancomycin dosing regimen in patients receiving high-flux hemodialysis. Am J Kidney Dis. 2005 Oct;46(4):681- 7. 4. Pai AB, Pai MP. Vancomycin dosing in high flux hemodialysis: a limited-sampling algorithm. Am J Health Syst Pharm. 2004 Sep 1;61(17):1812-6. 5. Zelenistky, SA et al. Initial vancomycin dosing protocol to achieve therapeutic serum concentrations in patients undergoing hemodialysis. Clin Infect Dis. 2012 Aug;55(4):527-33. 6. Brown, M et al. Weight-based loading of vancomycin in patients on hemodialysis. Clin Infect Dis. 2011;53(2):164.\
Approvals
Departmental Date: 10/2017 Pharmacy and Therapeutics Committee Date: 11/2017 Medical Executive Committee Date: 11/2017 Board of Trustees Date:
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Appendix A: T.D.M.S. now also know as Precise PK
T.D.M.S. 2000TM Therapeutic Drug Monitoring System (Healthware, Inc. ©1986-2012, http://www.tdms2000.com/) is a software package for therapeutic drug monitoring, with capability to monitor and interpret levels for 16 different drugs. It has a 30 year track record of clinical use, and is beta-tested by the Applied Pharmacokinetics Service at UC San Diego Medical Center and at Rady Children’s Hospital, San Diego.
T.D.M.S. 2000TM uses a set of pharmacokinetic equations to calculate population pharmacokinetic parameters based on patient-specific data, predicting steady-state drug levels for regimens inputted by the user. The equations are assessed and updated twice annually. When analyzing drug levels, T.D.M.S. 2000TM uses Bayesian and nonlinear least-squares fitting algorithms, combining dosage and serum concentration data with population pharmacokinetic parameters, to create modified pharmacokinetic parameters and predictions of steady-state levels for regimens inputted by the user.
T.D.M.S. 2000TM allows for creation of a patient database, retaining patient drug history, patient-specific pharmacokinetic parameters, and inter-user communication via patient- and case-specific notes. It also can create a pre-populated note that can be used for patient charting.
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Appendix B: Vancomycin Dosing Nomogram
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Alameda Health System
INFECTION PREVENTION AND CONTROL ANNUAL PLAN: 2016 ASSESSMENT 2017 PLAN
Department Infection Control Effective Date New Plan Campus AHS Core Date Revised 10/2017 Unit Infection Control Next Scheduled Review 10/2020 Manual Infection Control Author Director, Infection Control Replaces the following Policies: Responsible Person Interim VP of Quality Printed copies are for reference only. Please refer to electronic copy for the latest version.
Table of Contents
EXECUTIVE SUMMARY ...... 2 INTRODUCTION...... 4 Infection Prevention and Control ...... 4 Vision Statement ...... 4 Mission Statement ...... 4 Scope of Service ...... 5 Geography, Community, Population, Care, Treatment and Services ...... 5 Authority and Responsibilities ...... 8 Surveillance...... 9 EFFECTIVENESS OF 2016, RISK ASSESSMENT, and PLANNING FOR 2017 ...... 10 Surveillance Activity: Hand Hygiene ...... 10 Surveillance Activity: Central Line-Associated Blood Stream Infections ...... 11 Surveillance Activity: Catheter-Associated Urinary Tract Infections ...... 13 Surveillance Activity: Surgical Site Infections by Procedure ...... 15 Surveillance Activity: Hospital-Acquired Multi-Drug Resistant Organisms ...... 18 Surveillance Activity: Hospital-Acquired Clostridium difficile ...... 20 Surveillance Activity: M. tuberculosis Statistics ...... 21 Fairmont Hospital IRF ...... 23 Surveillance Activity: Influenza Vaccination ...... 24 Employee Health: Bloodborne Pathogen Exposures ...... 25 Surveillance Activity: Antibiotic Stewardship ...... 26 Surveillance Activity: High Level Disinfection (HLD)...... 27 Surveillance Activity: Immediate Use Steam Sterilization (IUSS) ...... 27 Surveillance Activity: Compliance with Isolation Precautions ...... 28 PROGRAM ELEMENTS ...... 28 Resource Allocation: Needs for 2017 to effectively manage IP program ...... 28 Infection Control Log: Major Incidents/Investigations 2016 ...... 29 Strategies to Minimize, Reduce, and Eliminate Infection Risk ...... 29 APPENDIX A: Employee Health ...... 36 Influenza Vaccination Compliance Grid, 2015-2016 Season ...... 36 Bloodborne Pathogen Exposures in 2016 ...... 36 Bloodborne Pathogen Plan Annual Review Statement ...... 37 APPENDIX B: TB Exposure Control Plan ...... 37 APPENDIX C: Infection Control Risk Assessment 2017 ...... 39
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EXECUTIVE SUMMARY
• Hand Hygiene: In 2016, the HH program is enhanced with unit based HH champions who are trained to do HH interventions and collect HH compliance data. This data will be provided to AHS managers on a monthly basis for timely feedback of performance improvement trends and activities. The hand hygiene program continues to make HH an organizational priority and is part of the Culture of Safety. John George and Fairmont Rehab achieved goal of >90% compliance. Highland and Fairmont SNF averaged 84% and 79% respectively. Action: Continue unit based champions, increase Hand Hygiene campaigns within all facilities.
• Device Related, Central Lines and Urinary Catheters: Central Lines Associated Blood stream infections (CLABSIs) did not meet goal in the IUC, and trended up for 2016, with a SIR of 1.23. Goal was met in the non-ICU areas with a SIR of 0.56. Action: Continue to analyze data in NHSN. Stratify data to reflect number of days from CVC insertion, to identify area of opportunities between insertion best-practice and maintenance best- practice. Physician led development of CVC insertion checklist. Continue Prevalence studies focusing on central line management and daily line necessity.
Catheter-Associated Urinary Tract Infections: did not meet goal facility-wide (ICU and non-ICU) with a SIR of 2.10 (ICU) and 1.22 (non-ICU). Data analysis of Standardized Utilization Ratio (SUR), shows that our line days are higher than predicted. Action: Continue implementation of nurse-driven protocols for removal of Foleys. Reassess indications for continued indwelling vs. intermittent catherization. Implement and monitor elements of performance for CAUTI prevention, by Joint Commission’s National Patient Safety Goals)
• Surgical Site Infections (SSI): Surgical site infections between 2015 and 2016 showed a significant reduction with a 2016 SIR of 0.879, which is below national benchmark, thus achieving our goal of <1 SIR. Action: However, Open-fracture reductions and Colon surgeries remain the highest percentage of SSIs of all surgeries being followed. A coordination of QAPI project and a root-cause analysis into Open-fracture reductions (FX) SSI is ongoing into 2017.
• AHS Program involvement in the community: o Highland Hospital received Certificate of Appreciation for outstanding contribution to the 2015 Emerging Infection Program Hospital Healthcare-Associated Infection and Antimicrobial Use Prevalence Survey
o Highland Hospital was also recognized by CALNOC for the CALNOC Annual Performance Excellence Awards, for exemplary work in reducing hospital acquired conditions in 2016, for hospitals with an ADC of 200+, with an annualized average SIR at or below the 50th quartile in CALNOC.
o AHS remain highly involved in with Alameda County Public Health Department in identification and control of TB within our community.
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INTRODUCTION
This document is a comprehensive evaluation, risk assessment, prevention and control plan completed annually. This document may be revised at any time based on significant changes in the healthcare setting and infection control field.
Infection Prevention and Control
The purpose of the Infection Prevention and Control Department is to minimize the morbidity, mortality, and economic burden associated with healthcare-associated infections (HAI) through prevention and control endeavors in both patient and staff populations. Using epidemiological principles, pertinent data are collected and analyzed in order to determine risk factors associated with infection and to define mechanisms of transmission and prevention. The most current CDC/NHSN/McGeer surveillance definitions and comparative databases are utilized to evaluate patient outcomes. The Infection Preventionist uses this information to seek opportunities for improvement; and then plans, implements, and evaluates control strategies. As a resource within Highland Hospital and the community, the Infection Preventionist educates other professionals and the public about risk of infection and measures to minimize and eliminate risk, and to enhance patient safety and quality. The objectives of the program are to:
1. Monitor and evaluate the infection risks and the appropriateness of risk intervention and reduction activities for all patients and personnel
2. Promote prevention, identification, and control of healthcare-associated infections in patients, staff, practitioners, visitors and families
3. To provide directions, information and guidelines in relation to: o Facilities, equipment, and procedures necessary to implement standard and additional (transmission-based) precautions for control of infections o Cleaning, disinfecting and reprocessing of reusable equipment o Waste management o Protection of health care workers from transmissible infections o Infection control practices in special situations
Vision Statement
Alameda Health Systems is committed to providing superior patient care. Alameda Health System’s Infection Prevention and Control’s program reduces health care associated infections.
