Policy Approval Workflow
*Clinical Workgroup broadly includes any medical staff committee, nursing committee such as Patient Care Leadership Team, administrative committee, and/or other ad hoc workgroups. Alameda Health System Executive Summary for Board of Trustees Policies and Procedures January 2020
TOPIC or Last Next review date Document Purpose Summary of Changes History of Review TITLE OF POLICY Approved after BOT Owners Committee Date approval
AHS System Policies Abuse Identification – N/A 3/2022 Manager, Care It is the policy of Alameda Minor revisions • Departmental Reporting and Patient Management Health System (AHS) to 3/2019 Protection report, in accordance with • Legal Review the provisions set forth 9/2019 herein and applicable laws and regulations, known or • HR review 10/2019 suspected abuse or neglect • CPC 10/2019 relating to children, elders or dependent adults. Central Venous Catheters N/A 8/2022 Director of To ensure the effective use, Minor revisions • Departmental (Central Infection Control safe and sterile insertion, 8/2019 Lines/PICC/PORT-a- proper maintenance and • CPC 11/2019 CATH)-Insertion, prompt removal of central Maintenance and line catheters. Removal Inpatient Influenza N/A 9/2022 VP Patient Influenza vaccination will Updated with CMS • Departmental Vaccination Policy Services be offered to eligible adult recommendation 9/2019 in-patients. Influenza • P&T Committee vaccination will be offered 9/2019 October through May (or longer as determined by • CPC 10/2019 state/federal public health entities). Distribution will be determined by vaccination supplies or any special determination by the CMS, CDC and/or state and local public health entities each year. Interdisciplinary Verbal N/A 9/2022 VP Patient To ensure that verbal or Updated with current EPIC • Departmental Orders and Patient Services telephone orders are system 10/2019 Safety v2 accurately transcribed and • CPC 10/2019 carried out.
CONFIDENTIAL PROTECTED UNDER CALIFORNIA EVIDENCE CODE 1157 Page 1 of 4
Alameda Health System Executive Summary for Board of Trustees Policies and Procedures January 2020
TOPIC or Last Next review date Document Purpose Summary of Changes History of Review TITLE OF POLICY Approved after BOT Owners Committee Date approval
Medications: Hazardous N/A 9/2022 System Personnel preparing Minor Revisions • Environment of Drugs Preparation and Medication hazardous drugs will take Care: 9/2019 Handling Safety Officer all necessary precautions, • Environmental as outlined, in order to protect themselves and the Services: 9/2019 environment from • Employee Health: hazardous medications. 9/2019 Specific disposal • Infection Control procedures for the Dept.: 9/2019 materials used in the • Pharmacy & preparation of these drugs, as outlined below, will be Therapeutics: followed. 10/2019 • Clinical Practice Council: 11/2019 Pharmacy Therapeutic N/A 4/2022 System To authorize Clinical Minor Revisions • System Clinical Drug Monitory Policy Medication Pharmacists to order Pharmacy 3/2019 Safety Officer selected drug levels and • System P7T 4/2019 related laboratory values • for the inpatients of CPC 11/2019 Alameda Health System to enhance the safe and effective use of these drugs Restraint and Seclusion N/A 5/2022 System Director To provide guidance for Minor Revisions • Departmental Use in Acute Care Regulatory staff use of restraints 9/2019 Affairs and/or seclusion while • Legal Review maintaining patient safety and dignity. 11/2019 • CPC review 11/2019
CONFIDENTIAL PROTECTED UNDER CALIFORNIA EVIDENCE CODE 1157 Page 2 of 4
Alameda Health System Executive Summary for Board of Trustees Policies and Procedures January 2020
TOPIC or Last Next review date Document Purpose Summary of Changes History of Review TITLE OF POLICY Approved after BOT Owners Committee Date approval
Highland Hospital Autosubstitution N/A 9/2022 System Director Decrease calls to the Minor revisions • Pharmacy Outpatient ED Policy Pharmacy emergency department Leadership :9/2019 providers for routinely • ED Leadership: prescribed medications that are not covered by 9/2019 insurance and therapeutic • System Pharmacy alternatives are available & Therapeutics: within the same medication 9/2019 class. This will in turn • Clinical Practice improve reimbursement of Council: 10/2019 medications, improve patient adherence, and prevent gaps in treatment.
John George Psychiatry Hospital Medical Care of Patients N/A 10/2022 Chair of To establish standards and New Policy • Departmental: at John George Psychiatry guidelines for medical care 10/2019 Psychiatric Hospital of patients at John George • Clinical Practice (JGPH) Psychiatric Hospital (JGPH). Council: 10/2019
San Leandro Hospital Pyxis ES Policy N/A 6/2022 System Director To provide medication New Policy • Pharmacy Pharmacy safely, effectively, &Thearapeutics: efficiently, securely, and 8/2019 with appropriate • Clinical Practice documentation. Council: 9/2019
Alameda Hospital
Submitted by: Marie Diane Schilly Date: 12/27/2019
A regular meeting of the CPC Committee was held on December 5, 2019.
CONFIDENTIAL PROTECTED UNDER CALIFORNIA EVIDENCE CODE 1157 Page 3 of 4
Alameda Health System Executive Summary for Board of Trustees Policies and Procedures January 2020
TOPIC or Last Next review date Document Purpose Summary of Changes History of Review TITLE OF POLICY Approved after BOT Owners Committee Date approval
CONFIDENTIAL PROTECTED UNDER CALIFORNIA EVIDENCE CODE 1157 Page 4 of 4
CHILD, ELDER, OR DEPENDENT ADULT ABUSE OR NEGLECT REPORTING
Department Social Services Effective Date 3/03 Campus All Date Revised 11/2017, 3/2019 Category Clinical Next Scheduled 3/2022 Review Document Manager Care Executive VP, Care Management Owner Management Responsible Printed copies are for reference only. Please refer to electronic copy for the latest version.
PURPOSE California law designates certain professions as “mandated reporters.” Mandated reporters have an individual duty to report known or suspected abuse or neglect relating to children, elders or dependent adults. Although there are many mandated reporters under the statute, not everyone is a mandated reporter. Despite the aforesaid, a non-mandated reporter may nonetheless report any known or suspected abuse or neglect relating to children, elders or dependent adults. In view of the foregoing, the purpose of this policy is to provide guidelines on what reporters (regardless of “mandated reporter” status) are required to report, when it must be reported, and to whom.
POLICY It is the policy of Alameda Health System (AHS) to report, in accordance with the provisions set forth herein and applicable laws and regulations, known or suspected abuse or neglect relating to children, elders or dependent adults.
DEFINITIONS − “Child” means a person under the age of 18 years. − “Elder” means any person 65 years of age or older. − “Dependent Adult” means a person, regardless of whether the person lives independently, between the ages of 18 and 64 years who has physical or mental limitations that restrict his or her ability to carry out normal activities or to protect his or her rights, including, but not limited to, persons who have physical or developmental disabilities, or whose physical or mental abilities have diminished because of age. − “Mandated Reporter” is a person who is required by law to report a particular category or type of known or suspected abuse or neglect to the appropriate law enforcement and/or social service agency. (A list of “Mandated Reporters” is included in Appendix A)
PROCEDURES I. Obligations of Mandated Reporters & Non-Mandated Reporters As indicated above, “mandated reporters” are statutorily required to report known or suspected abuse or neglect relating to children, elders or dependent adults. AHS, however, recognizes that a non-mandated reporter may report any known or suspected
Page 1 of 10 abuse or neglect relating to children, elders or dependent adults. In view of the foregoing, an AHS employee designated as a “mandated reporter” who (a) receives information and/or (b) knows or reasonably suspects that a child, elder or dependent adult is a victim of abuse or neglect is ultimately responsible for making the report to the appropriate authorities. A non-mandated reporter who (a) receives information and/or (b) knows or reasonably suspect that a child, elder or dependent adult is a victim of abuse or neglect may (1) make the report to the appropriate authorities in accordance with the provisions set forth herein, or (2) inform a mandate reporter of a known or suspected abuse or neglect. II. Reporting Known or Suspected Child Abuse and/or Neglect a. California law requires specified health care practitioners and other persons who have knowledge of or observe a child in his or her professional capacity or within the scope of his or her employment whom he or she knows or reasonably suspects1 has been the victim of child abuse or neglect to report the known or suspected instance of child abuse immediately or as soon as practicably possible by telephone and to prepare and send a written report thereof within 36 hours of receiving the information concerning the incident.
b. Forms of Child Abuse and/or Neglect – i. In accordance with the California Penal Code, the following categories of abuse and neglect must be reporter when a mandated reporter knows or reasonably suspects that a child has been the victim of child abuse or neglect: 1. A physical injury or death that is inflicted by other than accidental means on a child by another person; 2. Sexual abuse; a. “Sexual abuse” means sexual assault or sexual exploitation. Sexual exploitation includes commercial sexual exploitation (e.g., sexual trafficking, the provisions of food, shelter, or payment to a child in exchange for the performance of any sexual acts). 3. Neglect; a. Although there are different forms of “Neglect,” the term generally means the negligent treatment or maltreatment of a child by a person responsible for the child’s welfare under circumstances indicating harm or threatened harm to the child’s health or welfare. 4. Unlawful corporal punishment or injury; 5. Willful harming or injuring of a child or endangering of the person or health of a child; and 6. Abuse or neglect in out-of-home care. ii. Additionally, a mandated reporter who knows or reasonably suspects that the home or institution in which a child resides is unsuitable for the child
1 “Reasonable Suspicion” means that it is objectively reasonable for a person to entertain a suspicion, based upon facts that could cause a reasonable person in a like position, drawing, when appropriate, on his or her training and experience, to suspect child abuse or neglect.
Page 2 of 10 because of abuse or neglect of the child shall report the condition to the attention of the agency to which he or she makes a report of the abuse or neglect, and must do so at the same time the report is made.
c. Reporting Protocol i. Mandated reporters are required to report immediately, or as soon as is practically possible by telephone to Alameda County’s Child Protective Services (CPS) 24-hour hotline (510-259-1800), or to local law enforcement agency where the suspected abuse took place. When the offender is in a non-caretaker role the alleged abuse should be reported to the local law enforcement agency. d. Child Abuse Report Form – Within 36 hours of receiving the information concerning the incident the mandated reporter ensures a written suspected Child Abuse Report Form (BCIA) Click this link for an electronic copy of the report form: https://oag.ca.gov/sites/all/files/agweb/pdfs/childabuse/ss_8572.pdf? i. The mandated reporter may receive mailed notification of the disposition (unfounded, substantiated, and inconclusive) once the legal investigation is complete.
III. Reporting Known or Suspected Elder or Dependent Adult abuse and/or Neglect
e. The Elder Abuse and Dependent Adult Civil Protection Act imposes mandatory reporting requirements for abuse of elders and dependent adults. Reporting requirements for elders and dependent adult are identical. Accordingly, any mandated reporter who, in his or her professional capacity, or within the scope of his or her employment, has observed or has knowledge of an incident that reasonably appears to be abuse, or is told by an elder or dependent adult that he or she has experienced behavior, including an act or omission, constituting abuse, must report the known or suspected instance of abuse by telephone or through a confidential Internet reporting tool (when available) immediately or as soon as practicably possible
f. Forms of Elder/Dependent Adult Abuse and/or Neglect i. The following categories of abuse and neglect must be reported when a mandated reporter knows or reasonable suspect that an elder or dependent adult has been the victim of abuse or neglect: 1. Physical abuse, neglect, abandonment, isolation, abduction, or other treatment with resulting physical harm or pain or mental suffering; 2. The deprivation by a care custodian of goods or services that are necessary to avoid physical harm or mental suffering (e.g., medical care, adequate clothing, adequate housing/shelter, transportation and assistance necessary to secure any of these services); and 3. Financial abuse. a. “Financial abuse” of an elder or dependent adult occurs when a person or entity takes (or assist in), secretes,
Page 3 of 10 appropriates, obtains, or retains real or personal property of an elder or dependent adult for a wrongful use or with the intent to defraud, or both.
g. Reporting Protocol i. Mandated reporters are required to report known or suspected abuse or neglect, immediately or as soon as possible, by phone (1-866-225-5277) and follow up with a completed written report (link below) within two days. https://alamedaaps.com/Intake/NewPublicIntakeReport.aspx ii. Long Term Care Facilities: If it is suspected that abuse has occurred in a long-term care facility the telephone report must be made immediately to California Department of Public Health and to the local Ombudsman. http://www.aging.ca.gov/programs/ltcop/Contacts/ A telephone report must be followed within 2 working days by a written report which can be faxed to the Ombudsman. A link to the report form can be found in Attachment IV. In addition to this report, a report should be made to local law enforcement. Be sure to get the report number and file this in the medical record. 1. Long Term Care Facilities will be notified on an annual basis of their obligation to report to the Secretary and relevant law enforcement agencies any abuse or suspicion of abuse. 2. Reporting Allegations: Abuse or neglect must be reported for: i. Serious bodily injury – telephone report shall be made to the local law enforcement immediately, but no later than within two hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse, and a written report shall be made to the local ombudsman, the state survey agency, and the local law enforcement agency. ii. Non-serious bodily injury – telephone report shall be made to the local law enforcement agency within 24 hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse, and a written report shall be made to the local ombudsman, state survey agency, and the local law enforcement agency. iii. Reporting Investigation Results: Investigations of allegations must be reported to the same authorities within 5 working days.
PRIVACY LAWS State (CMIA) and federal (HIPAA) health information privacy laws permit the disclosure of patient-identifiable information to report known or suspected abuse or neglect.
FAILURE TO REPORT A mandated reporter who fails to report an incident of known or reasonably suspected child, elder or dependent adult abuse or neglect is guilty of a misdemeanor and may be subject to disciplinary action, including up to termination.