Mission Statement
The mission of the infection prevention and control program is to promote a healthy and safe environment by preventing transmission of infectious agents among patients, staff and visitors. The goal of the infection prevention program is to provide surveillance, prevention, and control strategies in order to reduce/eliminate HAIs to the irreducible minimum. This will be accomplished in an efficient and cost effective manner by a continual assessment and modification of our services based on regulations, standards, scientific studies, internal evaluations and guidelines. These strategies are intended to support the Alameda Health Systems in the areas of People, Service, Quality, Growth/Community, and Finance.
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A. People • To facilitate participation of each healthcare worker in infection prevention strategies at their level • To promote disease prevention, and control, in HAI reduction • To promote a safe environment for patients, families, visitors, staff, physicians, and others • To limit unprotected exposure to pathogens
B. Service • To provide service excellence
C. Quality • To ensure the safety, health, and welfare of all patients • To evaluate processes and outcomes in order to continuously improve quality, safety, and efficiency
D. Growth/Community • To promote education for patients, and as needed, their families about infection prevention • To enhance patient volume by improving quality of care through reducing HAIs
E. Finance • To provide evidence based infection prevention strategies in a cost effective manner • To enhance cost savings through continuous reduction of HAIs
Scope of Service
The Infection Control Program Plan applies to Alameda Health System (AHS), inclusive of Highland Hospital, John George Psychiatric Pavilion, Fairmont Hospital, and the Ambulatory Clinics. Infection prevention and control is a facility-wide patient safety component involving all departments. The infection prevention program reports through the Alameda Health Systems Patient Safety and Quality, and Medical Executive Committees. The Infection Preventionist, along with the Infection Prevention and Control Committee, determine the specific focus of surveillance, education, and consultation efforts on an ongoing basis, dependent on hospital epidemiology, community disease surveillance and real or perceived local or world threats.
San Leandro Hospital and Alameda Hospital data and Infection Prevention assessments and plans are presented separately, as those facilities continue to operate under their own licenses.
Geography, Community, Population, Care, Treatment and Services
Alameda Health Systems (AHS) is headquartered in the east bay area in Oakland, California. This plan includes the care of inpatients, outpatients, all diagnostic or treatment areas, and support services at Alameda Health Systems. AHS is comprised of three hospital campuses (Highland Hospital, John George Psychiatric Pavilion, Fairmont Hospital) and clinics (Highland, Eastmont, Hayward, and Newark) all located in Alameda County, California.
Specifically, Highland Hospital is a 445 bed acute care hospital which encompasses level 1 trauma, level 2 NICU, medical, surgical, critical care, maternal-child, interventional radiology, acute psychiatric, skilled nursing, acute rehabilitation and emergency services. Fairmont Hospital is a 206 bed inpatient rehabilitation facility (also housed within is subacute and Skilled nursing), and John George is an 80 bed inpatient behavioral health facility. Outpatient includes Highland, Eastmont, Hayward, Newark, and Fairmont Wellness Clinics.
AHS is also a teaching/training institution, and is committed to maintaining an environment that is supportive of a wide range of educational programs and activities including education of medical students, interns, residents, and fellows. AHS provides continuing education for medical, nursing and other staff, along with medical Page 6 of 43 research. AHS has been a nationally recognized teaching institution since 1927, providing 5 major graduate physicians’ residency training programs in internal medicine, general surgery, oral surgery, emergency medicine and primary care.
Statistics for FY 2016 (July 2015- June 2016)
AHS Facilities Statistics - Overall discharges 14,911
- Average daily census 257
- Regional Level I Trauma Center patients served 1,777
- Emergency room visits total 73,962
- Surgeries performed - inpatient and outpatient 5,264
- Maternal-Child Health services deliveries (including NICU) 1,144
Licensed Beds 445
- Highland General Hospital (HGH) 206
- Fairmont Hospital (FH) 159
- John George Psychiatric Pavilion (JGPP) 80
Admissions 14,918
- Highland General Hospital 11,364
- Fairmont Hospital 453
- John George Psychiatric Pavilion 3,101
Average Length of Stay (ALOS; days) (HGH, FH, JGPP) 6.70
- Highland 2.70
- Fairmont 94.87
- John George 8.02
Outpatient Clinic Statistics
- Highland Clinic Visits 170,535
- Eastmont Clinic Visits 65,764
- Hayward Clinic Visits 30,070
- Newark Clinic Visits 27,221
- Fairmont Outpatient Clinic Visits 1,225
- Psych Day Care (patient days) 24,969
Alameda County is the 7th most populous county in California, with a population of approximately 1,647,704 people as reported by the US Census Bureau in 2016 (not including those who are uncounted due to homelessness or illegal immigration).
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Alameda County Demographics* Age and Sex
Persons under 18 years 21.0%
Persons 65 years and over 13.1%
Female persons 50.9%
Race and Hispanic Origin
White alone 50.9%
Black or African American alone 11.6%
American Indian and Alaska Native alone 1.1%
Asian alone 30.2%
Native Hawaiian and Other Pacific Islander alone, 1.0%
Two or More Races 5.3%
Hispanic or Latino 22.5%
White alone, not Hispanic or Latino 32.1%
Language
Language other than English spoken at home, percent of persons age 5 years+, 2011-2015 43.5
Population Characteristics
Foreign born persons, percent, 2011-2015 (1 in 3 residents is an immigrant)** • Asia (62%) • Latin America (26%) • Europe (7%) 31.4% • Africa (2%) • Oceania (2%) • Northern America (1%)
Documented Immigrants** 75%
Undocumented Immigrants** 25%
Health
With a disability, under age 65 years, percent, 2011-2015 6.1%
Persons without health insurance, under age 65 years, percent 6.0%
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Income & Poverty
Median household income (in 2015 dollars), 2011-2015 $75,619
Per capita income in past 12 months (in 2015 dollars), 2011-2015 $37,285
Persons in poverty, percent 11.5%
*United States Census Bureau, Alameda county, California Quick Facts, Retrieved, June 2017 from https://www.census.gov/quickfacts/fact/table/alamedacountycalifornia/PST045216 **Immigration in Alameda County, Retrieved August, 2017 from http://www.acphd.org/media/470440/immig_infog.pdf
Incidence of Reportable Communicable Diseases, Alameda County 2013
Communicable Disease Incidence rate/1000,00 population
Campylobacteriosis 23.9*
Meningitis 6.1*
Salmonellosis 16.1*
Pertussis (whooping cough) 8.9*
HIV Prevalence Rates/100,000 All races population African American 1,3822 White 374.0 Tuberculosis Incidence rate/100,000 population All races 9.1 African American 6.8 Asian Pacific Islander 21.2 Birthplace United States 1.5 Birthplace Outside of United States 22.3
Alameda County Public health Department, Data & Reports, Retrieved, August, 2017 from http://www.acphd.org/data-reports.aspx *Communicable Diseases, Published May 2016 ** HIV in Alameda County, Published February 2017 *** Tuberculosis n Alameda county, Published March 2017
Authority and Responsibilities
The Infection Prevention and Control Committee (IPCC), is a committee of multidisciplinary members, who have the overall authority and responsibility for the Infection Prevention and Control Program. The Infection Preventionist has primary responsibility for the daily management of infection prevention and control activities. This includes developing and implementing policies that govern control of infections and communicable diseases and developing a system for identifying, reporting, investigating and controlling infections and communicable diseases. The Infection Preventionist, Infection Control Committee Chair and/or the Chief Medical Officer has authority to institute any surveillance, prevention, and control measures or studies when there is reason to believe that any patient or personnel may be in danger from a potential or actual outbreak of, or exposure, to infectious disease. All employees have responsibility for adherence to infection prevention and control processes/strategies. The specific verbiage regarding responsibility is detailed in AUTHORITY OF INFECTION CONTROL COMMITTEE, 2017.
The IPCC reports directly to the Medical Executive Committee and provides oversight for the infection control program. The IPCC shall be a medical center wide multidisciplinary committee chaired by a physician who has credentials, knowledge and special experience in infection control. The chairperson must complete the infection control educational requirements mandated by the State of California (SB 1058). The committee shall be Page 9 of 43 composed of physicians, nurses including the infection control practitioners, administration and other assigned members as necessary and appropriate. Membership includes representation from AHS hospitals and ambulatory care clinics. Infection Control Committee Responsibilities: • Meet every other month or more often if needed
• Maintain a record of its proceedings and shall submit reports of its activities and recommendations to Quality & Patient Safety and the Medical Executive Committee
• Review and maintain policies and procedures pertaining to the infection control program at least every three years.
• Update the annual IC Program plan and Risk Assessments.
• Develop and implement a preventive program designed to minimize infection risks.
• Review the antimicrobial susceptibility/resistance trend studies in conjunction with the Antimicrobial Stewardship Program.
• Reviews proposals, protocols and findings for special infection control studies to be conducted throughout the hospital.
Surveillance
The surveillance plan at AHS is determined by the annual IC Risk Assessment, regulatory requirements, mandated public health reporting, and IC staffing resources. CDC National Healthcare Safety Network (NHSN) definitions are used to determine healthcare-associated infections (HAI). AHS Infection Prevention team identifies HAI, communicable diseases and significant microorganisms by reviewing a combination of the following: • Microbiology reports • Referrals from hospital staff and physicians • Daily admissions case finding • Public Health Department communications • Patient records • IC rounding
The ID physician who serves as Chair of the IC Committee is available as needed to consult on SSI, CAUTI and CLABSI cases. Page 10 of 43
EFFECTIVENESS OF 2016, RISK ASSESSMENT, AND PLANNING FOR 2017
Surveillance Activity: Hand Hygiene Evaluation of 2016 Program Effectiveness
Goal 2016 Target 2016 Outcome 2016 Effectiveness 2016
Increase compliance Alameda Healthcare target: Highland Hospital 84% Goal not met and observations 90% Fairmont Hospital SNF 79% Goal not met Fairmont Rehab 99% Goal met John George Psychiatric Goal met 95%
2016 Activities/Analysis
Hand hygiene compliance is audited by observations of gel in / gel out activity. The observers will captures HH activity of all disciplines in the patient care area with the goal to have a significant sample size for each discipline. These data are submitted to IC for collating and reporting purposes.
In 2016, the HH program is enhanced with unit based HH champions who are trained to do HH interventions and collect HH compliance data. This data will be provided to AHS managers on a monthly basis for timely feedback of performance improvement trends and activities. The hand hygiene program continues to make HH an organizational priority and is part of the Culture of Safety.
2017 Surveillance Plan Goal 2017 Program Planned Actions for 2017 Priority Continue high High * • Continue peer audits on floor compliance • Continue education in New Hire Orientation • Continue staff and public education Goal 95% • Continue IPC observations • Continue Hand Hygiene Champions • Hand Hygiene campaign during International Infection Prevention Week, October 15-21, 2017 • Include wellness clinics in Hand Hygiene monitoring * Also required by regulatory agencies and Alameda Health Systems [National Patient Safety Goal (NPSG)]
Patient Population: Inpatient populations Analysis: Incident rate, number compliant over total number observations Case Finding Methodology: 1. Peer observations on units as detailed above 2. IPC staff observations 3. Secret Shoppers Page 11 of 43
Surveillance Activity: Central Line-Associated Blood Stream Infections Evaluation of 2016 Program Effectiveness
Goal 2016 Target 2016* Outcome 2016 Effectiveness 2016
Reduce and Zero central line ICU 1.23 Med Surg ICU Med Surg eliminate CLABSI infections, and or SIR <1 0.56 Goal not Goal , met HAI met 2016 Activities/Analysis Analysis: In 2016 there were 4 CLABSI’s identified in the ICU compared to zero in 2015. 20% more than predicted. There were 3 CLABSIs identified in Med/Surg, 44% lower than national benchmark, statistically significantly lower than benchmark.
Central Line log on nursing units to document daily necessity
CLABSI prevention bundle monitoring (eg. Disinfectant caps on all ports, appropriate labeling on bags and tubing)
Met with Nursing leadership and education to discuss 2017 competencies. Training will include information on CLABSI prevention bundle
Physician and Licensed Independent Practitioner (LIP) training has been created.
Central Line blood draws are prohibited for Blood Cultures.
*(2015 Re-base-lining)
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2017 Surveillance Plan
Goal 2017 Program Planned Actions for 2017 Priority Reduce and eliminate High* • Continue the following engineered systems currently in CLABSI place: o Central line insertion kit with CHG patch Zero central line infections, o Alcohol Line Caps and/or SIRs < the national o Daily CHG bathing in ICU benchmark: o Occlusive dressings and use of line securement ICU SIR < 0.613** device Med Surg SIR < 0.560 • Physician led development of CVC insertion checklist • Continue Prevalence studies focusing on central line PRIME metric goal < 0.613 management and daily line necessity • Continue annual education to physicians and staff • Continue MIDAS processes for best mechanism of documentation of central lines • Develop nursing initiated protocols to remove unnecessary Central Lines * Also required by regulatory agencies and Alameda Healthcare Systems [National Patient Safety Goal (NPSG)] **CMS HAC prevention program 70th percentile
Patient Population: All patients with central lines (ICU and Med/Surg, adult, pediatric) Analysis: Incidence rate per 1000 line days or NHSN Standardized Infection Ratio (SIR) Case Finding Methodology: 1. Infections will be identified through a review of blood cultures and clinical record using the CDC/NHSN definitions and entered into NHSN and the Prime Healthcare PI Dashboard as appropriate 2. Process Review: Prevalence studies to include occlusive dressing, CHG protective disk, labeling, and use of alcohol swab caps, securement devices, daily line necessity, and immediate change of soiled dressings or gauze dressings Page 13 of 43
Surveillance Activity: Catheter-Associated Urinary Tract Infections Evaluation of 2016 Program Effectiveness
Goal 2016 Target 2016* Outcome 2016 Effectiveness 2016
Reduce and Zero catheter associated ICU 2.10 Med Surg 1.22 ICU Med Surg eliminate CAUTI infections, and or SIR <1 Goal Goal not not met met 2016 Activities/Analysis
In 2016 there were 11 CAUTI’s identified in the ICU, 120% more than national. There were 7 CAUTIs identified in non-ICU units, 22% more than national bench march.
Updated Foley Cather log on the nursing units to document daily necessity Monitoring of CAUTI prevention bundles (eg, foley catheter has securement device, bags not on floor, seal not broken, bag not above bladder).
Met with Nursing Leadership and the Education department to discuss 2017 competencies. Training will include information on preventing infections associated Foley Catheters.
Implemented the requirement of the presence of pyuria to process culture.