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RECORD KEEPING Each department must develop record keeping procedures to designate a record keeper. Records must be kept for a minimum of 7 years.
NON-RETAILIATION It is prohibited to retaliate against any employee who reports known or suspected abuse or neglect of an individual receiving care at AHS. Regardless of “mandated reporter” status, employees have a right to file a complaint with Human Resources if they feel anyone at AHS has retaliated against an employee who reported a known or suspected abuse or neglect of a patient.”
REFERENCES 1. California Penal Code Section 11160 et seq. 2. The Joint Commission Standard PC.01.02.09 3. California Welfare and Institutions Code Section 15600 et seq. 4. OBRA F 223 – 225
APPROVALS
System Alameda AHS/Highland/John George/San Leandro Department: Care Date: N/A 3/2019 3/2019 Management Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 10/2019 N/A N/A Council (CPC) Medical Executive Date: N/A 11/2019 11/2019 Committee Board of Trustees Date: N/A N/A
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APPENDIX A: CALIFORNIA ABUSE/NEGLECT MADATED REPORTERS Child Abuse/Neglect (Penal Elder/Dependent Adult Injury by Firearm or Code § 11165.7) Abuse (Welfare & Inst. Assault/Abuse (Penal Code § Code §§ 15630, 15610.37) 11160) Mandated Reporters include: Mandated Reporters include: Health Practitioners include: (1) A teacher. (1) Any employee (including (2) An instructional aide. administrators, supervisors, i. Physician, surgeon, (3) A teacher's aide or and any licensed staff) psychiatrist, teacher's assistant employed working in any facility that psychologist, dentist, resident, by a public or private school. provides care or services for intern, podiatrist, chiropractor, (4) A classified employee of a elder or dependent adults. licensed nurse, dental public school. hygienist, optometrist, (5) An administrative officer (2) Any employee providing marriage, family and child or supervisor of child welfare direct health care counselor, clinical social and attendance, or a or social services to an elder worker, or other licensed certificated pupil personnel or dependent health care professional. employee of a public or adult. private school. ii. Certified emergency medical (6) An administrator of a (3) Health care practitioners technician I or II, paramedic, public or private day camp. include: or other emergency services (7) An administrator or i. Physician, surgeon, personnel. employee of a public or psychiatrist, psychologist, private youth center, youth dentist, resident, intern, iii. Registered psychological recreation program, or youth podiatrist, chiropractor, assistant. organization. registered nurse, iv. Marriage, family and child (8) An administrator, board dental hygienist, therapist member, or employee of a optometrist, marriage, trainee or unlicensed intern. public or private organization family and child v. Any person who performs whose duties require direct counselor, clinical social autopsies. contact and supervision of worker, or other licensed children, including a foster health care family agency. professional. (9) An employee of a county ii. Certified emergency office of education or the medical technician I or II, State Department of paramedic, or other Education whose duties bring emergency services the employee into contact personnel. with children on a regular iii. Registered psychological basis. assistant. (10) A licensee, an iv. Marriage, family and child administrator, or an employee therapist of a licensed community care trainee or unlicensed intern. or child day care facility. (4) Clergy. (11) A Head Start program teacher.
Page 6 of 10 (12) A licensing worker or licensing evaluator employed by a licensing agency, as defined in Section 11165.11. (13) A public assistance worker. (14) An employee of a child care institution, including, but not limited to, foster parents, group home personnel, and personnel of residential care facilities. (15) A social worker, probation officer, or parole officer. (16) An employee of a school district police or security department. (17) A person who is an administrator or presenter of, or a counselor in, a child abuse prevention program in a public or private school. (18) A district attorney investigator, inspector, or local child support agency caseworker, unless the investigator, inspector, or caseworker is working with an attorney appointed pursuant to Section 317 of the Welfare and Institutions Code to represent a minor. (19) A peace officer, who is not otherwise described in this section. (20) A firefighter, except for volunteer firefighters. (21) A physician and surgeon, psychiatrist, psychologist, dentist, resident, intern, podiatrist, chiropractor, licensed nurse, dental hygienist, optometrist, marriage and family therapist, clinical social worker,
Page 7 of 10 professional clinical counselor, or any other person who is currently licensed under Division 2 (commencing with Section 500) of the Business and Professions Code. (22) An emergency medical technician I or II, paramedic, or other person certified pursuant to Division 2.5 (commencing with Section 1797) of the Health and Safety Code. (23) A psychological assistant registered pursuant to Section 2913 of the Business and Professions Code. (24) A marriage and family therapist trainee, as defined in subdivision (c) of Section 4980.03 of the Business and Professions Code. (25) An unlicensed associate marriage and family therapist registered under Section 4980.44 of the Business and Professions Code. (26) A state or county public health employee who treats a minor for venereal disease or any other condition. (27) A coroner. (28) A medical examiner or other person who performs autopsies. For a complete list of “mandated reporters” click here
Page 8 of 10 APPENDIX B: CLINICAL GUIDELINES There are procedures common to any type abuse or age of victim.
1. AHS Provides Patients a Safe Environment During Investigation: a. If the suspected perpetrator is another patient i. Separate the patients so they have no further interaction with each other ii. Respond to immediate medical and emotional needs iii. Update family as indicated b. If the suspected perpetrator is an employee: i. Immediately remove the employee from the care of the patient and consider placing the employee on administrative leave pending completion of the investigation. ii. Consider relocating the patient to another provider team to protect the patient from repercussions from staff. iii. HR will be notified. They will investigate misconduct in this case as well as possible pattern of misconduct. c. If the suspected perpetrator is the patient’s family member or friend: i. Request that the suspect leave the patient area. Call security if necessary. ii. Notifysecurity to ban the suspect from visiting until notified otherwise.
2. Assessment and Protection of Patients from Further Abuse a. If patient is in immediate danger and/or perpetrator is on site, the staff will call the police (sheriff for Highland campus). b. Assigned staff shall conduct a risk assessment and intervention plan. i. Assessment includes what further help patient needs and if there are immediate dangers – for example protection of children or other dependents of the patient- as well as what the patient wants c. Assigned staff informs the patient that a report is being filed; when appropriate. d. Assigned staff partners with the patient’s family and/or support system to create a safety plan. e. The assessment and all interventions including engagement of law enforcement are documented in the medical record.
3. Communication within AHS, to patient, and authorities about suspected abuse by mandated reporters: a. AHS employees will refer all identified cases of abuse or suspected abuse immediately and report the suspicion in the AHS Safety Alert System. i. Assigned staff will interview, assess the patient to determine if there is reasonable suspicion and report to the appropriate authorities. ii. Details of the suspected abuse will be recorded in the patient’s medical record b. County Social Services and Law enforcement i. All incidences of suspected abuse, will be reported to appropriate authorities in the time frame specified by California law. ii. Non-clinical mandated reporters will communicate concerns to a clinical staff such as the nurse, physician or social worker who will follow up on
Page 9 of 10 the concerns as indicated by this and the AHS Safety Alert System policy and procedures. 4. Medical Providers - for more information about mandated DV reporting, please refer to your medical directors.
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AUTOSUBSTITUTION OUTPATIENT ED POLICY
Department Pharmacy and ED Effective Date: 3/2014 Campus Highland Campus Date Revised: 12/2018, 9/2019 Category Clinical Practice Next Scheduled 9/2022 Review: Document Director of Pharmacy Executive Responsible Chief Administrative Owner Officer/Chief Nurse Executive Printed copies are for reference only. Please refer to electronic copy for the latest version.
Purpose: Decrease calls to the emergency department providers for routinely prescribed medications that are not covered by insurance and therapeutic alternatives are available within the same medication class. This will in turn improve reimbursement of medications, improve patient adherence, and prevent gaps in treatment.
Policy: The Outpatient Pharmacy at the Highland campus will follow automatic substitution policy for prescriptions from Emergency Department for medications that are not covered and only when appropriate alternatives exist as approved by the P&T committee.
Procedure: 1. Upon receiving a prescription order for a medication that is not covered by the patient’s insurance, pharmacy will auto- substitute for an equivalent drug (dose and strength) that the patient’s insurance will cover. (see Attachment A)
Page 1 of 15 2. A call to emergency department physicians is not required for all approved drugs on this protocol list.
3. For a drug not on the pre-approved auto-substitution list, a provider must be notified of the drug not covered by the patient’s insurance and verbal confirmation from an ED provider/attending is required.
4. The pharmacist will note the date, time and auto-substitution on the prescription including drug name, strength, sig., and quantity. If ED provider approval is needed for medications not on the auto-substitute list, the provider name will be documented on the prescription.
APPROCALS
System Alameda AHS/Highland/John George/San Leandro Department: Date: N/A 9/2019 9/2019 Pharmacy and ED Pharmacy and Date: 9/2019 N/A N/A Therapeutics (P&T) Clinical Practice Date: 10/2019 N/A N/A Council (CPC) Medical Executive Date: N/A 11/2019 Committee Board of Trustees Date: N/A N/A
Page 2 of 15 ATTACHMENT A – Autosubstitution List Per P&T for ED Prescriptions Pharmacy and Therapeutics Committee Department of Pharmacy Services AHS Pharmacy will substitute with formulary drug based on patient's insurance
ACE-Inhibitor and Dose (PO) benazepril fosinopril lisinopril moexipril perindopril quinapril ramipril enalapril (Lotensin) (Monopril) (Prinivil/Zestril) (Univasc) (Aceon) (Accupril) (Altace) (Vasotec) 3.75 mg 1.25 mg 5 mg daily 5 mg daily 5 mg dialy 2 mg daily 5 mg daily 5 mg daily daily daily 7.5 mg 10 mg 2.5 mg 10 mg daily 10 mg daily 10 mg daily 4 mg daily 10 mg daily daily daily daily 15 mg 20 mg 5 mg 20 mg daily 20 mg daily 20 mg daily 8 mg daily 20 mg daily daily daily daily 30 mg 40 mg 10 mg 40 mg daily 40 mg daily 40 mg daily 16 mg daily 20 mg BID daily daily daily 20 mg 40 mg BID 40 mg BID daily **All ACE inhibitors (except Monopril) require a 50% reduction in initial dosing for patients with ClCr <30 ml/min.
Angiotensin Receptor Blocker (ARB) and Dose (PO) candesartan irbesartan olmesartan losartan telmisartan eprosartan valsartan (Diovan) (Atacand) (Avapro) (Benicar) (Cozaar) (Micardis) (Teveten) 80 mg daily 25 mg 400 mg 8 mg daily 75 mg daily 20 mg daily 40 mg daily (hypertension) or 40mg daily daily BID (heart failure) 160 mg daily 50 mg 600 mg 16 mg daily 150 mg daily 40 mg daily 80 mg daily (hypertension) or 80mg daily daily BID (heart failure) 320 mg daily 100 mg 800 mg 32 mg daily 300 mg daily 80 mg daily 160 mg daily (hypertension) or 160 daily daily mg BID (heart failure)
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Alpha-1 Adrenergic Blocker and
Dose (PO) terazosin (Hytrin) doxazosin (Cardura) 1 mg QHS 1 mg QHS 2 mg QHS 2 mg QHS 5 mg QHS 4 mg QHS 10 mg QHS 8 mg QHS
Antihistamine (Non-sedating) and Dose (PO) fexofenadine (Allergra) loratadine (Claritin) 60 mg BID or 180mg Qday 10 mg daily
Antacid and Dose
(PO) Mylanta Maalox ES (Antacid Double Strength) 30 ml 15 ml
Antiplatelet Clopidogrel Prasugrel 75mg qday 10mg qday
Anticholinergic inhaler Atrovent inhaler Incruse Ellipta (umeclidinium) Spiriva inhaler All SIG *max dose 12 inh per day 1 puff (62.5 mcg) once daily 18mcg inh qday All SIG *max dose 12 inh per day
Page 4 of 15 Calcium Channel Blocker and Dose (PO)
nifedipine felodipine (Plendil) amlodipine (Norvasc) (Adalat CC) 2.5 mg daily 30 mg daily 2.5 mg daily 5 mg daily 60 mg daily 5 mg daily 10 mg daily 90 mg daily 10 mg daily
Carbonic Anhydrase Inhibitor and
Dose dorzolamide (Trusopt) brinzolamide (Azopt) 1 drop in affected eye(s) TID 1 drop in affected eye(s) TID
Calcium supplement and dose (PO) Calcium Gluconate 500 mg Calcium Gluconate 650 mg Calcium Carbonate 500 mg Calcium Carbonate 650 mg
H-2 Blocker and Dose nizatidine cimetidine (Tagamet) ranitidine (Zantac) (Axid) 300 mg PO q6h 400 mg PO 150 mg PO BID 150 mg PO BID q12h 300 mg PO daily 800 mg PO daily 300 mg PO daily 300 mg IV q6h 50 mg IV q8h **Famotidine dosing in renal dysfunction: Decrease dose to 20 mg daily for ClCr < 50 ml/min
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HMG-CoA Reductase Inhibitor and Dose (PO) fluvastatin atorvastatin lovastatin rosuvastatin pravastatin simvastatin (Zocor) (Lescol) (Lipitor) (Mevacor) (Crestor) (Pravachol) 20 mg QHS 10 mg QHS 10 mg QHS 5 mg QHS
40 mg QHS 20 mg QHS 20 mg QHS 10 mg QHS
80 mg QHS 10 mg QHS 40 mg QHS 5 mg QHS 40 mg QHS 20 mg QHS
20 mg QHS 80 mg QHS 10 mg QHS 80 mg QHS 40 mg QHS
40 mg QHS 20 mg QHS 80 mg QHS
80 mg QHS 40 mg QHS
**Pravastatin is allowed when concurrently used with HIV or transplant medications or if a patient cannot tolerate simvastatin
**Simvastatin 80 mg is limited to patients that have been taking this dose for >12 consecutive months and without evidence of myopathy **Common simvastatin DDI: CI with itraconazole, ketoconazole, posaconazole, erythromycin, clarithromycin, gemfibrozil, cyclosporine, HIV protease inhibitors. Not to exceed 10mg/d with amiodarone, verapamil, diltiazem. Not to exceed 20mg/d with
amlodipine, ranolazine
Hydrocodone/acetaminophen and oxycodone/acetaminophen For combination products hydrocodone/acetaminophen or oxycodone/acetaminophen; auto- substitution will only be made based on the APAP component to APAP 325mg (e.g. Oxycodone/APAP 7.5/500mg will be changed to Oxycodone/APAP 7.5/325mg)
Hydroxyzine 1:1 coversion Pamoate hydrochloride formulation form
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Insulin, short acting and Dose lispro (Humalog) aspart (Novolog) glulisine (Apidra) 10 units 10 units 10 units **this applies only for conversion from vials to vials and pens to pen BUT not vials to pens or vice versa
Regular insulin OK to autobsub between brands or generic regular insulin
Long action insulin 1:1 conversion Insulin glargine (ok to autosub between Lantus and Basaglar as 1:1) Insulin Detemir
**If switching from vial to pens, can automatically dispense pen needles. When switching from pen to vials, can automatically dispense insulin syringes
Lispro insulin Admelog insulin 1 unit 1 unit **if switching from vial to pens, can automatically dispense pen needles. When switching from pen to vials, can automatically dispense insulin syringes
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Inhaled corticosteroids/LABA Advair Diskus Airduo Respiclick Fluticasone Symbicort Dulera Breo Ellipta (aerosol powder)/salmeterol (Serevant Diskus) 100/50- 1 puff BID 55/14mcg- 1 puff 100/50mcg-1 puff 80mcg/4.5mcg- 2 100/5mcg-2 puffs 100/25mcg- 1 puff BID bid puffs BID BID qday 250/50- 1 puff BID 113/14mcg- 1 puff 250/50mcg-1 puff 80mcg/4.5mcg- 2 100/5mcg-2 puffs 100/25mcg- 1 puff BID bid puffs BID BID qday 500/50- 1 puff BID 232/14mcg- 1 puff 250- 2 puffs bid/50- 160mcg/4.5mcg- 2 200/5mcg-2 puffs 200/25mcg- 1 puff BID 1 puff bid puffs BID BID qday
Inhaled corticosteroids/LABA Fluticasone (aerosol powder)/salmeterol Advair Diskus (Serevant Diskus) Symbicort Dulera 80mcg/4.5mcg- 2 100/5-2 puffs 100/50- 1 puff BID 100- 1 puff bid/50-1 puff bid puffs BID BID 80mcg/4.5mcg- 2 100/5-2 puffs 250/50- 1 puff BID 250- 1puff bid/50-1 puff bid puffs BID BID 160mcg/4.5mcg- 200/5-2 puffs 500/50- 1 puff BID 250- 2 puffs bid/50- 1 puff bid 2 puffs BID BID **If pt's insurance does not cover any of the combo inhaler products, please call the physician. Can recommend to physician what patient's insurance will cover and take it as a verbal order if physician agrees to change the order.