*(2015 Re-base-lining)
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2017 Surveillance Plan
Goal 2017 Program Planned Actions for 2017 Priority Reduce and High* • Continue engineered systems currently in place: eliminate CAUTI o Assessment of Foley insertion Tray o Use of Foley securement device 0/1000 catheter days, • Perform Prevalence studies focusing on Foley catheter and/or SIR < the line management national benchmark: • Continue annual education to physicians and staff ICU CAUTI < • Support the SCIP and endeavors to remove the urinary 1.035** catheter within 48 hours after surgery Med Surg CAUTI • IPC serve as a resource in developing nurse driven < 0.802 protocols to remove Urinary catheters • Continue processes for best mechanism of documentation PRIME metrics SIR of Foley catheter days in electronic medical record goal ≤ 1.035 • Implement and monitor elements of performance for CAUTI prevention, by Joint Commission’s National Patient Safety Goals)
* Also required by regulatory agencies and Alameda Healthcare Systems [National Patient Safety Goals (NPSG)] **CMS HAC prevention program 70th percentile Patient Population: Patients with urinary catheters (ICU and Med/Surg) Analysis: Incidence rate per 1000 catheter days or NHSN SIR Case Finding Methodology: 1. Review of cultures and clinical record – use NHSN definitions to diagnose CAUTI and enter into NHSN and the Prime Healthcare PI Dashboard as appropriate. Include CAUTI in Rehab Units, Skilled Nursing and Inpatient Behavioral Medicine, as applicable 2. Process Review: Prevalence studies to include appropriateness, care of tubing/bag, securement, tamper seal, prompt removal Page 15 of 43
Surveillance Activity: Surgical Site Infections by Procedure Evaluation of 2016 Program Effectiveness
Goal 2016 Target 2016 Outcome 2016 NHSN Effectiveness Proc # Proc # observed HAIs 2016 SIR Reduce and Zero SSIs, All 1985 38 0.879 Goal met eliminate SSI and or SIR <1 procedures APPY 95 2 BILI 26 2 CEA 3 0 CHOL 254 0 COLO 100 7 CSEC 277 3 FUSN 53 4 FX 259 14 GAST 28 0 HPRO 69 3 HYST 78 0 KPRO 50 0 KTP 1 0 LAM 62 0 NECK 1 0 NEPH 38 0 OVRY 125 0 PACE 9 0 All procedures REC 26 0 include those SB 116 3 reported as SPLE 10 0 required by CMS THOR 44 0 THYR 2 0 and State of VHYS 24 0 California VHSN 6 0 XLAP 229 0 2016 Activities/Analysis
Includes only procedure and associated SSIs that are reported with primary closure technique SSIs by date of event of all procedures, all wound classes = 38, with an SIR of 0.883, 11% less than national benchmark. Of all SSIs FX and COLO showed the highest number of SSIs with 14 and 7 respectively accounting for over 50% of all SSI in all procedure types • Presented SSI data to the Operating Room Executive Committee. • FX and Colon procedures presented to Perioperative Services System • IC and PI to form QAPI project FX SSI’s with Chief of Orthopedic Surgery • A list of patients identified with FX Surgical Site infections was sent to the Quality Department for review. • Surgical Site Infection Prevention policy approved by IC Committee needs organizational approval. • Physician and Licensed Independent Practitioner training have been developed that includes SSI prevention. Current SSI prevention bundle processes in place: • CHG pre-op showers • Screening for MRSA • Pre-op antibiotic dosing within 1-2 hours of incision Page 16 of 43
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2017 Surveillance Plan
Goal 2017 Program Planned Actions for 2017: Priority Reduce and High for FX and • Continue surveillance of the same procedures from eliminate SSI COLO previous year • Continue utilizing CDC, IHI, SHEA and APIC Guidelines Zero SSI infections, Medium for all for Prevention of SSIs and/or SIR < other procedure • Continue serving as a resource for SCIP measures national types • Continue with QAPI project on FX benchmark: o Planned OR tracers ( minimum of 7) COLO SIR < 0.919 • Continue education to physicians and staff as needed HPRO SIR < 0.734 • Discuss with relevant committees further SSI prevention KPRO SIR < 0.600 initiatives to include: HYST SIR < 0.862 o OR Traffic Control FX SIR ≤ 0.734 Enforce AORN Surgical Attire FUSN and CSEC – o o Nasal decolonization for MRSA zero infections or CHG wound irrigation reduce rate from o o Enhance AAMI guidelines for point-of-use pre- 2016 cleaning • Continue use of UV light as part of terminal/end –of-day cleaning and disinfection of the OR Patient Population: Patients that receive the procedures Analysis: Incidence rate per 100 procedures or NHSN SIR Case Finding Methodology: 1. Infections will be identified through review of both inpatient and outpatient records including; wound cultures, antibiotics, and readmissions using the CDC/NHSN definitions and enter into NHSN and Quality Council reporting. 2. Process Review: Prevalence studies to include compliance with the 7 Step Bundle and infection prevention surgical processes Page 18 of 43
Surveillance Activity: Hospital-Acquired Multi-Drug Resistant Organisms Evaluation of 2016 Program Effectiveness
Goal 2016 Target 2016 Outcome 2016 Effectiveness 2016
Reduce and MRSA Bacteremia: <1 SIR MRSA: 1.059 Goal not met eliminate HAIs associated with CRE Bacteremia: 0.5/1000 patient days CRE: 0 Goal met
MDROs VRE Bacteremia: 1.06/10,000 patient days VRE: 0.017 Goal met
2016 Activities/Analysis
Implementation of MDRO reduction strategies: CHG bathing of ICU patients, contact precautions, environmental decontamination, on-demand PCR testing for immediate identification of MRSA for improved isolation and antimicrobial stewardship.
AHS enacts CRE prevention measures as described in the CDC 2015 CRE Toolkit, including application of contact precautions for CRE cases. Active surveillance screening of patients housed in the same area as a CRE case may be performed on recommendation of Infection Control. AHS will use an Interfacility Transfer Form for all CRE case transfers between healthcare facilities.
AHS will participate in the CDPH Bay Area CRE Collaborative that will be in effect from May 2016 - May 2017.
2017 Surveillance Plan
Goal 2017 Program Planned Actions for 2017: Priority Reduce and Low • Continue use of MDRO evidence based practice strategies eliminate MDROs using CDC, SHEA, APIC guidelines • Continue use of CDC, APIC Guidelines for C difficile CRE, VRE <0.5 / • Continue annual education to physicians 10,000 patient days • Implement education in New Hire Orientation • Continue staff and patient/family education upon isolation LabID Event HO • Alameda County requirement to report All LabID events MRSA bacteremia: for CRE SIR < 0.917
Patient Population: All patients Analysis: Incidence rate per 1000 patient days LabID Event HO MRSA bacteremia SIR or CRE and VRE rate/10,000 Case Finding Methodology: 1. Infections will be identified through review of cultures and screenings, clinical records, antibiotics, and readmissions using the CDC/NHSN definitions and enter into NHSN.
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MRSA Screening (per state requirements) and NHSN MRSA Bacteremia Evaluation of 2016 Program Effectiveness
Goal 2016 Target 2016 Outcome 2016 Effectiveness 2016
Comply with Screening on Admission 100% (per Screening on Admission Goal Met state facility policy and procedure) 100% requirement for MRSA screening Goal not met SIR 1.059 LabID MRSA <1 SIR BSI
2016 Activities/Analysis: Screen high risk patient on admission as per required by State of California HAI (patient’s on dialysis, ORTHO surgeries, admission into the ICU) LabID events MRSA Bacteremia for 2016 = 3 Hospital Onset with a SIR of 1.059.
Healthcare Onset MRSA Bacteremia SIR, by Year 3.5
3
2.5
2
1.5
1 SIR (Observed/Predicted) 0.5
0 2012 2013 2014 2015 2016 2016RB SIR 3.3 2.1 0 0.7 0.9 1.059 Observed Count 11 7 0 2 3 3 Predicted Count 3.4 3.4 4.1 2.9 3.3 2.8
2017 Surveillance Plan Goal 2017 Program Planned Actions for 2017: Priority Screening on Low • Continue screening on admission with same risk Admission 100% indicators • Consider using MRSA nasal decolonization for ICU SIR <1 patients • Implement education on New Hire Orientation on MDRO • Continue staff and patient/family education upon isolation Patient Population: All patients Analysis: Incidence rate or NHSN LabID Event HO MRSA bacteremia SIR Page 20 of 43
Case Finding Methodology: 1. Infections will be identified through review of cultures and screenings, clinical records, antibiotics, and readmissions using the CDC/NHSN definitions and enter into NHSN and Quality Council reporting as appropriate
Surveillance Activity: Hospital-Acquired Clostridium difficile Evaluation of 2016 Program Effectiveness
Goal 2016 Target 2016 Outcome 2016 Effectiveness 2016
Reduce and C. difficile: SIR <1 C. difficile: SIR 0.450 Goal met eliminate HAIs associated with C. difficile
2016 Activities/Analysis Target of SIR <1 achieved
Implementation of MDRO reduction strategies: • CHG bathing of ICU patients • Enteric contact isolation • Environmental decontamination by use of bleach for C. difficile room disinfection
Healthcare Onset C. difficile SIR, by Year 1.20
1.00
0.80
0.60
0.40 SIR (Observed/Predicted) 0.20
0.00 2012 2013 2014 2015 2016 2016RB SIR 0.75 0.84 0.59 0.80 0.36 0.45 Observed Count 23 26 21 28 13 13 Predicted Count 30.7 31.2 35.3 35.0 35.9 28.9
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2017 Surveillance Plan Goal 2017 Program Planned Actions for 2017: Priority Reduce and High • Continue use of MDRO evidence based practice strategies eliminate MDROs using CDC, SHEA, APIC guidelines • Continue use of CDPH, CDC, APIC Guidelines for C. LabID Event HO difficile CDI • Continue annual education to physicians SIR < 0.30 • Implement education in New Hire Orientation • Continue staff and patient education upon isolation PRIME goal ≤ 0.8 • Continue use of UV light as part of terminal cleaning for all C. diff isolation rooms.