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Inhaled steroids Budesonid Beclomethason e Fluticason Flunisolide Fluticasone Mometasone Triamcinolon e (QVAR (Pulmicor e (Arnuity (Aerospan) (Flovent) (Asmanex) e (Azmacort) REDIhaler) t Ellpta) Flexhaler) 100 to 40mcg 1-2 200mcg 1 44mcg 1- 100mcg 2 puffs BID OR 180mcg 80mcg puff once 2puffs BID 220mcg 1-2 puffs BID to 80mcg 1 puff 1puffs BID 2puffs BID daily (max OR 110mcg 1 puffs qday QID BID 200mcg puff BID qday) 110mcg 2 80mcg 2 puffs 180mcg 2 80mcg 220mcg 2-3 puffs BID ro 3 BID puff BID 3puffs BID puffs qday puffs BID 180mcg 3 80mcg 220mcg 2 220mcg 2
puffs BID 4puffs BID puffs BID puffs BID
K-Dur 10 & 20 mEq tabs (not covered by MediCal) Substitute with nearest number of KCl 8 mEq K-Dur 10 & 20 mEq tablets tabs
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Maalox Maalox DS with (Aluminum simethicone 200mg/Magnesium (Aluminum 200mg/5ml) 400mg/Magnesium 400mg/Simethicone 40mg/5ml) 10mL 5mL OK to autosub at 2:1mL ratio from Maalox to Maalox DS with simethicone
Naloxone Nasal Spray: Naloxone Nasal Kit Dose: 4 mg/0.1 mL Dose: 2mg/2mL Sig: Spray 1ml into each nostril (total Sig: 4 mg (contents of 1 nasal spray) as a single dose; may repeat 2mL) via atomizer x1 PRN. Repeat in 3 every 2 to 3 minutes in alternating nostrils until medical assistance min if no response. Dispense 2 syringes becomes available and 1 atomizer OK to autobsub between spray and kit based on pt insurance coverage
ondansetron tab ondansetron ODT tab OK to autobsub between regular and ODT tabs based on pt insurance coverage
Prostaglandin Agonist and Dose lantanoprost (Xalatan) 1 drop in affected eye(s) QHS bimatoprost (Lumigan) 1 drop in affected eye(s) QHS travoprost (Travatan) 1 drop in affected eye(s) QHS
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Proton Pump
Inhibitor and Dose pantoprazole lansoprazole omeprazole rabeprazole esomeprazole (Nexium) (Protonix) (Prevacid) (Prilosec) (Aciphex) 20 mg daily 15 mg daily 20 mg daily 20 mg daily 20 mg daily 40 mg daily 30 mg daily 40 mg daily 40 mg daily 20 mg BID 40 mg daily 40 mg BID 30 mg BID 40 mg BID
Miscellaneous Therapeutic Drug Conversions Metipranolol 1 Timolol ophthalmic 0.5%- 1 drop BID drop BID Ortho-dienestrol vaginal cream Premarin vaginal cream Dilacor XR (same Cardizem CD dose) Cholestyramine 4 Colestipol 5 gm gm Ciprofloxacin eye drop Ofloxacin eye drop Gentamicin eye Tobramycin eye oint oint
Flurbiprofen eye drop Ketorolac eye drop
Miconazole vag. Cream Clotrimazole vag. Cream Polysporin topical oint (Double antibiotic Neosporin topical oint oint)
Page 11 of 15 SABA inhalers 1:1 conversion Albuterol HFA Levalbuterol HFA
Serotonin 5-HT3 Receptor
Antagonist dolasetron (Anzemet) ondasetron (Zofran) 12.5 mg IV/PO q6h 4 mg IV/PO q6h
Steroid Nasal Inhaler and Dose (per
Nostril) Beconase/Vancenase 1 spray BID-QID Beconase AQ 1-2 sprays BID Nasarel 2 sprays BID Flonase 2 sprays daily (non-Medical pts) Nasacort 2 sprays daily OR Veramyst 2 sprays daily (medical pts) Nasacort AQ 2 sprays daily Nasonex 2 sprays daily Triamcinolone [Nasacort AQ] 2 sprays Rhinocort 2 sprays BID daily (for Medical pts) Rhinocort AQ 1 spray daily Vancenase AQ 1-2 sprays daily
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Sulfonylureas* Glyburide Glipizide 1.25 mg/day 2.5 mg/day 2.5 mg/day 5 mg/day 5 mg/day 10 mg/day
10 mg/day 20 mg/day (divided in 2 doses)
20 mg/day 40 mg/day (divided in 2 doses) *autosub glyburide to glipizide only
Tetracycline Doxycycline Doxycycline
hyclate monohydrate 100mg BID 100mg BID
Thiazolidinedione and Dose (PO) rosiglitazone (Avandia) pioglitazone (Actos) 4 mg daily 15 mg daily 8 mg daily 30 mg daily (2x15 mg)
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Combination antibiotics/steroid ear drops Ofloxacin 0.3% ear drops: 10 drops to affected ear(s) daily for 7 days AND Dexamethasone 0.1% EYE drops: 3 drops to the EAR(s) BID for 7 days
OR Ciprodex ear drop Ofloxacin 0.3% ear drops: 10 drops to affected ear(s) daily for 7 days AND Prednisolone 1% EYE drops: 2 gtts to affected EAR(s) BID for 7 days
Ofloxacin 0.3% ear drops: 10 drops to affected ear(s) daily for 7 days AND Dexamethasone 0.1% EYE drops: 3 drops to the EAR(s) BID for 7 days
OR Cipro HC ear drop
Ofloxacin 0.3% ear drops: 10 drops to affected ear(s) daily for 7 days AND Prednisolone 1% EYE drops: 2 gtts to affected EAR(s) BID for 7 days
Docusate conversion between different salt forms
Docusate Ca 240mg Docusate Na 250mg
Tiotropium inhaler form interchanges Spiriva HandiHaler vs. Spiriva Respimat
Spiriva HandiHaler 1 capsule (18mcg) inhaled once Spiriva Respimat 2 inhalations (5mcg) once daily daily
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Sevelamer conversion between different salt forms
Sevelamer carbonate 800mg Sevelamer HCL 800mg
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CENTRAL VENOUS CATHETERS (CENTRAL LINES/PICC/PORT-a-CATH) - Insertion, Maintenance and Removal
Department Nursing, Medical Staff Effective Date 5/03 Campus All Date Revised 6/2010, 8/2013, 8/2019 Category Clinical Next Scheduled 8/2022 Document Nurse Managers, Executive VP, Patient Care Services Owner Infection Prevention Responsible Printed copies are for reference only. Please refer to electronic copy for the latest version.
PURPOSE
To ensure the effective use, safe and sterile insertion, proper maintenance and prompt removal of central line catheters.
POLICY 1. Only credentialed and privileged providers shall insert central venous catheters. • Exception: A registered nurse (RN) who has been certified proctored and demonstrated competency in the insertion of peripherally inserted central venous catheters (PICC lines) can insert PICC lines, with a physician’s order 2. Physician trainees who perform catheter insertion must be certified or directly supervised by certified senior resident or credentialed provider. 3. Central line catheters will be managed by Registered Nurses (RN) and physicians, meeting the standards set forth by the Center for Disease control and Prevention (CDC) and the American Association of Critical Care Nurses (AAACN). 4. Central venous catheter dressing change will be managed by Registered Nurses meeting the standards set forth by the CDC and AACN.
DEFINITIONS
A Central Venous Catheter is a catheter which has a distal end that terminates at or close to the heart or one of the great vessels, which are used for infusion, hemodynamic monitoring, or blood draws Central venous catheters are either non-tunneled or tunneled devices.
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NON-TUNNELED central venous catheters: • Multi-lumen, single-lumen catheter; • A catheter inserted directly into the vein with its tip usually located in the vena cava. • Non- tunneled central venous catheters can be placed at the bedside or in the operating room.
TUNNELED central venous catheters: • Includes, but is not limited to, CVC, Quinton, Hickman, Broviac, Cook, Groshong, and implantable ports • A catheter which has been surgically “tunneled” through subcutaneous tissue, then inserted into a large central vein until its tip lies in the vena cava – often with cuff which helps decrease infections (commonly referred to as Hickman or Broviac) • The insertion site is usually on the chest wall, between the nipple and clavicle • They are used for six months to a year • Tunneled central venous catheters are inserted in the operating rom.
IMPLANTABLE PORTS: • A tunneled catheter placed by the physician in a subcutaneous pocket • The silicone catheter is tunneled to the vein, or artery. • Ports allow for continuous or bolus delivery of antineoplastic drugs, analgesics, and other parenteral medications and infusates. • Implanted ports are inserted in the operating room.
Peripherally Inserted Central Catheters (PICC): A peripherally inserted central catheter or “PICC” is a flexible tube that is inserted into a vein in the upper arm and guided (threaded) into a large vein above the right side of the superior vena cava. Treatments, such as IV medications, can be given though a PICC. Blood for laboratory tests can also be withdrawn from a PICC
Central Line Associate Blood Stream Infection (CLABSI): National Healthcare Surveillance Network (NHSN) definitions will be used to conduct CLABSI surveillance.
Central Line Associated Blood Stream Infection Prevention Bundle: is a group of insertion, maintenance and removal interventions that when implemented together results in reduced risk of infections attributed to the device.
Central Line Insertion Practice (CLIP) is a checklist used to ensure all steps are completed with each insertion.