Patient Population: All patients excluding babies (NICU, nursery, etc.) Analysis: Incidence rate per 10,000 patient days and NHSN LabID Event HO C. difficile SIR Case Finding Methodology: 1. Infections will be identified through review of cultures and screenings, clinical records, antibiotics, and readmissions using the CDC/NHSN definitions and enter into NHSN and the UHS Dashboard as appropriate
Surveillance Activity: M. tuberculosis Statistics
The 2016 TB Statistics and Risk Assessment will be updated in mid-year (June or July) when the County, State and Federal TB statistics become available.
Evaluation of 2016 Program Effectiveness Goal 2016 Target 2016 Outcome 2016 Effectiveness 2016
Identify and Identify and appropriately isolate 100% based on follow-up Goal met early isolation suspected TB Cases: 100% screening and no TB of suspected exposures resulting in cases of M. conversions. tuberculosis
2016 Activities/Analysis 1. In 2016, there were 39 cases of active TB reported to Alameda County Department of Public Health, TB Control Program.
2. In 2016, there were no employee TB screening conversions identified by our Employee Health Department. ---- need to verify.
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2012-2016 Count of Cases (Pulmonary and Extra-Pulmonary involvement), Alameda County** & California (**excludes the City of Berkeley) YEAR ALAMEDA COUNTY** CALIFORNIA
2012 136 2187
2013 114 2164
2014 108 2134
2015 139 2137
2016 136 2073
2016 TB Cases Rates by Location Location Rate per 100,000 Population
Alameda County** 9.1
California 5.3
United States 2.9
2016 Biologic Site of TB Infection, Alameda Health System, Highland Hospital Culture Culture Site Positive Negative Total # of employee TB N N screening conversions (%) (%)
Pulmonary Lungs 16 (70%) 7 (30%) 23
Extra-Pulm Pleural, 5 (71%) 2 (29%) 7 Pericardial, 0 Lymphnodes
Pulm & 8 (89%) 1 (11%) 9 Page 23 of 43
Extra-Pulm
Total 39
2017 Surveillance Plan Goal 2017 Program Planned Actions for 2017 Priority Identify and early High 1. Perform contact investigations when exposures occur and isolation of review case for educational issues. suspected cases of M. tuberculosis. 2. Continue employee TB screening annually.
Continuing clinical 3. Review and update TB Control Plan annually. rounds with pulmonary physician 4. No change to the annual employee TB screening protocol on all high suspect 5. Collaborate with Employee Health for any employee cases of TB. exposures
6. Review cases for performance improvement opportunities related to appropriate precautions
Fairmont Hospital IRF
Goal 2016 Target 2016 Outcome 2016 Effectiveness 2016
Reduce and CAUTI 0 Goal Met eliminate HAIs 0 CLABSI 0 1 LabID MRSA Bactermia
HO LabID C. diff 2016 Activities/Analysis:
Continue surveillance activities
2017 Surveillance Plan Goal 2017 Program Planned Actions for 2017: Priority Maintain, reduce High Dedicate additional point contact infection and/or eliminate preventionist for post-acute care facilities including: MDROs Fairmont Hospital John George Psychiatric Hospital
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Surveillance Activity: Influenza Vaccination
Evaluation of 2015-2016 Influenza Season Program Effectiveness. This is a collaborative effort between Employee Health and Infection Prevention.
Pursuant to California SB 1318, AHS requires all employees, contractors, students, volunteers, persons with privileges on the medical staff, and all other onsite health care workers affiliated with the clinic to either annually receive an influenza vaccination or, as an alternative to the annual influenza vaccination, wear a surgical or procedural mask, or other mask that covers the mouth and nose area of the face while this person is performing his or her duties in any patient care area of the clinic during the influenza season, as defined by the State Health Officer or a local health officer, or both.
Acute care hospitals participating in the Centers for Medicare & Medicaid Services' Hospital Inpatient Quality Reporting Program are required to submit summary data on influenza vaccination of healthcare personnel via the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Hospitals are required to report vaccinations received by healthcare personnel at the facility, vaccinations received outside the facility, medical contraindications and declinations. Data must be reported for all employees on payroll, licensed independent practitioners (who are physicians, advanced practice nurses, and physician assistants affiliated with the hospital but not on payroll), and students, trainees, and volunteers aged 18 or older. Only healthcare personnel physically working in the facility for at least 30 days between October 1 and March 31 should be counted.
Goal 2015-2016 Target 2015- Outcome 2015-2016 Effectiveness 2015- 2016 2016
Achieve same or better 90% 90% compliance for Goal met compliance than last season vaccinations or signed for vaccination and declinations. declination rates 2015-2016 Activities: Annual Influenza Immunization Program, Reporting of vaccine program in NHSN
2016-2017 Surveillance Plan
Goal 2016-2017 Program Planned Actions for 2016-2017: Priority Achieve same or High • Influenza vaccine campaign in September including: better from 2015- o Continue use Flu Champions in key areas such 2016 season. as the ED, ICU and MCH in administering vaccines o Continue department Flu Clinics to administer vaccine o Continue to partner with the Benefits Fair to administer vaccine o Continue with Department Reports to target those that haven’t participated • Target top reasons for declinations in previous years Page 25 of 43
Population: Clinical and non-clinical employees, volunteers, physicians, LIPs, residents, fellows, students, contractors (optional) working in the facility for at least one day during the influenza season Analysis: Incident rate, number receiving the vaccine over total number as defined by CDC guidelines. The information is placed in NHSN Case Finding Methodology: Employee health coordinates data collection to include populations listed above
Employee Health: Bloodborne Pathogen Exposures
Employee Health Services (EHS) monitors and analyzes trends related to significant employee infections, BBP exposures from splash or sharps injury, communicable disease exposures/outbreaks, annual TB screening and TST conversions, influenza vaccinations, and pre-employment screenings and vaccinations. Employee Health and Infection Control share responsibility in exposure prevention, outbreak management and other activities involving employees, contractors and volunteers. EH provides pre-employment screenings & immunizations including management of the influenza vaccination program for employees. EH provides follow up of occupational exposure to or diagnosis of infectious disease in medical center employees. The Infection Control Team and Infectious Disease physician manages patient exposure situations for isolation and prophylaxis if needed.
Evaluation of 2016 Program Effectiveness
Goal 2016 Target 2016 Outcome 2016 Effectiveness 2016
Decrease number of Lower than 2015 Increase/same as previous Goal note met sharps exposure year
2016 Activities Sharps Safety evaluation, Annual review of Blood borne Pathogen Plan, Annual review of needle stick reduction devices at Infection Control and Environment of Care and Value Analysis if needed.
2017 Surveillance Plan Goal 2017 Program Planned Actions for 2017: Priority Reduce the number High Implement campaign to encourage safe needle practices, use of exposures from of protective devices, proper disposal and encourage correct 2014 PPE during splash-producing procedures Ensure that proper PPE is available in all departments Benchmark (EPINet) Develop a specific action plan for employees who are exposed for Needlesticks and to include 3 key elements: Required evaluation with Sharp Exposures: employee health nurse, devise an action plan based upon 19.46 per 100 exposure circumstances, review to confirm terms of action occupied beds plan met
Benchmark (EPINet) for Blood and Body Fluid Exposures 7.23 per 100 occupied beds
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Population: Employees, volunteers, physicians working in the facility Analysis: Incident rate, number of needle sticks/BBP exposures Case Finding Methodology: Exposures reported through loss control
Surveillance Activity: Antibiotic Stewardship
The Antimicrobial Stewardship Program (ASP) will promote and monitor compliance with evidence based guidelines or best practices regarding antimicrobial prescribing which may include but not limited to the following activities including those recommended by the CDC’s Core Elements of a Hospital Antimicrobial Stewardship Program
Evaluation of 2016 Program Effectiveness
Goal 2016 Target 2016 Outcome 2016 Effectiveness 2016
Pharmacy interventions Publish Antibiograms Antibiograms published Goal Met accepted by physicians
2016 Activities Pharmacists review focused/restricted antibiotic usage to determine if ordered appropriately, including the culture results. Recommendations made to physician if issues are identified
2017 Surveillance Plan
Goal 2017 Program Planned Actions for 2017: Priority Continue to Determined by • Collaborate with Antimicrobial Stewardship Team/Project implement ASP • Provide data as requested to the team components of • Assist with education of physicians as requested Antibiotic Stewardship program
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Surveillance Activity: High Level Disinfection (HLD)
Evaluation of 2016 Program Effectiveness
Goal 2016 Target 2016 Outcome 2016 Effectiveness 2016
Ensure compliance with Documentation: 90% Documentation: 100% Documentation: both the process and Process: 100% Process: Gaps in process Goal met documentation of HLD Process: Gaps in by direct observation of processes infection prevention 2016 Activities Evaluate use of Cidex OPA in Central Sterile processing; and other areas performing HLD, explore the purchase of additional H2O2 Trophon in Vaginal Probe Ultrasound. Both were monitored for process and documentation.
2017 Surveillance Plan Goal 2017 Program Planned Actions for 2017: Priority Improve on Process High Complete and total assessment of all areas performing HLD compliance 100% Develop and implement overarching AHS policy based on best- Continue same practice guidelines by CDC, AAMI and AORN. documentation 100% Re-education and competency of all staff performing HLD
Population: Items needing High Level Disinfectant Analysis: Incidence rate, observations of process and documentation elements Case Finding Methodology: Direct observation and review of documentation
Surveillance Activity: Immediate Use Steam Sterilization (IUSS)
Sterile Processing reports quarterly to IC Committee on Immediate Use Steam Sterilization performance improvement.
Evaluation of 2016 Program Effectiveness Goal 2016 Target 2016 Outcome 2016 Effectiveness 2016
Minimize use of the <2% 4% Goal not met Express cycle 2016 Activities
Standardized system for dirty instrumentation transport
2017 Surveillance Plan Goal 2017 Program Priority Planned Actions for 2017:
Achieve IUSS below the High Continue current processes including exploration of ways to AHS benchmark of <2% reduce the need to use the express cycle
Expand the hours of service for CSP Page 28 of 43
Population: Items processed via Express Cycle Analysis: Incidence rate, count of express cycles outlined by AAMI standards Case Finding Methodology: Log review, aggregated results from CSP Supervisor or OR Director
Surveillance Activity: Compliance with Isolation Precautions
Evaluation of 2016 Program Effectiveness Goal 2016 Target 2016 Outcome 2016 Effectiveness 2016
Ensure compliance 100% 100% Goal met with isolation precautions 2016 Activities/Analysis Daily rounding on units to determine appropriate isolation and documentation of patient/family education Prevalence surveys of isolation technique, isolation supplies and signage was measured by direct observation during IPC rounds
2017 Surveillance Plan Goal 2017 Program Priority Planned Actions for 2017:
100% Low Continue prevalence surveys, report findings to Nursing Leadership, implement immediate corrective action if incorrect signage is visible, immediate correction action for observed breaks in technique Continue with survey of documentation for Isolation Precautions Work with nursing informatics to add measure to EMR
Population: Prevalence of isolation cases on nursing units on a specific day Analysis: Prevalence rate: # incorrect signage/#isolation cases # breaks in technique/#isolation cases # inadequate isolation supplies/#isolation cases Case Finding Methodology: Direct observation during IP rounds on nursing units
PROGRAM ELEMENTS
Resource Allocation: Needs for 2017 to effectively manage IP program
The IC Team is comprised of an Infectious Disease Physician who has training in infection control and is assigned to be the Infection Prevention and Control Committee Chairperson, System Director of Infection Prevention, Infection Preventionists, TB Coordinator, and access to clerical assistance through Quality Division. Needs as assessed through observational and direct use requirements: • Computer o Midas o Microsoft office productivity o Sorian EMR software (e.g Word, Excel, o Sorian Financials Powerpoint) o NHSN SAMS access o Novius Laboratory Information o ORMIS Systems (LIS) o EDM Pharmacy Page 29 of 43
o Wellsoft o AAMI Standards (online access) o Softmed • Personnel o Continue to review productivity needs as beds capacity is increased • Resource Guides o 2016 two vacant IP positions for o CDC, SHEA guidelines AHS Core o APIC Text (online access) • Supplies CMS Conditions of Participation o o Office Space (COP) o Supplies o AORN Standards o The Joint Commission Standards (TJC)
Infection Control Log: Major Incidents/Investigations 2016
SUBJECT BACKGROUND ASSESSMENT RECOMMENDATIONS/ACTION January 2016 One month old Five patients were exposed No additional actions and/or Chicken Pox male had rash on and contacted by IC recommendations per this exposure Exposure at head and body department. No vaccines Highland Pediatric areas. Later given, no one developed clinic diagnosed as symptoms with 21 days of Chicken Pox monitoring.
Five employees were exposed, all with immune status. 21 days monitoring, no symptoms development. No secondary cases identified Hand/Foot/Mouth 1 patient 1 employee exposure No cases identified Disease No patient exposure Head Lice 7th Floor of ACT 15 employees had direct 15 employees screened exposure contact 0 reports of lice No patient exposure TB exposure 1 TB patient 6 Employees exposed No conversions
Strategies to Minimize, Reduce, and Eliminate Infection Risk Strategies Description Plan
A. VAE • Ventilator associated events are • Report any VAPs monitored and reported by Critical identified to Critical Care Care Committee Respiratory Committee if identified by Therapy IP staff.
B. Environmental • The Infection Preventionist • Continue environmental participates in environmental rounding processes rounds independently and with including:
other facility team members to o Analyze trends assess patient and environmental o Share the safety and quality information o Collaborate with Page 30 of 43
• The Infection Preventionist leaders aggregates both IC and Hazard o Encourage posting Surveillance rounding data and of results distributes information to leaders o Report in for responses Committees (IPC and Safety as • ATP testing on all terminal clean appropriate) isolation rooms, in addition to random testing.
C. Dialysis Testing • Water used to prepare dialysis • Continue Dialysis Water, solutions must meet AAMI Endotoxins and Dialysate Standards for hemodialysis water Testing per existing quality, including endotoxins requirements and • Total viable bacterial counts in guidelines water used to prepare dialysate or to reprocess hemodialyzers • Continue to work with 0-49 CFU/ml Acceptable o vendor in OP dialysis area 50-199 CFU/ml Action o to ensure compliance o 200 CFU/ml or greater Unacceptable with IPC standards
• Endotoxins 0-0.99 EU/ml Acceptable • Continue to report data o monthly to Infection o 1-1.99 EU/ml Action level Prevention o 2 EU/ml Unacceptable • Action range = Machine is “Ok to use” pending repeat. • Unacceptable range = Machine is removed “out of Service” pending repeat. D. Sterilizer • Sterilizer testing is done in • Ensure adequate reporting Testing accordance to AORN, AAMI and to the IPC committee CDC recommendations E. Water system • The Infection Preventionist • Facility establishes and Testing collaborates with Engineering continues process for regarding facility waterborne waterborne pathogen pathogen prevention strategies, prevention strategies including Legionella water testing • Continue testing and plan. reporting of water results as appropriate • Engineering manages Water Management Plan Tools and Training through HC Info LAMPS ( Legionella assessment and management plan support)
F. Construction • An infection control risk • Work with construction assessment (ICRA) is completed team prior to construction on areas for renovation or new in determining infection Page 31 of 43
construction in the facility to control risks via the ICRA determine isolation and barriers and attend meetings as required, practices required to needed • eliminate and/or reduce dust and Continue monitoring debris, air monitoring precautions, hospital wide construction negative pressure monitoring activities in conjunction (HEPA), patient placement, and with Plant Operations clean up. • ICRAs reported to ICC and held in separate binders within infection prevention department
G. Active • MRSA Nasal screening per • Monitor ASC populations Surveillance California Code of Regulations, as identified and report Cultures Title 22, Sections 1255.8 and appropriately 1288.55 • Protocols to be developed to obtain ASC for targeted MDROs
H. Facilitate/ • Facilitate/participate in review of • Review Participate in identified cases of unanticipated reported/identified cases HAI case deaths or major permanent loss of and compare to CDC and review, or other function and HACs (never events) other guidelines. Report infection related processes associated with a healthcare results of review as requiring RCA / associated infection appropriate FMEA/HAC /QAPI and task • Task force to assess measures and • Participate in force review metrics for True North Metrics and RCA/FMEA as requested PRIME measures • Participate in True North Metrics planning and PRIME measures planning I. Outbreak • An outbreak is described as the • A full scale investigation Management sudden occurrence or increase of will be conducted in the infectious and non-infectious event of a suspected disease and conditions. outbreak using sound epidemiological principles • The Infection Prevention and Control Program investigates potential outbreaks to identify the source and/or likely cause of infections and also investigates patients from who pathogens with high transmission potential have been identified or suspected to assure that control measures appropriate to the pathogen have been instituted. Page 32 of 43
• In circumstances where a significant potential for transmission of an infectious pathogen from either a patient or employee has been identified, the Infection Prevention and Control Program works closely with the Employee Health Program to identify both patients and employee who may be at risk for disease acquisition and to intervene as appropriate to the circumstance.