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GUIDELINES
1. Strict aseptic technique is required for all procedures involving central venous access devices. Maximum barrier precautions are used for insertion and line changes (gown, gloves, drapes, for operators, mask and caps for all in the room including patient). When adherence to aseptic technique cannot be ensured (i.e. catheters inserted during a medical emergency) replace catheters within 48 hours. 2. For PICC line insertions, a questionnaire to determine appropriateness will be completed by the PICC nurse prior to placement. 3. Flush unused ports every shift using a push-pause technique with 10mL Normal Saline syringe, removing syringe, and then clamp line. (Note: Use no smaller than a 10mL syringe to access, draw from, administer, or flush a central line. NEVER apply excessive pressure when flushing the catheter. Forceful flushing may cause breaking and/or rupture of the catheter). 4. NEVER clamp a central line with a hemostat or other sharp edge clamp – these may cut the catheter. Only the clamp attached to the central line port should be used to clamp the central line. 5. Do not apply tourniquet, take blood pressure, or perform venipuncture on an arm with a PICC line catheter. 6. Radiology contrast media may be inserted only via the PICC port labeled Power Injectable or other large bore line approved for power injection. 7. Incompatible solutions may be administered using separate ports in a multi- lumen catheter with tubing label appropriately. The same port should be used consistently thereafter. 8. For Hickman, Broviacs, or other infusion devices not mentioned in this policy refer to the manufactures recommendations for flushing volumes and instructions. 9. Tubing and connectors are changed every 7 days and anytime the connector appears damaged, is leaking, or has residue blood that can’t be cleared (exception see #11 & 12 below). For blood products refer to the policy “Blood Product Transfusion” 10. Central line primary and secondary tubing will be labeled with Central Line or Peripheral line label as indicated and with the day of week label for tubing change. 11. Replace tubing used with TPN or fat emulsions every 24 hours. 12. Propofol tubing is changed every 12 hours and with every vial change. (Note: distal lines should be saved for CVP monitoring as indicated). 13. Blood sampling from a central line is strongly discouraged but may be considered when a patient has limited vascular access and must then be performed by an RN with documented competency. A physician’s order is required in areas other than Critical Care units. (Note: Blood cultures will not
Page 3 of 12 be drawn from a central line unless a physician specifically orders it to be accessed to ascertain CLABSI.) 14. If blood is to be drawn through the central line, strict sterile technique should be followed like the line insertion (sterile gloves mask, and observation of sterile field), with close attention to medication administration which might be administered through the line. The nurse providing care for the patient should be informed. 15. The vascular access Port-A-Cath is an implantable device used to provide access to the vascular system for drawing blood specimens or for administering drug, blood products, and TPN solutions. During extended periods between injections, the system must be flushed at least once every 4 weeks, or as directed by physician. 16. A physician order is needed when Heparin flush must be utilized for specific catheters. 17. Quinton/Perm or other dialysis catheters may be accessed by Dialysis staff and physicians only (Exception: In an emergency, a physician may order to have a nurse with competency access the line). 18. Femorally inserted central venous catheters (except those used for hemodialysis) should be replaced within 48 hours of insertion, and not used outside of the Intensive Care Units. 19. Surveillance of CVC/PICC for Central Line-Associated Blood Stream Infections (CLABSI) will be routinely carried out by the Infection Preventionist. This will include querying the nurse of physician for removal of lines no longer necessary.
INSERTION of CENTRAL VENOUS CATHETERS (CVC) or PICC: See Elsevier Clinical Skills for stepwise procedures for insertion, maintenance, site care and removal of CVCs. • Physicians are responsible for insertion of vascular access ports, tunneled, or non- tunneled • Insertion of a PICC is done by a physician or PICC RN with a physician’s order • The femoral vein site should be avoided for central line insertion to decrease the risk of infection and deep vein thrombosis (DVT) • When femoral placement is unavoidable, the line should be replaced within 48 hours or as soon as possible o If a patient has a femoral line, there must be an order for bedrest • Central lines placed emergently should be removed within 48 hours or as soon as possible • Luer-lock connectors will be used on triple-lumen central vein catheters • Any lumen intended for TPN infusion will be labeled and used only for this purpose o A lumen that has previously been plugged may not be used for TPN • Attachments of infusion lines will be secured using the luer-lock device or tape • Daily Assessment of Necessity: MDs must assess Central Venous Catheters daily
Page 4 of 12 and document its necessity in patient’s electronic medical record. • Prior to insertion, educate the patient, and as needed the family about prevention of central line associated bloodstream infection (CLABSI) and if information on Central Lines will be given to the patient and his/her family. • A Central Line Insertion Practice (CLIP) form will be filled out as part of the procedural notes in the electronic health record (EHR) • The insertion procedure should have an observer (ensuring sterile technique is not broken/filling out the CLIP form) and the operator (performing the insertion). The exception is for PICC line insertions. • Chlorhexidine impregnated disk will be placed on all CVC/PICC around the catheter next to the skin. • Alcohol impregnated hub caps (e.g. Swabcaps) will be placed on the hubs of all ports • Avoid using the Subclavian site for non-tunneled catheters, the Jugular site is preferred. In the event a subclavian is the only option, it will be allowed. • Tip location will be confirmed by X-ray prior to using the line to deliver prescribed therapy. (Exception: femoral insertion site does not need X-ray confirmation prior to use, although this is not a preferred site due to high risk of infection). • All documentation for lines and indwelling devices will be in the patient’s electronic medical record under Lines/Devices/Access (LDA)
CENTRAL VENOUS CATHETER SITE CARE: Central venous catheter dressing change will be managed by Registered Nurses (RN) meeting the standards set forth by the Center for Disease Control (CDC) and the American Association of Critical Care Nurses (AACN). • Central line dressing changes will be done every 7 days or as needed if dressing soiled, lose or damp. • Dressings will be changed using sterile techniques
See Elsevier Skills for stepwise CVC/PICC Dressing Change and Site Maintenance
ASSESSMENT AND DOCUMENTATION • The patient with a central venous catheter is assessed for the following: o Vital signs, including temperature taken per unit routine or per physician order. o Insertion date, location and type of catheter are noted in the patient care notes. o The insertion site is assessed each shift for appearance, for signs and symptoms of complications, and for integrity of the dressing, with documentation in the central line process intervention field in the patient care record. o Patency of the line is checked at least every shift and is reviewed with the next RN assigned to the patient at the time of handoff.
Page 5 of 12 • Report signs and symptoms of infection (redness or tenderness at the insertion site or fever), bleeding, catheter leakage, occlusion, or dislodgement of the catheter to the physician. Note: Sterile phlebitis may occur during the first 24 hours and/or up to 5 days post insertion of a PICC line and can be relieved by using heat. Request Physician to assess any potential signs of phlebitis.
DRAWING BLOOD FROM CENTRAL VENOUS CATHETER: See Elsevier Central Venous Catheter: Blood sampling via intranet: PICC: Blood Sampling with the following additions for AHS general guidelines: • Blood specimens should never be drawn from Quinton catheters. • Blood cultures should not be drawn from central line because of the high rate of false positive culture results o In the rare exception that blood culture(s) must be drawn from a line, clearly identify which line and which lumen (in the case of multi-lumen lines) has been accessed. This information must be transmitted to the microbiology lab with the specimen. o If blood is to be drawn through the central line, strict sterile procedure should be followed similar to the line insertion (sterile gloves mask, and observation of sterile field), with close attention to medication administration which might be administered through the line. The nurse providing care for the patient should be informed • Only the attendings from ID, ICU, or Hem/Onc services can request cultures from blood obtained from indwelling lines. • This policy is set to maximize the clinical usefulness of line draws to assess for line colonization and to minimize the practice of obtaining blood from indwelling lines when other peripheral venous access sites are available • Aseptic techniques (use of gown, sterile gloves, masks) must be strictly followed for obtaining blood from any indwelling line to prevent false positive blood cultures • The Clinical Laboratory has instructional materials to assist with educating staff on proper aseptic technique for obtaining peripheral blood for culture • If blood does not flow into the blood tube or syringe a. Have patient change position, cough, move arm above head, or hold a deep breath b. Attempt to flush catheter with saline and attempt to withdraw blood attain c. Replace blood tube with a new one d. If still unsuccessful, notify physician e. Draw the blood specimen peripherally
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FLUSHING or ADMINISTRATION OF MEDICATIONS THROUGH CVCs
PROCEDURE 1. Perform hand hygiene with alcohol rub or soap and water 2. Don gloves 3. Inspect injection/access port for integrity 4. Disinfect with 70% alcohol and let air dry 5. Aspirate to confirm catheter patency, via positive blood return, using 10ml or greater syringe 6. After positive confirmation of blood return, discard 5ml from port and remove syringe 7. Insert 10 ml syringe or larger, syringe filled with preservative-free 0.9% sodium chloride, injectable, into injection/access port 8. Flush port with required amount of preservative-free 0.9% sodium chloride, with 10 ml syringe 9. Discard syringe in appropriate puncture-resistant container 10. Disinfect injection/access port with antiseptic solution 11. Connect medication administration set to injection/access port 12. Administer medication 13. Disconnect medication administration set from injection/access port 14. Disinfect injection/access port with antiseptic solution 15. Insert appropriate syringe filled with preservative-free 0.9% sodium chloride, injectable, into injection/access port 16. After positive confirmation of blood return, flush injection/access port and remove syringe 17. Discard syringe in appropriate puncture –resistant container 18. Disinfect injection/access port with antiseptic solution 19. Insert appropriate syringe filled with 0.9% sodium chloride/heparin (implantable ports) (See Appendix A for concentration) into injection/access port 20. Flush injection/access port and remove syringe 21. Discard syringe in appropriate puncture-resistant container 22. Perform hand hygiene with alcohol rub or soap and water
REMOVAL OF A CENTRAL VENOUS CATHETER See Elsevier Clinical Skills for stepwise procedures for insertion, maintenance and removal of CVCs. With the following additions/cautions for AHS: Removal of central venous catheters should occur as soon as the catheter is no longer needed, when therapy is completed, a mechanical malfunction has occurred, the catheter has become occluded or mispositioned, or the patient has developed a catheter-related
Page 7 of 12 infection. • Central lines may be discontinued by an RN with a physician’s order • The central line should be removed promptly when no longer needed o The RN will perform a daily review of central line necessity and request physician order for line removal when central venous access is no longer required o The MD will review the need for the line daily and document on the patient’s medical record • The central line should not be routinely replaced solely to prevent catheter related infection o The central line should be replaced if purulence is observed at the insertion site and the patient still requires the line o Determine from the physician whether catheter tip needs to be cultured o Catheter tips should be cultured only when line sepsis is suspected o Physicians only will remove tunneled, cuffed catheters or implanted ports and pumps, as it is the physician’s responsibility to remove such devices
MEDICAL EMERGENCY-CALL H.O. STAT IF . . . Monitor the patient’s vital signs, pulse oximetry, and level of consciousness before and after the CVC is removed – changes in any of the above may indicate
Venous air embolism o Immediately place patient on left side in Trendelenburg position o Administer oxygen as ordered
Catheter integrity Inspect the catheter after it is removed – compare length of catheter to original insertion length to ensure entire catheter is removed. If catheter tip is not attached, notify the physician STAT.
IMPLANTED PORTS (Port-a-cath) See Elsevier Clinical Skills for stepwise procedures for implanted Port removal, Care after. with the following general information for AHS:
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PATIENT MONITORING AND CARE: IMPLANTED PORTS 1. Do NOT attempt to repair a defective implanted port 2. Culture access site, access device, or infusate if an infusion- related infection is suspected 3. During IV infusions assess the venous access device for patency and signs of infiltration every 4 hours and as needed 4. Place a biopatch and sterile gauze under the device wing to prevent rocking motion of needle within septum and anchor to skin using steri-strips or sterile tape 5. Replace gauze dressing every 2 days, transparent dressing every 7 days – change the dressing if it becomes damp, loosened, or soiled or when inspection of the site is necessary 6. Change access device every 7 days 7. Follow-up care for de-accessed device includes flushing monthly with 5 ml heparin (100 units/ml) 8. Occluded devices may be treated after determination of cause of occlusion 9. Assess for signs and symptoms of infection
DECLOTTING Central Venous Catheters should only be done by appropriately trained RN.
REFERENCES
1. Elsevier Clinical Skills – AHS Intranet https://epm601.elsevierperformancemanager.com/Personalization/Home?VirtualNam e=alamedacountymedicalcenter-caoakland 2. Lynn-McHale Wiegand, DF & Carlson, KK 2011). AACN Procedure Manual for Critical Care 6th edition. Elsevier Saunders, St. Louis, MO. 3. (2011) American Association of Critical Care Nurses Procedure Manual for Critical Care (6th ed). 4. Lippincott Manual of Nursing Practice, 8th edition, pp 94-96 5. CDC 2011, Guidelines for Prevention of Intravascular Catheter Related Infections. 6. Proehl, Jean (2009) Emergency Nursing Procedures 4th edition, Saunders Elsevier, St Louis, Mo. 7. Infusion Nursing, 3rd Edition, (2006), Infusion Nurses Society, pp. 90-93, 117-133 8. Joint Commission National Patient Safety Goals 07.04.01 9. Institute for Healthcare Improvement Central Line Bundle Compliance: http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Measures/CentralLineBundleC omplianceRate.htm
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APPROVALS
System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 8/2019 8/2019 Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 11/2019 N/A N/A Council (CPC) Medical Executive Date: N/A 11/2019 11/2019 Committee Board of Trustees Date: N/A N/A
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Attachment Appendix A: Quick Reference Guide for Central Venous Catheters
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INPATIENT INFLUENZA VACCINATION POLICY
Department Nursing Effective Date 5/2016 Campus All Date Revised 9/2019 Category Clinical Next Scheduled 9/2022 Review Document VP Patient Care Services Executive Chief Administrative Owner Responsible Officer/Chief Nurse Executive Printed copies are for reference only. Please refer to electronic copy for the latest version.
PURPOSE
To guide clinicians regarding hospitalizations, morbidity or mortality associated with influenza; and allow non-physician personnel to provide vaccine per protocol.
POLICY
Influenza vaccination will be offered to eligible adult in-patients. Influenza vaccination will be offered October through May (or longer as determined by state/federal public health entities). Distribution will be determined by vaccination supplies or any special determination by the CMS, CDC and/or state and local public health entities each year. (Reference: Immunizations in Adult Clinics Protocol).
PROCEDURE 1. Registered Nurses will complete an assessment of all in-patients eligibility and indication upon admission according to criteria set forth by CMS, Centers for Disease Control (CDC), and AHS standing protocol policy -see criteria listed below.
2. Efforts are made by the RN/LVN to find out information about the patient’s vaccination status from the patient, their legal representative, or healthcare providers. If the vaccination status cannot be determined, the patient should be considered unvaccinated.
3. Patients who refuse or those with contraindications will not be vaccinated. Patient refusal will be documented in medical record.
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4. If eligible, a registered nurse will activate the order to pharmacy and pharmacy will validate the order.