J. Policies and • Infection Control policies and • Continue policy and Procedures procedures are based on procedure review at least recognized guidelines and every three years or as applicable laws and regulations. needed based on The policies address the regulatory prevention of infection recommendations, transmission among patients, guidelines. However, the employees, visitors, and Tuberculosis Exposure environmental issues. Control Plan is reviewed annually • Policies will reflect current accepted and approved Infection • Assist Employee Health Prevention practices based on in review of the regulatory recommendations, Bloodborne Pathogen standards, and guidelines. Exposure Control plan annually
• Review Respiratory Protection Plan Annually
• TB Exposure Plan Annually
K. Information • Continue participating in public • NHSN and State Reporting databases and reporting as initiatives indicated • Continue reporting of Reportable • Per State Reportable conditions as indicated by law Conditions
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L. Education • Infection prevention education is • Education provided at new provided to employees at hire and staff orientation annually as required based on job • Education to Medical Staff in description. Department meetings • On-site education done per • Coordinate with Nursing schedule Education for competency fairs, • Individual and unit education and periodic nursing staff done during rounding and at education. request of management • Additionally education is provided • Televised public education to LIPs, patients, visitors, and done as requested families • Patient/Family education done as requested • Offsite education done as requested • Annual online modules M. Communication • Communication regarding the Hospital Level Infection Prevention and Control • Leadership – scheduled Program is ongoing leadership meetings and as requested • Communication between local and • Physicians - Committees, regional health care organizations physician newsletter, one on offering opportunities for early one identification of infections • Staff – individual and small groups during rounds, reports • Communicable Disease to managers to share with their Reporting staff o Prompt reporting of all • Students – IC orientation Title 17 reportable diseases • Volunteers – orientation is ongoing to Alameda County Public Health Community Level Department. • Between hospitals (referring o Prompt reporting of hospital will be notified when specific diseases to an infection is identified in California Emerging transferred patient) Infections Program (CEIP). o Prompt follow-up and • Health Department meetings reporting of communicable disease exposures to first responders (Ryan White Act). o Reporting to California Department of Public Health as required (e.g., outbreaks, significant exposures).
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N. Influx of • IC participates for disaster planning, • Refer to Facility Emergency Patients pandemic response & preparedness Management Plan including the management of an influx of infectious patients. The IC team participates in disaster drills and emergency management meetings. O. Data Analysis • Case definitions for healthcare • All data collected for associated infections shall be those infection control should be developed and published by the presented in a rate-based National Healthcare Safety Network format for clarity and (NHSN), and CDC guidelines if it’s a comparison purposes measure that is not being followed by NHSN. • For data in the NHSN system, a standardized infection ratio • Continue to work through processes (SIR), shall be used for with Cerner to collect the most national benchmark accurate data. comparisons P. Cleaning of • The Infection Preventionist collaborates • Reassess systematic medical with hospital departments and the designation for clean vs dirty equipment, Environment of Care/Safety Committee medical equipment, to include supplies and to assure that a system for the cleaning cleaning schedule, who and devices of medical equipment, devices, supplies when an item is to be cleaned. and supply rooms is implemented. • The IPC in conjunction with • Manufacturer’s recommendations will the Environment of Care be adhered to committee to review and • Reprocessed single use items are done assess compliance during with the selected vendor – the items EOC rounds. will be placed in the appropriately • Germicidal sanicloths and labeled containers provided by the disinfectant will be made company available in patient care areas • A monitoring system will be implemented to assure compliance with cleaning of medical equipment, devices and supplies. (CDC Level II) Compliance will be reported in IPC committee. • UV Disinfectant machine(s) are being used to augment chemical and mechanical cleaning. • Before the technology is o This is a joint project utilized, a full program will between IPC and EVS. be implemented to guide its usage
Q. BHC, Rehab, • The Infection Preventionist will • As appropriate, infection and the Wound coordinate with leaders from these control indicators will be Center facilities to ensure elements from reported to the committee this Plan are implemented in these offsite arenas. Page 35 of 43
R. Presence in • IPC staff members attend multiple These include, but are not limited facilities meetings in the hospital providing a to: constant presence and reminder about • Infection Prevention and the importance of infection Control Committee prevention. • Policy and Procedures Committees (Clinical Practice Council and Committee on Interdisciplinary Practice) • Medical Executive Committee • Antimicrobial Stewardship Committee • Nurse Leadership Council • EOC Committee • Quality Council • Nurse Staffing Committee • Construction Strategic pre- planning sessions • Value Analysis Team (VAT) Meeting • Fairmont quality Council • OR Executive Committee • Emergency Management Committee • Critical Care committee S. SSI reduction 1. Safe OR Practices Implement measures efforts 2. Screen –for MRSA recommended by CDC, APIC, 3. Shower – with CHG pre-procedure IHI, SHEA, AORN, AAMI and 4. Skin prep – Alcohol based saniziters other organizations with SSI 5. Solution – CHG irrigant prevention strategies T. Zika Virus: Per the CDC, Zika virus is transmitted to Infection Control will follow humans primarily through the bite of an developments related to Zika infected Aedes species mosquito. The Virus and follow CDC mosquito vectors typically breed in recommendations for our patients domestic water-holding containers; they and community. are aggressive daytime biters and feed both indoors and outdoors near dwellings. Nonhuman and human primates are likely the main reservoirs of the virus, and anthroponotic (human-to-vector-to- human) transmission occurs during outbreaks. Perinatal, in utero, and possible sexual and transfusion transmission events have also been reported.
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APPENDIX A: Employee Health
Influenza Vaccination Compliance Grid, 2015-2016 Season
HCP Categories Employee Non-employee HCP HCP Employees (on Licensed independent Students, & facility practitioners; physicians, and volunteers payroll) physician assistants/Contractors # HCP who worked at this healthcare facility for at least 30 days between 2217 64 49 October 1, 2015 and March 31, 2016 # HCP who received influenza vaccination at this healthcare facility 1234 37 16 since influenza vaccine became available this season # HPC who provided a written report or documentation of influenza vaccination 675 9 33 outside of TMC since influenza vaccine became available this season
# HCP who declined influenza vaccine 202 Unknown Unknown
# HCP Noncompliant 106 33 Unknown
Bloodborne Pathogen Exposures in 2016 (HGH, JGH, Fairmont, Wellness Clinics)
Injuries by type of Exposure Total # 86 % of the all incidents
Splashes 14 16%
Needlestick Injuries 52 60% Lacerations/Punctures 19 22% Other/bite 1 1% Injuries by Job Classification RN 29 34% Residents/Medical Students 29 34% Physicians 15 17% Other (RT, PT, EVS etc) 13 15% Injuries by Location OR 25 29% Podiatry/Dental Clinic 18 21% ED 13 15% Other (Lab, JGH, FMT, NUCL Med, Vas Clinic, Parking lot) 9 10% Page 37 of 43
Med/Surg 8 9% L&D 6 7% ICU 3 3% Peds/NICU 2 2% Wellness Clinics 2 2% Mechanism of Injury by ranking Carelessness 1 Stuck while disposing needle 2 Patient’s sudden movement 3 Stuck during procedure 4
Bloodborne Pathogen Plan Annual Review Statement
The existing Blood borne Pathogen Plan was reviewed and compared to OSHA standards. It was revised by Employee Health with IPC staff serving as a resource. The document was presented and approved by the Infection Prevention and Control Committee, Environment of Care Committee.