5. Vaccines are administered as ordered.
6. For eligible patients accepting the vaccination the following will be included in medical record documentation: a. A Vaccine Information Statement (VIS) will be provided to the patient by the nurse and documentation of patient receipt of the VIS, including edition date of VIS. Refer to www.cdc.gov/vaccines/pubs/vis/default.htm. b. The Vaccine administration site, lot number and expiration date. c. Administration must be entered into the electronic medical record, that is linked to the state’s vaccination database, California Immunization Registratry.
ELIGIBILITY DETERMINATION
Inactivated Influenza Vaccination 1. Influenza Vaccine should be offered every year during the “Flu Season” to anyone at least 6 months of age or older.
2. Per AHS policy patients with active fever greater than 100.4 degrees F should not be vaccinated until temperature is less than 100.4.
3. Influenza Vaccine should NOT be given to the following patients: a. Anyone that has had a life-threatening allergic reaction after a dose of flu vaccine, or have a severe allergy to any part of this vaccine (i.e. hypersensitivity to eggs or other component(s) of the vaccine. b. Bone Marrow transplant within the past 6 months. c. Anaphylactic latex allergy. d. Has had Guillain-Barré Syndrome after receiving the vaccine (a severe paralyzing illness, also called GBS).
REFERENCES 1. The safety of vaccines is always being monitored. For more information, visit: www.cdc.gov/vaccinesafety/.
2. Influenza Vaccination Information Statements: www.cdc.gov/vaccines/pubs/vis/default.htm.
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APPROVALS
System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 9/2019 9/2019 Pharmacy and Date: 9/2019 N/A N/A Therapeutics (P&T) Clinical Practice Date: 10/2019 N/A N/A Council (CPC) Medical Executive Date: N/A 11/2019 11/2019 Committee Board of Trustees Date: N/A N/A
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INTERDISCIPLINARY VERBAL ORDERS AND PATIENT SAFETY
Department Multiple Effective Date 5/2003 Campus Alameda Hospital, Date Revised 7/2010, 3/2013, Highland Hospital, 9/2019 San Leandro Hospital, John George Psychiatric Hospital Category Clinical Next Scheduled 9/2022 Review Document Owner Chief Administrative Executive Chief Administrative Officer/Chief Nurse Responsible Officer/Chief Nurse Executive Executive Printed copies are for reference only. Please refer to electronic copy for the latest version.
PURPOSE To ensure that verbal or telephone orders are accurately transcribed and carried out.
POLICY 1. The use of verbal orders is discouraged and not to be used for staff convenience.
2. No verbal orders accepted for Admissions and Discharges.
3. All physicians’ orders shall be validated (noted) by the appropriate personnel after each entry noting date, time, final initial, last name and professional title within the electronic health record or appropriate downtime form.
4. Verbal orders present multiple risks for error, and are permitted only in urgent or emergency situations.
5. Verbal orders (including telephone or other oral orders) shall be processed in accordance with medical staff Rules and Regulations and as described in this policy and procedure.
6. Clinical personnel who are functioning within their sphere of competence or scope of practice are authorized to transcribe verbal telephone orders given by a credentialed, Medical Staff member or authorized House Staff Member.
7. Verbal or telephone orders may only be transmitted or dictated by a practitioner
Page 1 of 5 credentialed, or authorized by the Medical Staff of the Alameda Health System (AHS).
8. Verbal or telephone orders must be authenticated pursuant to the Medical Staff policy on Authentication of Verbal Orders.
9. Clarification of verbal or telephone orders shall be accordance with this policy.
10. Conflicts between clinical personnel and practitioners shall be in accordance with this policy and/or the Chain of Command policy.
PROCEDURE a. A physician or licensed independent practitioner, or House Staff Member that has been credentialed, or authorized to practice at this facility may transmit or dictate verbal or telephone orders to clinical personnel within the facility. b. Practitioners may only transmit or dictate verbal or telephone orders within their scope of practice and clinical practice. c. All orders transmitted verbally or over the telephone shall be done so by the practitioner. Practitioners may not delegate this responsibility to their office staff (clerical/nursing).
2. Individuals that May Receive Verbal or Telephone Orders a. A verbal or telephone order from a practitioner may only be taken by: i. A Registered Nurse (RN) or Licensed Psychiatric Tech (LPT) Licensed Vocational Nurse (LVN) An LVN may not take a verbal order on the Highland campus ii. A Registered Pharmacist (RPH) iii. A Respiratory Care Practitioner (RCP) – within the scope of practice iv. A Registered Dietitian (RD) – within the scope of practice v. A Registered Radiology Technologist (RT) – within the scope of practice vi. A Licensed Physical Therapist, Occupational Therapist, Speech Pathologist – within the scope practice b. A verbal or telephone order may NOT be taken by: i. A unit secretary ii. A nursing assistant iii. A student intern in any of the above disciplines (a-i – a-vi). c. In these cases, the individual must refer the practitioner to an individual that is permitted to accept the order.
3. Processing of Verbal or Telephone Orders a. Read Back Protocol i.Verbal or telephone orders transmitted or dictated by a practitioner are verified by “read back” procedures where all information regarding the order is read back to the prescriber, including the patient identification information and critical patient data. This includes all
such orders, including, but not limited to medications, diagnostic tests, procedures and specific instructions for patient care. ii. The information is to be “read back” verbatim to the individual giving the order. The practitioner should then verbally confirm that the order is correct. The read back protocol shall include the following: § Patient Name § Drug name, dose, route and frequency/interval for EACH item ordered § Diagnostic or therapeutic orders or specific instructions for patient Care iii. In certain situations, such as a medical code, trauma code, or in the OR, it may not be feasible to do a formal “read back”. In such cases, “repeat back” is acceptable. If the physician calls out the medication order and the RN repeats it back before administering the drug, and the code recorder documents the name of the drug, dose, time, route, and ate, his is an appropriate “repeat back” procedure. iv. The receiver of the order should enter it into the electronic health record, then read it back and receive confirmation from the individual who gave the order. As noted in iii. above, the order should be written by the recorder in a medical code, trauma code, or in the OR. For verbal or telephone orders that occur during a downtime of the electronic health record, the Epic Downtime Policy should be followed. b. Documentation i. Verbal orders or telephone orders shall be immediately entered into the electronic health record or onto other authorized document by the individual that received the order. ii. Verbal or telephone orders shall include: § The date and time of entry § The prescribing practitioner’s name § The signature and title of the person who accepted the order iii. Verification that the verbal or telephone order has been read back shall be noted in the medical record by the transcriber in the verbal order/telephone order notation. § Example: Lasix 40mg IV now for lung congestion T.O. Dr. Smith/N. Nurse, RN (read back).
4. Validation and Authentication of Verbal or Telephone Orders a. Verbal or telephone orders must be authenticated pursuant to the Medical Staff Policy on Authentication of Verbal Orders. b. Verbal or telephone orders or medications must be authenticated by the prescriber or designee within forty-eight (24-48) hours pursuant to the Medical Staff Policy on Authentication of Verbal Orders. c. Verbal or telephone orders for restraints have special authentication requirements, depending on if the restraint is a medical-Surgical Emergency Behavioral or
Page 3 of 5 Psychiatric restraint. Please refer to the specific restraint policies for these authentication time frame requirements. d. Other verbal or telephone orders must be authenticated within fourteen (14) days of patient discharge.
5. Clarification of Verbal or Telephone Orders a. An order clarification is needed whenever an order is incomplete or unclear, or appears to be incorrect or unsafe. b. Any question as to drug, dosage, or meaning of an order shall be clarified with the prescribing practitioner. Please refer to AHS System Medication Administration Policy. c. If the nurse cannot clarify the verbal or telephone order with the practitioner, the order shall not be entered into the electronic health record, transcribed, or implemented and the nursing supervisor shall be immediately notified. d. All clarifications of orders must be re-entered into the electronic health record or re- written on the appropriate authorized form within the medical record with indications to discontinue previous order and to activate the new and clarified order. e. Telephone/verbal orders are not permitted for use of chemotherapy drugs: please refer to System Medication: Prescribing and Ordering Policy. f. Telephone/verbal orders are also not permitted for use of non-formulary drugs.
6. Conflict Resolution with Verbal or Telephone Orders a. If a physician cannot clarify and order or refuses to change an order that is unsafe for the patient, the nurse shall immediately notify their direct supervisor. b. If their direct supervisor can resolve the issue, the order will be carried out. If their direct supervisor cannot resolve the issue, the supervisor shall follow the Chain of Command policy to achieve clarification or resolution. c. Mechanisms that may be employed to reduce the number of conflicts between the prescriber and transcriber include, but are not limited to: i. Read back the order to the prescriber and to the individual entering the verbal order for clarification. ii. Have this second person listen to the verbal order while being transcribed. 1.Have this second person verify the accuracy of the order entered into the electronic health record with the original receiver of the verbal order.
APPROVALS
System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 10/2019 10/2019 Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 10/2019 N/A N/A Council (CPC) Medical Executive Date: N/A 11/2019 11/2019 Committee Board of Trustees Date: N/A N/A
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MEDICAL CARE OF PATIENTS AT JOHN GEORGE PSYCHIATRIC HOSPITAL (JGPH)
Department Behavioral Health Effective Date 10/2019 Campus John George Psychiatric Date Revised 10/2019 Hospital Category Clinical Next Scheduled 10/2022 Review Document Chair of Psychiatry Executive Responsible Chief Medical Owner Officer
PURPOSE To establish standards and guidelines for medical care of patients at John George Psychiatric Hospital (JGPH).
POLICY John George Psychiatric Hospital will establish processes that contribute to continuing care of patient’s ongoing medical conditions; as well as optimal response to and interventions for any medical decline including medical emergencies.
A. Prior to acceptance of patient at JGPH. 1. JGPH is free standing psychiatric facility with limited ability to take care of patients with acute medical problems and certain medical conditions. All referrals are screened by psychiatrist using the Medical Transfer Acceptance Guidelines (Appendix A) 2. All patients who are sent out to emergency rooms for treatment are screened for medical stability for return by internist on call.
B. JGPH Psychiatric Emergency Services (PES) 1. All patients arriving at JGPH receive a brief screening evaluation by psychiatrist and nursing. Any patient needing medical attention that cannot be provided at JGPH are transferred to nearest emergency room for treatment and accepted back when medically stable. 2. All patients admitted to the PES receive a comprehensive nursing assessment and a psychiatric assessment by psychiatrist. 3. There is a psychiatrist present in PES 24/7 to respond to all urgent medical concerns in person. 4. Internists round daily in the PES to assess any patients that are referred to them by psychiatrists for assessment of any acute medical conditions. 5. Internists are available 24/7 by phone for any consults for medical care of the patients.
Page 1 of 2 6. Nurses are assigned to patients on a 1:6 ratio. Nursing assessments are done and documented q shift. 7. Q15 min checks is the minimal level of observation for all patients in PES.
C. JGPH Inpatient Unit 1. Nurses are assigned to patients on a 1:6 ratio. Nursing assessments (behavioral and physical) are done and documented q shift. 2. All patients admitted to the inpatient unit receive a H&PE by internist within 24 hrs of arrival. 3. Internists round on the unit daily to do initial evaluations, follow up on patients needing medical attention and assess patients referred for evaluations by psychiatrists and nursing. 4. For any medical decline observed by nursing staff, internal medicine physicians are on phone call 24/7. Nursing staff refer to Escalation Guidelines for Medical Decline in the JGPH Medical Emergency Response Policy. 5. In case of a medical emergency 911 is called. Staff follow the JGPH Medical Emergency Response Policy .
APPROVALS
System Alameda AHS/Highland/John George/San Leandro Department Date: N/A N/A 9/2019 Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 10/2019 N/A N/A Council (CPC) Medical Executive Date: N/A N/A 11/2019 Committee Board of Trustees Date: N/A N/A
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APPENDIX A MEDICAL TRANSFER ACCEPTANCE GUIDELINES
Vital Signs • If hypertensive (SBP >160), there must be documentation of an appropriate treatment plan to address the hypertension (e.g., scheduled amlodipine, PRN clonidine, etc). • HR < 120 at the time of transfer • RR 20 or below • Finger-stick blood glucose must be > 60. If FSBS > 300, there must be documentation of an appropriate treatment plan to address the hyperglycemia (e.g., scheduled long-acting insulin, PRN sliding-scale, etc).
Labs: No specific labs are necessary from sending facilities unless indicated clinically. However, due to the difficulties in obtaining urine and prompt labs, it is appreciated when sending facilities can obtain the UTOX and urine pregnancy tests on women ≤ 50yo. Obtaining these tests should not be a reason to delay transfers. Results can be sent to JGPH at a later time if needed.
Alcohol Intoxication: The patient should be ambulatory, not in active withdrawal, and able to perform ADLs.
Overdoses: • TCA OD must have an EKG. • Tylenol, ASA levels preferred on ODs. • Tylenol OD must have stable LFTs. • Lithium OD must have 2 consecutive levels, descending. • All other ODs require approval by Poison Control or clearance per Poison Control standards.
Age > 65yo: • Can be accepted if a complete medical clearance is done at an outside medical ED as per county EMS policy. • CANNOT be brought directly to JGPH from the field. • They MUST be medically stable first.
NO pure dementia or neurological illness: 5150 is invalid in straight dementia cases. The PES psychiatrist is not “dropping the hold.” Tell the outside hospital MD that the 5150 was not valid and can be disregarded. • In Alameda County, patients with dementia or organic brain syndromes are
Page 1 of 2 considered to be suffering from neurologic diseases, not psychiatric illness, and thus do not qualify for a 5150 hold. • Such patients should NOT be accepted for transfer unless there is absolute evidence of treatable concurrent psychiatric illness unrelated to the dementia.
NO IVs, oxygen, or anything that requires external lines: Except Foley, colostomy or abdominal tubes if patient can self-care.
NO unconscious patients
NO patients requiring constant monitoring via EKG or other devices
NO crutches or canes in PES. If wheelchair dependent, patient MUST be able to weight transfer without assistance.
NO medically unstable patients. PES psychiatrist can decline unstable transfers. Dispute between JGPH and a referring facility should be referred to the Lead PES Psychiatrist or designee.
Revised 04.18.2018
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MEDICATIONS: HAZARDOUS DRUGS PREPARATION AND HANDLING
Department Pharmacy, Nursing, Effective Date 11/2019 Employee Health, EOC Campus System Date Revised 9/2019 Category Clinical Next Scheduled 9/2022 Review Document Directory of Pharmacy Executive Chief Administrative Owner Medication Safety Officer Responsible Officer/Chief Nurse Employee Health Director Executive EOC Director Printed copies are for reference only. Please refer to electronic copy for the latest version.
POLICY Personnel preparing hazardous drugs will take all necessary precautions, as outlined, in order to protect themselves and the environment from hazardous medications. Specific disposal procedures for the materials used in the preparation of these drugs, as outlined below, will be followed.
PURPOSE To promote safe work practices for all employees who prepare, handle and administer hazardous medications. These guidelines should be implemented wherever hazardous drugs are received, stored, prepared, or disposed.
DEFINITION As stated in NIOSH (National Institute for Occupational Safety and Health), hazardous drugs (HD) include those used for cancer chemotherapy, some antiviral drugs, antibiotics, hormones, some bioengineered drugs, and other miscellaneous drugs.
Therefore, when working with any hazardous drug, healthcare workers should follow the approaches described in Table 1, along with any recommendations included in the manufacturer’s Safety Data Sheet (SDS) or the drug package inserts (DPIs).
PROCEDURE A. GENERAL 1. Personnel who are pregnant or breast feeding will not prepare or handle hazardous drugs.
Page 1 of 9 2. Personnel planning to become pregnant in the immediate future may choose to prepare or handle hazardous agents knowing the potential risks. 3. Personnel preparing or handling oral or parenteral hazardous agents should follow current NIOSH 2016 Personal protective equipment and engineering controls for working with hazardous drugs in healthcare settings recommendation (See Appendix 1). 4. Wash hands before putting on gloves and after gloves are removed. 5. Use a separate counting tray, and clean under soap and water after use for oral or topical hazardous drugs 6. Each campus will maintain a list of those hazardous medications that are handled at their site.
B. RECEIPT OF HAZARDOUS MEDICATIONS 1. Receipt and unpacking of hazardous medications must be clearly designated and signs displayed before the entrance to the HD handling area 2. Antineoplastic HDs and all HD APIs must be unpacked (i.e., removal from external shipping containers) in an area that is neutral/normal or negative pressure relative to the surrounding areas. HDs must not be unpacked from their external shipping containers in sterile compounding areas or in positive pressure areas
C. STORAGE OF HAZARDOUS MEDICATIONS 1. HDs must be stored in a manner that prevents spillage or breakage if the container falls. 2. Do not store HDs on the floor. 3. Antineoplastic HDs requiring manipulation other than counting or repackaging of final dosage forms and any HD API must be stored separately from non-HDs in a manner that prevents contamination and personnel exposure. These HDs must be stored in an externally ventilated, negative-pressure room with at least 12 air changes per hour (ACPH). 4. Non-antineoplastic, reproductive risk only, and final dosage forms of antineoplastic HDs may be stored with other inventory 5. Sterile and nonsterile HDs may be stored together, but HDs used for nonsterile compounding should not be stored in areas designated for sterile compounding to minimize traffic into the sterile compounding area. 6. Refrigerated antineoplastic HDs must be stored in a dedicated refrigerator in a negative pressure area with at least 12 ACPH. 7. If a refrigerator is placed in a negative pressure buffer room, an exhaust located adjacent to the refrigerator's compressor and behind the refrigerator should be considered
D. PREPARATION 1. GENERAL A. Please refer to USP 800 for specifics on Sterile Compounding Hazardous Medication as it relates to: a. Engineering controls b. Use of Closed System Transfer Devises
Page 2 of 9 c. Deactivating, decontaminating, cleaning and disinfecting B. NON-antineoplastic hazardous drugs a. Properly trained pharmacists or pharmacy technicians shall reconstitute and/or dilute all parenteral NON-antineoplastic hazardous drugs intended for administration in an ISO 5 CAI which within the ISO Class 7 anteroom, or segrated compounding are using aseptic technique. b. Wear disposable, single-use, back closure gowns when compounding NON-antineoplastic hazardous agents. C. Antineoplastic hazardous drugs a. Properly trained pharmacists or pharmacy technicians shall reconstitute and/or dilute all parenteral antineoplastic hazardous drugs intended for administration in negative pressure ISO 5 CAI which within the ISO Class 7 anteroom, using aseptic technique using a Closed Transfer System. 2. TABLETS/CAPSULES A. Manipulation of hazardous tablets (uncoated and coated) and capsules by cutting, crushing, or opening should be done by trained personnel in a hazardous medication designated preparation area. (please see Table 2 for definition of manipulations and other types of exposure) B. For drugs which are hazardous if the dosage form is altered: crushing, breaking, splitting, or otherwise modifying the drug from its intended, stable dosage form, requires the individual preparing or administering the drug to wear double chemotherapy gloves and a protective gown. C. Additional protective equipment (biosafety cabinet, face and eye shield, respiratory protection) may be required if altering the dosage form of these drugs constitutes a splash or aerosol risk.
E. TRANSPORT 1. NON-antineoplastic hazardous drugs A. All NON-antineoplastic hazardous medications (intravenous and oral) will be transported in an enclosed zip lock bag labeled with the following: “CAUTION: HAZARDOUS DRUG”. 2. Antineoplastic hazardous drugs A. All antineoplastic hazardous intravenous medications will be first placed in an enclosed ziplock bag labeled with “CAUTION: CHEMOTHERAPY MATERIAL.” B. All antineoplastic medications will be transported from one unit to another in a red box labeled “Chemotherapy Drug”
F. SPILL CONTROL 1. All personnel who may be required to clean up a spill of HDs must receive proper training in spill management and the use of proper PPE 2. Spills must be contained and cleaned immediately.
Page 3 of 9 3. Signs must be available for restricting access to the spill area. Spill kits containing all of the materials needed to clean HD spills must be readily available in all areas where HDs are routinely handled. 4. If HDs are being prepared or administered in a non-routine healthcare area, a spill kit must be available. 5. All spill materials must be disposed of as hazardous waste. 6. The circumstances and management of spills must be reported as a safety event to the AHS Safety Alert system. 7. Personnel who are potentially exposed during the spill or spill clean up or who have direct skin or eye contact with HDs require immediate evaluation. 8. If the containment and cleaning of spill exceeds the capacity of the spill kit, EVS leadership will contact the vendor to address or escalate to the Fire Department HazMat team.
G. TRAINING AND COMPETENCY 1. All personnel who handle HDs must be trained based on their job functions (e.g., in the receipt, storage, compounding, repackaging, dispensing, administrating, and disposing of HDs). 2. Training must occur before the employee independently handles HDs. 3. The effectiveness of training for HD handling competencies must be demonstrated by each employee. 4. Personnel competency must be reassessed at least every 12 months. 5. Personnel must be trained prior to the introduction of a new HD or new equipment and prior to a new or significant change in process or SOP. 6. All training and competency assessment must be documented. 7. The training must include at least the following: A. Overview of entity's list of HDs and their risks B. Review of the entity's SOPs related to handling of HDs C. Proper use of PPE D. Proper use of equipment and devices (e.g., engineering controls) E. Response to known or suspected HD exposure F. Spill management G. Proper disposal of HDs and trace-contaminated materials
H. MEDICAL SURVEILLANCE 1. Refer to Employee Health Policy
REFERENCES 1. NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings 2016
2. ASHP (American Society of Health-System Pharmacists) [2018]. ASHP guidelines on handling hazardous drugs. Am J Health-Syst Pharm Volume 75, issue 24: 1996-2031.
3. ONS (Oncology Nursing Society) [2011]. Safe handling of hazardous drugs. 2nd Ed. M. Polovich, ed. Pittsburgh, PA: Oncology Nursing Society.
Page 4 of 9 4. Polovich M, Giesker KE [2011]. Occupational hazardous drug exposure among non- oncology nurses. Medsurg Nurs 20(2):79–85,97.
5. USP 800: https://www.usp.org/compounding/general-chapter-hazardous-drugs-handling- healthcare
APPROVALS
System Alameda AHS/Highland/John George/San Leandro Department: Infection Date: N/A 8/2019 8/2019 Control Department: Date: N/A 9/2019 9/2019 Environment of Care Department: Date: N/A 9/2019 9/2019 Environmental Services Department: Employee Date: N/A 9/2019 9/2019 Health Department: Pharmacy Date: N/A 9/2019 9/2019 Pharmacy and Date: 9/2019 N/A N/A Therapeutics (P&T) Clinical Practice Date: 11/2019 N/A N/A Council (CPC) Medical Executive Date: N/A 11/2019 11/2019 Committee Board of Trustees Date: N/A N/A
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Table 1 (1)
Personal protective equipment# and engineering controls for working with hazardous drugs in healthcare settings*
Double Chemo- Eye/Face Ventilated Protective Respiratory Formulation Activity Therap protectio engineering gown protection y n control Gloves YES, if not done YES, if not YES†, BSC Compounding YES YES in a done in a OR CACI control control device device Topical Drug YES; if YES, if liquid that Administration inhalation YES YES could N/A potential‡ splash‡
YES, if not done YES, if not YES† Oral liquid Compounding YES YES in a done in a drug control control device device Administration NO‡ NO‡ YES YES N/A
YES, if YES, BSC or not done YES, if not CACI; in a done in a Compounding YES YES recommend control control device use of CSTD device Intravenous solution YES; if YES, if N/A; recom- Administration liquid that inhalation mend use of of prepared YES YES could potential‡ CSTD solution§ splash‡
YES, IF NOT Preparation YES, IF NOT DONE IN YES (withdrawing DONE IN A YES YES A BSC OR from vial or CONTROL Subcutaneous, CONTRO CACI intramuscular ampoule) DEVICE L injection DEVICE
YES; if YES, if Administration liquid that inhalation from prepared YES YES N/A could potential‡ syringe splash‡
Page 6 of 9 YES yes, if not BSC or yes, if not done in a CACI; use of Compounding YES YES done in a control CSTD control device Solution for device recommende irrigation d Administration (bladder, YES YES YES YES N/A HIPEC, limb perfusion, etc.) NO (single Intact tablet or Administration glove NO capsule from unit-dose NO NO N/A should package be used)
Cutting, YES crushing or Tablets or cap- ,if not done in otherwise YES† sules YES YES NO a control manipulating device tablets or cap-
sules YES; if Drug YES, if Disposal and liquid that Contaminated YES YES inhalation N/A cleaning could Waste potential‡ splash‡ YES; if Drugs and YES, if Disposal and liquid that metabolites in YES YES inhalation N/A cleaning could bodily fluids potential‡ splash‡ Spills Cleaning YES YES YES YES N/A
The table provides general guidance for some of the possible scenarios that may be encountered in healthcare settings, but cannot cover all possible situations. For more detailed information on safe handling practices, see the reference list [NIOSH 2004; ASHP 2006; USP 2008, and ONS 2011]. BSC = Class II biological safety cabinet; CACI = compounding aseptic containment isolator; CSTD = closed system drug transfer device; HIPEC = hyperthermic intraperitoneal chemotherapy.
†For nonsterile preparations, an engineering control such as a fume hood or Class I BSC is sufficient. It is recommended that these activities be carried out in a control device, but it is recognized that under some circumstances, it is not possible. If the activity is performed in an engineering control that is used for sterile intravenous preparations, a thorough cleaning is required following the activity.
‡Required if patient may resist (infant, unruly patient, veterinary patient) or if administered by feeding tube.
§Intravenous tubing already attached and primed.
Page 7 of 9 * For more detailed information on safe-handling practices, see the reference list [NIOSH 2004; ASHP 2006; ONS 2011; USP 2016; OSHA 2016].
# Appropriate PPE must be worn when handling HDs including during: • Receipt • Storage • Transport • Compounding (sterile and nonsterile) • Administration • Deactivation/decontamination, cleaning, and disinfecting • Spill control • Waste disposal
Page 8 of 9
Table 2- Definition of types of exposure Routes of unintentional entry of HDs into the body include dermal and mucosal absorption, inhalation, injection, and inges-tion (e.g., contaminated foodstuffs, spills, or mouth contact with contaminated hands). Containers of HDs have been shown to be contaminated upon receipt. Both clinical and nonclinical personnel may be exposed to HDs when they handle HDs or touch contaminated surfaces. See below for potential routes of exposure based on activity.
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Title: PHARMACY THERAPEUTIC DRUG MONITORING POLICY
Department Pharmacy, Medical Effective Date 11/2019 Staff, Nursing Campus All Date Revised 4/2019 Category Clinical Next Scheduled 4/2022 Review Document Owner System Medication Executive Chief Administrative Safety Officer Responsible Officer/Chief Nurse Executive Printed copies are for reference only. Please refer to electronic copy for the latest version.
PURPOSE To authorize Clinical Pharmacists to order selected drug levels and related laboratory values for the inpatients of Alameda Health System to enhance the safe and effective use of these drugs.
JUSTIFICATION Drug related problems are known to increase morbidity, mortality and healthcare costs. Drug related problems such as non-optimal use of dose, drug interaction and need for monitoring are more frequently associated with narrow therapeutic index drugs.
DEFINITIONS TDM – Therapeutic Drug Monitoring Trough – 30 min before the next scheduled dose. Peak – 1 Hour post dose (Time to peak may be used to determine alternative peak times).
POLICY 1. When indicated, Clinical Pharmacists may order drug levels and related laboratory values such as serum creatinine and albumin for narrow therapeutic index drugs:
Drug Optimal Sampling Time Time to Steady State Amikacin Trough and Peak for standard After 3-4 doses dosing and random level nomogram for once daily dosing Carbamazepine Trough Unable to predict since autoinduction Digoxin Trough Normal renal function: ~7 days (If loading dose given, draw serum concentration 12-24h after Impaired renal function: ~at least 14 the initial loading dose) days
Page 1 of 2 Gentamicin Trough and Peak for standard After 3-4 doses dosing and random level per nomogram for once daily dosing Lithium Trough ~5 days* Phenobarbital Trough ~14 days Phenytoin Trough 6-7 days Valproic Acid Trough 3-4 days (may depend on formulation)
2. Indications for drug monitoring include (but are not limited to): a. Newly prescribed drug b. New dosage change of drug c. Change in renal or liver function d. Drug interactions e. No or non-therapeutic drug level within the past six months
3. Pharmacy and nursing staff will work together to determine the optimum time for specimen collection. For TDM to be meaningful, the patient should be in steady-state on the present dose of the drug or for nephrotoxic medications to be checked prior to steady state to help assess with appropriate dosing. In general, samples should be taken after drug dosing has continued for at least four half-lives.
4. In cases of suspected toxicity, waiting to attain steady-state is not necessary and a random drug level may be collected to aid in clinical decision making.
5. After ordering the drug level, the Clinical Pharmacist will follow, interpret the level and contact the patient’s physician for any recommendations and/or dosage adjustments if needed.
6. Clinical Pharmacists will maintain competency in this area of practice via an annual competency exam.
APPROVALS
System Alameda AHS/Highland/John George/San Leandro Department: Date: N/A 3/2019 3/2019 Clinical Pharmacy Pharmacy and Date: 4/2019 N/A N/A Therapeutics (P&T) Clinical Practice Date: 11/2019 N/A N/A Council (CPC) Medical Executive Date: N/A 11/2019 Committee Board of Trustees Date: N/A N/A
Page 2 of 2
PYXIS ES Policy
Department Pharmacy Effective Date 9/2019 Campus San Leandro Hospital Date Revised 6/2019 Category Clinical Next Scheduled 6/2022 Review Document Director of Pharmacy Responsible Person System Director of Pharmacy Owner Services
Printed copies are for reference only. Please refer to electronic copy for the latest version.
Purpose To provide medication safely, effectively, efficiently, securely, and with appropriate documentation.
Policy 1. Access to Pyxis is limited to authorized patient care staff and pharmacy staff. Authorization and specific privileges are granted based on job descriptions and assigned patient care areas.
2. Medications are stocked in a manner to minimize the risk of errors, such as look-alike, sound-alike medications (see policy: Medications: Look-alike, Sound-alike).
3. Profile and Non-Profile a. Devices with an interface to electronic health record will be non-profile. b. Devices with an interface to Epic will be profile.
Procedure
Authorized access 1. User Account Request Process a. Manager or designee will request through the ISLR intake form (http://acmc- intranetb/eform/logonrequest/) b. The ISLR form will be routed for the manager’s approval, then to the IS Service Center for adding the user to the Pyxis Active Directory Group (“Pyxis ES”). c. An email notification will be generated to Pharmacy for assigning facility and user role (“SLH Pyxis Pharmacy” distribution list). d. Pharmacy will grant the appropriate user access and notify the user and supervisor.
Page 1 of 4 2. Password resets a. Users will contact the IS Service Center for password resets. b. Pharmacy cannot reset passwords.
3. Disabling accounts a. For terminated employees: The IS Service Center uses an HR separation list to disable accounts. b. For non-AHS employees: The manager will submit an ISLR deactivation request.
4. Visitor access a. When a nurse is floating to a unit that they aren’t permanently assigned to, the nurse manager, house supervisor, or charge nurse will grant visitor access to that unit using the station on the unit.
5. BioID a. BioID fingerprint identification system will be used for all devices. b. For users who can’t register a finger scan, user ID and password will be used to sign on.
Education/Training 1. All persons responsible for administering or handling medications will receive training prior to use of the Pyxis System.
2. Training consists of the following: a. Observation of Pyxis use by an experienced staff member b. Shadowing with experienced Pyxis user as needed.
Returning Medications 1. Medications not intact in their original package a. Medications not intact in their original package will be disposed of per policy “Pharmaceutical Waste”. b. If the medication is a controlled substance, it must be documented as waste. See section “Wasting Medications”.
2. Medications intact in their original package a. Non-controlled meds: Return to Pyxis Medstation internal return bin. i. Exceptions: If needed, Pharmacy may designate in the Pyxis ES system that a medication will be wasted or returned to stock. If this is the case, the station will alert the user. b. Controlled meds: i. Return to stock in the Pyxis Medstation. ii. A witness is required. iii. Scanning of the barcode on return is required. 1. If the barcode can’t be scanned, the medication will be disposed of per section “Wasting Medications”.
Page 2 of 4 Wasting Medications 1. Waste of controlled substances and other medications designated by pharmacy will be documented in Pyxis. See policy “Controlled Substance Management”.
2. Disposal of medication waste is per policy “Pharmaceutical Waste”.
3. A witness is required for waste of controlled medications and other medications designated by pharmacy. a. All Pyxis users may act as a witness for controlled substance waste. b. The witness is responsible for verifying the name, strength, and quantity of the wasted medication, and for witnessing disposal of the medication per policy “Pharmaceutical Waste”.
Discrepancies 1. See policy “Controlled Substance Management”.
Inventory Count 1. See policy “Controlled Substance Management”.
Stock 1. The pharmacy may adjust inventory levels and add or remove medications from the stations based upon usage.
Problem Solving 1. For log on issues, contact the IT Help Desk at 510-437-4503.
2. For all other issues: a. When the pharmacy is open, contact the pharmacy for assistance. b. When the pharmacy is closed: i. Contact Pyxis Tech Support at 800-727-6102. ii. If Pyxis Tech Support is unable to resolve the issue, contact the house supervisor to contact the on call pharmacist.
Power Outage/Emergency Procedures 1. Pyxis MedStations are plugged into emergency power (red outlets) and will remain operational in the event of a power outage. a. Exceptions: i. Pyxis Medstation located in Fast Track is not plugged into emergency power. During a power outage, Fast Track users will access the ED Medstation ii. Pyxis Medstation located in Dialysis is not plugged into emergency power. During a power outage, Dialysis user will access the 2nd floor Med/Surg Medstation.
Page 3 of 4
2. Failure of emergency power a. Stations may be manually opened if needed during an outage of both power and emergency power. b. Process for manually opening Pyxis i. During pharmacy operating hours: May contact the pharmacy to request manual opening of the stations. ii. While pharmacy is closed: House supervisor may notify the on call pharmacist and access the Pyxis keys located in the Night Locker. c. All medications removed from the station will be documented by the user on the Pyxis Downtime Med Log. The Pyxis Downtime Med Log will be sent to pharmacy. d. Once Pyxis is back online, an inventory must be completed for all controlled medications.
Levels of Access and Privileges 1. User roles and their privileges are determined by the pharmacy director with input from nursing leaders.
Approvals
System Alameda AHS/Highland/John George/San Leandro Department: Date: N/A N/A 6/2019 Pharmacy Pharmacy and Date: 8/2019 N/A N/A Therapeutics (P&T) Clinical Practice Date: 9/2019 N/A N/A Council (CPC) Medical Executive Date: N/A 11/2019 11/2019 Committee Board of Trustees Date: N/A N/A
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RESTRAINT AND SECLUSION USE IN ACUTE CARE
Department Nursing, Medical Effective Date 9/2016 Staff Campus AHS System Date Revised 5/2016, 5/2019 Category Clinical Next Scheduled 5/2022 Review Document Owner General Counsel Executive Chief Administrative Responsible Officer/Chief Nurse Executive Printed copies are for reference only. Please refer to electronic copy for the latest version.
PURPOSE 1. To provide guidance for staff use of restraints and/or seclusion while maintaining patient safety and dignity.
2. To provide guidance for staff so that patients are free from restraints and/or seclusion, of any form, imposed by staff as a means of coercion, discipline, convenience, or retaliation.
PHILOSOPHY Each person’s safety is important for successful treatment. It is the goal of Alameda Health System to reduce the use of restraints and/or seclusion. If a patient’s behavior poses an immediate danger to others or self and all non-physical interventions have failed, brief episodes of restraint or seclusion may be necessary to maintain a safe environment for treatment. Trained staff will make efforts to limit episodes of restraint or seclusion to the least amount of time possible. Every effort is made to preserve the safety and dignity of all staff and patients.
POLICY It is the policy of Alameda Health System to limit the use of restraints and/or seclusion for non-behavioral/and behavioral management to situations where less restrictive interventions have been determined to be ineffective to protect the patient or others from harm. It is also our policy to limit the use of restraints and/or seclusion for behavioral management and only for management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others.
GENERAL GUIDELINES
Page 1 of 12 Patient and family will be provided restraint and seclusion education information, as applicable. The reason for restraint and/or seclusion use will be explained. Restraint and seclusion are each a temporary measure. The use of restraints and/or seclusion is an exception to care, and will be based on an assessment of individual need. Attempts to discontinue restraints and/or seclusion will be considered with each observation. Restraint and/or seclusion use initiation will be communicated to the Nurse Manager/Director, House Supervisor, and/or Charge Nurse. (Note: This is not required at John George Psychiatric Hospital.) A licensed independent practitioner (e.g., M.D., D.O., Clinical Psychologist) or qualified Registered Nurse will conduct restraint/seclusion needs assessment and reassessments to determine the justification for the restraint/seclusion and to select the appropriate restraint. Application, removal and monitoring may be delegated to other clinical staff that has had the appropriate training.
A drug or medication is used as a standard treatment or dosage for the patient's condition; to treat a specific patient’s clinical condition based on that patient's symptoms, overall clinical situation, and on the physician's or other licensed independent practitioner’s (LIP) knowledge of that patient's expected and actual response to the medication. No drug or medication will be administered as a restriction to manage the patient's behavior or restrict the patient's freedom of movement or staff convenience, i.e. as a restraint.
Restraint initiation on a patient for staff convenience, to coerce or discipline a patient, or as a method of retaliation is strictly forbidden across Alameda Health System.
DEFINITIONS 1. Physical Restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his arms, legs, body, or head freely. Unless otherwise specified, all uses of the word “restraint” in this document refer to physical restraint.
2. Convenience refers to any action taken by the facility to control a resident’s behavior or manage a resident’s behavior with a lesser amount of effort by the facility and not in the resident’s best interest.
3. Discipline refers to any action taken by the facility for the purpose of punishing or penalizing residents.
4. Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member or others. NOTE: THE SAME POLICIES, PROCEDURES, AND GUIDELINES THAT GOVERN THE USE OF RESTRAINT BELOW ALSO GOVERN THE USE OF SECLUSION. SECLUSION AREA IS AVAILABLE AT JOHN GEORGE PSYCHIATRIC HOSPITAL ONLY.
Page 2 of 12 5. Administrative Law Enforcement Restraints are restraints applied by the law enforcement agency. Administrative law enforcement restrains will be honored, unless care is compromised. Only law enforcement staff can administer or remove these types of restraints. Their use is governed by Federal and State law and regulations. Typically these are handcuffs, manacles, shackles, or other restraint devices. (Note: The use of handcuffs or other restrictive devices applied by law enforcement officials is for custody, detention, and public safety, and is not involved in the provision of patient care. Therefore, the use of restrictive devices applied and monitored by law enforcement officials are not considered restraints for purposes of this document.)
The following devices and methods are not restraints: 1. Adaptive/Protective Devices, such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a patient for the purpose of conducting routine physical examination or tests, or to protect the patient from falling out of bed, or to permit the patient to participate in activities without the risk of physical harm.
2. Side Rails are not restraints when: • used to protect or prevent the patient from falling out of bed, unless all four side rails are raised with the intent to restrain the patient; • used with gurneys to prevent patient from falling off; • used with a patient who is recovering from anesthesia, sedated, experiencing involuntary movements, or on therapeutic beds/mattresses; • used for a patient who on a bed that constantly moves to improve circulation or prevent skin breakdown; or • padded and raised for seizure precautions.
3. Medically Necessary Immobilization for Procedures is the use of any usual and customary device for medical, diagnostic, or surgical procedures. These mechanisms usually include arm boards during intravenous therapy, gurney, or exam table straps or belts, use of body restraints during circumcision or the restriction of movement post- operative/post-anesthetic care patient until they are cognizant.
4. Immobilization Devices in use during post-anesthesia care are considered part of the surgical procedure and are not considered a restraint. This post-anesthesia care can occur in ICU, the PACU, or on a nursing unit.
Medicare Standards The Medicare Conditions of Participation have delineated standards for the use of restraints. These standards are not specific to the treatment setting, but to the situation for which the restraint is being used to address. The following are definitions and examples of the two standards. 1. Indications for Restraint of the Non-Violent, Non-Self Destructive Patient Medical restraints are used to ensure the safety of the non-violent or non-self destructive patient. The decision to use a medical restraint is determined by a comprehensive
Page 3 of 12 individual patient assessment to identify medical problems that may be causing behavior changes in the patient. For example, fever, hypoxia, UTI, sepsis, hypoglycemia, electrolyte imbalances, drug interactions, drug side effects, and thyroid problems, may cause confusion, agitation, and combative behaviors. Addressing these medical issues may eliminate or minimize the need for the use of restraints. Patients are restrained only when essential and after less restrictive alternative interventions have been considered and deemed ineffective. Patients may be restrained in the following situations: a. To protect patients who attempt to remove therapeutic medical devices such as peripheral intravenous lines, central lines, endotracheal tubes, gastric tubes, catheters, drains, dressings, and other medical devices. b. Patients who, due to an acute or chronic confusional state (such as traumatic brain injury or delirium) are unable to follow and thus continue to remove therapeutic devices. c. Examples: i. A patient with Alzheimer’s disease requires IV therapy but is unable to remember why the IV is in his arm and make numerous attempts to remove it. He cannot be diverted by other means and is restrained to protect the infusion. ii. A confused patient with a fractured hip is attempting to get out of bed and compromising his hip precautions. Other efforts to remind, and distract him have been unsuccessful. He is restrained to preserve the hip precautions.
2. Indications for Restraint of the Violent or Self-Destructive Patient Restraint for a patient with violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member or other, is necessary when an unanticipated outburst of severely aggressive or destructive behavior that poses an imminent danger. For example: a. A patient with Alzheimer’s disease has a catastrophic reaction where he/she becomes so agitated and aggressive that he/she physically attacks a staff member. He cannot be calmed by other methods. He/she is restrained to manage behavior, which is dangerous to him, staff and others. b. An intoxicated patient in the emergency department becomes suddenly aggressive and violent and strikes out at staff as he/she tries to elope from the unit. He will not respond to attempts to reassure and calm him. He/she is restrained to manage behavior, which is dangerous to himself, staff or others.
Note: At John George Psychiatric Hospital, a patient is only restrained if he/she is a danger to self. Patients who are a danger to others are secluded/not restrained.
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ALTERNATIVES TO RESTRAINT Alternatives and nonphysical interventions are less restrictive interventions and must be attempted and determined to be ineffective to protect the patient and/or others from harm prior to the application of restraints. 1. Psychological Alternatives a. Provide pain relief/comfort measures b. Schedule position changes c. Assess medications to determine if a medication may be contributing to or may alleviate the underlying problem d. Alter treatment regiments, e.g., saline or heparin lock vs. continuous IV when it is not necessary for hydration e. Promote patient’s normal patterns for eating, sleeping, toilet f. Provide sensory aids (glasses, hearing aids) to prevent misinterpretation of cues in the environment g. Ambulate h. Foods/Fluids offered
2. Environmental Alternatives a. Move the patient closer to the nurse’s station for increased supervision b. Increase lighting to compensate for vision loss, use night lights. c. Decrease extraneous noise to provide a more restful environment
3. Least Restrictive Alternatives a. Bed alarm b. Lap belt c. Abdominal Binder d. Distractions (television, music, movies, games, art work, journaling, etc. e. Companionship (staff or family stay with the patient) f. Low bed g. Toileting h. Massage/Back rub i. Comfortable positioning j. Decreased Stimuli
RESTRAINT PROCEDURE STEP 1: Conduct initial restraint assessment of the patient for whom physical or medication restraints are being considered. Document the clinical assessment, including: a. Specific behavior which is interfering with medical care or posing an imminent danger to patient or others. b. Identification of underlying causes, i.e., hydration, nutrition, bowel and bladder function, abnormal labs, medications, pain, etc., your intervention to correct and patient response to the intervention. c. Which alternatives were attempted and their effectiveness. (Note: The use of restraints for the prevention of falls should not be considered a routine part of a fall prevention program.)
Page 5 of 12 The assessment should be conducted by a licensed independent practitioner (e.g., M.D., D.O., Clinical Psychologist) or a qualified Registered Nurse.
STEP 2: Implement a written patient’s plan of care for the use or restraints.
STEP 3: Notify Physician, if not currently aware, and obtain order.
STEP 4: Notify Charge Nurse/Nurse Manager/Director and/or Nurse Supervisor.
STEP 5: Decide which type of restraint is least restrictive for the situation to be effective to ensure the patient’s well-being is maintained, if alternatives have been ineffective.
STEP 6: If restraint use is for management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the a patient, a staff member, or others, a face-to- face evaluation of the patient must be conducted by a physician trained in conducting face-to- face evaluation, within one (1) hour of the initiation of the restraint. Document the one (1) hour face-to-face in the medical record, which should include the following: a. The patient’s immediate situation/condition or symptoms that warranted the use of restraints. b. The patient’s reaction/response to the intervention c. Alternatives or other less restrictive interventions attempted (if applicable) d. The patient’s medical and behavioral condition e. The need to continue or terminate the restraint.
GUIDELINES
Restraint Orders Generally 1. Use of restraint must be in accordance with the order of a licensed independent practitioner (e.g., M.D., D.O., Clinical Psychologist) who is responsible for the care of the patient, and approved per hospital policy to order restraint.
2. All orders for restraints must be time-limited. Restraint orders shall never be written as standing orders or PRN (as needed) orders. The order must include the type of restraint to be used, the reason for the restraint, and the length of time the restraint is to be utilized.
3. The order for use of restraint must be for a specified period of time. For non-violent/non- self-destructive behavior the provider must reassess the patient and write a new order daily.
4. For non-violent/non-self destructive behavior restraint use, an RN who is qualified by experience and training is authorized to initiate the use of restraint. A physician order for restraint must be obtained within one (1) hour and a telephone order must be countersigned by the physician within 24 hours of restraint initiation.
5. Implementation of a time-limited order for restraint does not require application of the intervention for the entire period. If the patient demonstrates reduction in the activity/behavior that led to the restraint, restraint must be discontinued at the earliest
Page 6 of 12 possible time, regardless of the length of time identified in the order.
6. If restraints are discontinued prior to the expiration of the original order, (see above) a new order must be obtained prior to reapplying the restraints and all the requirements met to re- start the restraint.
7. All orders must be followed by consultation with the patient’s attending physician, when possible, if the patient’s attending physician does not order the restraint.
Restraint Orders for Management of Violent or Self-Destructive Behavior 1. In addition to the above standards, if restraint use is for management of violent or self- destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, a face-to-face evaluation of the patient must be conducted by a licensed independent practitioner (e.g., M.D., D.O., Clinical Psychologist).
2. In an emergency where the patient can reasonably be expected to immediately bring harm upon him/herself or others, an RN who is qualified by experience and training is authorized to initiate the use of restraint. Within one (1) hour of restrain application, a face-to-face evaluation of the patient must be conducted by a licensed independent practitioner (e.g., M.D., D.O., Clinical Psychologist) and an order obtained.
Time Limitations for Restraint Orders for Management of Violent or Self-Destructive Behavior 1. The order for use of restraints for management of violent or self-destructive behavior must be limited to: a. Four (4) hours for adults b. Two (2) hours for children 9 – 17 c. One (1) hour for children under 9
2. The original order may specify that an RN may reassess the patient at indicated intervals and request that the physician continue the original order for an additional: a. Four (4) hours for adults b. Two (2) hours for children 9 – 17 c. One (1) hour for children under 9
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APPLICATION OF RESTRAINTS 1. To assure that patient rights, dignity, and well-being are protected, select and obtain the least restrictive restraint with the maximum freedom of movement, while ensuring the physical safety of the person and others, and using the least number of restraint points. Ensure that it is the appropriate size consistent with the patient’s stature.
2. Some of the following types of restraining devices available at Alameda Health System include: a. Mittens b. Lap/seat belts c. Full use of Bedrails d. Limb e. Trays with spring release devices (geri-chair) f. Waist Roll Belts g. Freedom Elbow Splints h. Twice as Tough restraints
3. Position the patient to maintain correct body alignment, prevent aspiration, and promote comfort.
4. Apply the restraint correctly and allow the maximum freedom of movement possible while maintaining effectiveness. a. Limb: i. Do not impede flow of IV infusion or arterial line ii. Never use restraints proximal to an AV fistula shunt b. Belt: i. Avoid tight application that could interfere with breathing
5. Secure restraints by a quick release method that provides for easy removal in the event of a fire or other emergency.
Note: Restraints designed for bed use should be secured to a moveable portion of the bed frame (e.g., the portion which elevates the head). NEVER tie the restraint to the mattress, side rails, or fixed portion of the bed frame.
Documentation, Monitoring, and Reassessment 1. Document time, type of restraint and name of staff that applied the restraint.
2. Re-assess the patient immediately following application to ensure restraints were properly and safely applied. Assess for injury, physical and psychological status and other needs.
3. Update the patient’s Interdisciplinary Care Plan to include the use of restraints.
Page 8 of 12 4. Monitor patients in restraints for violent or self-destructive behavior every fifteen (15) minutes. Staff monitoring the patient should consider or address the following items every fifteen (15) minutes based on clinical judgment and knowledge of the patient and their individual needs. a. Signs of injury associated with the application of restraint. b. Nutrition/hydration c. Circulation, range of motion in the extremities and position change d. Vital signs e. Hygiene and elimination f. Physical and psychological status and comfort g. Readiness for discontinuation of restraint
Note: Patients in restraint for violent or self destructive behavior must be continually monitored face-to-face by an assigned, trained staff member.
5. Provide the patient as soon as medically reasonable with the rational for restraint and the behavior criteria for its discontinuation. (For example: Patient able to comply with safety requests, patient oriented to environment, and/or cessation of verbal threats).
6. Provide patient and family with restraint education information and explain the reason for restraint use and why alternatives are not effective. Reassure them that the restraint will be removed as soon as feasible. Document the patient/family education.
7. Monitor the patient in Non-Behavioral Restraints at least every two (2) hours. a. Assess for release of restraints b. Evaluate the patients physical and mental status, emotional, and physical well- being c. Assess circulation, skin condition d. Provide exercise or range of motion and allow for position changes e. Nutritional, Hydration, Hygiene, and Elimination Needs
8. Document reassessment and restraint release during care measures in the medical record and/or on the appropriate restraint documentation form.
9. Evaluate and document the use of alternatives, less restrictive methods and release of restraint with every observation. Look for changes in behavior or clinical condition which would allow the removal of restraints.
10. If the need for restraint extends beyond 8 hours, a face-to-face reassessment of the patient must occur before writing a new order. The licensed independent practitioner (e.g., M.D., D.O., Clinical Psychologist) must conduct a face-to-face reassessment at least every 8 hours (i.e. at 16 hours and 24 hours). The RN may then reassess and consult with the practitioner at 12 hours and 20 hours, and take a phone order to continue restraints if indicated.
Page 9 of 12 11. Document the date, time, condition of the patient in the medical record when restraints are discontinued.
12. If restraints for violent or self-destructive behavior are discontinued prior to the expiration of the original order, a new order must be obtained as soon as possible, but within one (1) hour of reapplying the restraints, and all the requirements met to re-start the restraints.
13. Update the electronic medical record or restraint log every shift. At John George Psychiatric Hospital this is a “denial of rights log”.
Monitoring Requirements During Simultaneous Use of Restraint and Seclusion In the rare circumstance that simultaneous use of restraint and seclusion is deemed necessary, the patient must be continually monitored face-to-face by an assigned, trained staff member or by trained staff using both video and audio equipment that is in close proximity to the patient for the duration of the restraint and seclusion episode. The assessment, reassessment, and documentation requirements outlined above remain applicable.
Staff Training Requirements for Restraints 1. Qualified Staff a. Practitioners authorized to order restraints at a minimum, will have a working knowledge of the hospital policy regarding the use of restraint. b. Staff members applying restraints, monitoring, assessing, and providing care for a patient in restraint, shall be trained and able to demonstrate competency prior to performing these actions.
2. Training and competency evaluation for staff with direct patient contact will occur at orientation, before participating in the use of restraint and on periodic bases thereafter. Training and demonstration will focus on the following: a. Techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances that require restraint; b. The use of non-physical intervention skills; c. Choosing the least restrictive intervention based on an individuated assessment of the patient’s medical or behavioral status or condition. d. The safe application and use of all types of restraints used in the hospital, including training in how to recognize and respond to signs of physical and psychological distress (e.g., positional asphyxia); e. Clinical identification of specific behavioral changes that indicate that restraint is no longer necessary; f. Monitoring the physical and psychological well-being of the patient who are restrained, including but not limited to, respiratory and circulatory status, skin integrity, vital signs, and special requirements specified for 1 hour face-to-face evaluation; g. The use of first aid and current certification in the use of CPR.
Note: Physicians and RNs and those staff under their direct supervision do not
Page 10 of 12 require first aid certification.
3. Training will be provided by qualified individuals.
4. Documentation of training and competency will be maintained in the staff personnel record.
Reporting Requirements The patient care unit shall complete and submit an occurrence report to the Risk Department within two (2) hours following knowledge of each death that: 1. Occurs while a patient is in restraint at the hospital (excludes soft wrist restraints).
2. Occurs within 24 hours after the patient has been removed from restraint.
3. Known to the patient care unit, occurred within one week after the restraint where it is reasonable to assume that the use of restraint contributed directly or indirectly to a patient’s death. “Reasonable to assume” includes, but is not limited to, death related to restriction of movement for prolonged periods of time, or death related to chest
4. Compression, restriction of breathing or asphyxiation.
Performance Improvement Monitoring
The goal of Performance Improvement is to identify the underlying causes for restraint use and with this understanding to evaluate and reduce the use. Alameda Health System collects, analyzes, and evaluates aggregate restraint use data on all restrain episodes to define ways to establish a baseline and to reduce the risk associated with restraint use through preventive strategies, alternatives to restraint use and process/care redesign improvements.
References
1. The Joint Commission: PC.03.05.01- PC .03.05.19
2. California Code of Regulations: 9 CCR § 865.4; 22, CCR §§ 70059, 70577
3. CMS Conditions of Participation: 42 CFR § 482.13 (e) - § 482.13 (g)
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APPROVALS
System Alameda AHS/Highland/John George/San Leandro Department Date: N/A 5/2019 5/2019 Pharmacy and Date: N/A N/A N/A Therapeutics (P&T) Clinical Practice Date: 11/2019 N/A N/A Council (CPC) Medical Executive Date: N/A 11/2019 11/2019 Committee Board of Trustees Date: N/A N/A
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