APPENDIX B: TB Exposure Control Plan
Incidence of TB 2016 2015 2014 Community Rate/100,000 residents 9.1 9.5 7.4 State Rate/100,000 residents 5.3 5.5 5.6 National Rate100,000 residents 2.9 3.0 2.9 # Suspected 39 38 28 # Confirmed 29 23 17 Cluster of MTb None None None Employee Conversion Rates 0 0 0 Any group/trend with increased rate None None None Risk Classification # of Cases diagnosed in Alameda 136 139 108 Co. Risk Assigned High High High Screening of HCW for mTb infection (Annual TST screening of staff and LIPs) Baseline – 2 step TST On Hire and/or last TST >1 year Frequency of TST Annually Records maintained 30 years Who maintains records Employee Health TB Infection Control Program Written Aerosol Transmissible Yes Disease Exposure control Plan Effective /Original Date 6/2010 Reviewed/Updated 10/2017 Infection Control Committee Yes Implementation of TB Control Plan Ongoing education provided? Yes Page 38 of 43
Person responsible for program TB infection prevention RN Lab Processing: Blood Culture Contamination Rate Laboratory started reporting Blood culture Contamination rates January 2017 and forward. Environmental Controls AIIR Rooms: 42 Negative pressure isolation or procedure rooms Routinely checked Engineering and Nursing Room directional flow checked daily when in use Process in place for annual assessment of negative pressures and air changes per hour for AIIR Respiratory Protection Program What type of mask is used? N95 Is Initial Fit test completed? Yes Annual fit testing program in place Yes
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APPENDIX C: Infection Control Risk Assessment 2017
Background: As part of its commitment to quality care and service, AHS conducts a periodic assessment of the risk(s) for transmission and acquisition of infectious agents. This risk assessment incorporates an analysis of the following:
1. The geographic location and community environment of the organization, the programs and services provided, and the characteristics of the population served. 2. The results of the organization’s surveillance, prevention, and control data. 3. The care, treatment, and services provided.
The risk assessment is conducted at least annually and whenever there is a significant change in any of the above factors.
Risk Assessment Findings:
The risks for the transmission and acquisition of infectious agents have been identified and weighted using a hazard probability format. Each IC issue is ranked numerically according to probability, risk and preparedness. Highest scoring issues will receive the highest priority for surveillance and process improvement. In addition, AHS must also comply with California State law surveillance and reporting requirements as well as requirements set forth by The Joint Commission, OSHA and CMS. The risk level scores are achieved by addition the scores for each event. The risk level scores are a range of 3 – 12, with 3 being the lowest score and 12 the highest score. The ranking is 1 thru 31 in chronological order.
How effective are How likely is our facility to have a If this were to happen, to what degree would it affect patients, our Current problem with ______? staff, or organization? Procedures Event Risk Catastrophic Minimal Level Temp loss Prolonged Moderate Rank Loss of life/limb/ of Function (Clinical (ICP High Med Low None Length of (Clinical or Poor Fair Good function Or or Stay Financial) only) Legal Financial)
Score: 4 3 2 1 5 4 3 2 1 3 2 1
POTENTIAL INFECTIONS
4 4 1 9 5 Multidrug-Resistant Organisms (MDRO) to include MRSA, ESBL, VRE, and CRE C. difficile 3 4 1 8 7 Page 40 of 43
How effective are How likely is our facility to have a If this were to happen, to what degree would it affect patients, our Current problem with ______? staff, or organization? Procedures Event Risk Catastrophic Minimal Level Temp loss Prolonged Moderate Rank Loss of life/limb/ of Function (Clinical (ICP High Med Low None Length of (Clinical or Poor Fair Good function Or or Stay Financial) only) Legal Financial)
Score: 4 3 2 1 5 4 3 2 1 3 2 1
Facility Acquired Procedure-Related 1 4 2 7 8 Wound Infections
Other
DEVICE RELATED INFECTIONS Catheter Associated Urinary Tract Infections 3 2 2 7 9 (CAUTI) Central Line Associated Blood Stream 2 3 1 6 19 Infection (CLABSI) SURGICAL SITE INFECTION Knee Prosthesis 2 5 3 2 12 1
Hip Prosthesis 2 5 2 9 5 Gastrointestinal 3 5 2 10 4 C- Section 3 2 1 6 20 FX Open Reduction of Fracture 4 5 2 11 2 Other
EXPOSURE-RELATED 2 2 1 5 26 Unusually Large Influx of Infectious Patients Bloodborne Pathogen Exposures 3 1 1 5 23 Influenza 2 2 1 5 28 Tuberculosis 2 1 1 5 29 3 1 1 5 22 Lack of Communication of Isolation Necessity of Patients Moving Between Units Page 41 of 43
How effective are How likely is our facility to have a If this were to happen, to what degree would it affect patients, our Current problem with ______? staff, or organization? Procedures Event Risk Catastrophic Minimal Level Temp loss Prolonged Moderate Rank Loss of life/limb/ of Function (Clinical (ICP High Med Low None Length of (Clinical or Poor Fair Good function Or or Stay Financial) only) Legal Financial)
Score: 4 3 2 1 5 4 3 2 1 3 2 1
Other
PEOPLE Hand Hygiene Compliance 4 2 1 7 10 4 2 1 7 11 Compliance with Isolation precautions/PPE 3 2 2 7 13 Inadequate Staff education and training in infection control practices 3 1 2 6 14 Inadequate Patient/Family Education about CLABSI, CAUTI, MDRO, and SSI Prevention
Other
ENVIRONMENT
4 1 1 6 16 Inadequate disease/ dust mitigation practices for Construction Activities
3 2 1 6 18 Inadequate Cleaning of Environment Inadequate Temperature / Humidity 3 1 2 6 15
Incorrect air flow of rooms. 2 1 1 4 27 Page 42 of 43
How effective are How likely is our facility to have a If this were to happen, to what degree would it affect patients, our Current problem with ______? staff, or organization? Procedures Event Risk Catastrophic Minimal Level Temp loss Prolonged Moderate Rank Loss of life/limb/ of Function (Clinical (ICP High Med Low None Length of (Clinical or Poor Fair Good function Or or Stay Financial) only) Legal Financial)
Score: 4 3 2 1 5 4 3 2 1 3 2 1
Other
SUPPLIES/EQUIPMENT Inadequate Cleaning, High Level 4 1 2 7 12 Disinfection, or Sterilization of supplies and equipment 2 1 2 5 24 Frequent Immediate Use Sterilization of Instruments Transport of supplies 2 3 1 6 17
Torn Furniture 3 1 2
RISK OF MDRO OR OTHER INFECTION FOR POPULATION SERVED
ICU 4 5 2 11 3
Pediatrics 2 1 1 4 30
Skilled Nursing Facility Patients 2 2 1 5 25
Oncology 2 4 1 7 13
Dialysis Patients 3 4 2 9 6
Inpatient Psychiatric Patients 2 1 1 4 31
Other Page 43 of 43
IMPORTANT: This tool is used for IC program planning & goal setting to determine priorities for IC surveillance activities for 2017 -2018. However, regulatory and accreditation requirements must be considered in combination with IC staffing to determine IC’s annual surveillance priorities.
* Issue or event is required by California State Law and is publically reported through NHSN.
Approvals
Departmental Date: 10/2017 Infection Control Committee Date: 10/2017 Quality and Safety Committee Date: 11/2017 Medical Executive Committee Date: 11/2017 Board of Trustees Date: