Executive Summary Policies and Procedures for Quality Professional Services Committee From the Medical Executive Committee January 2018 Title of Policy Last BOT due Next review Policy Purpose Summary of History of Review Type Approved date date after Owner/Author/ Changes Committee Date from last BOT approval Reviewer approval Labor and Delivery New Policy N/A 3 Years Rachel Hogan (Asst Establish parameters Changes: • Clinical Practice Clinical Triage (HH Only) Nurse Manager), for obstetric triage, Council (3/2017), Theresa Cooper including admission, This policy was Patient Care (Director of transport and originally Leadership Nursing –MCH), discharge criteria, presented to MEC (3/2017) Sophie Shabel, MD acuity assignment in March 2017 • Medical Executive (Chair, MCH), Kinzi and standardization and not Committee Richholt (CNE) of nursing approved. (11/2017) documentation for Document all patients who Owner/ Writer present to Labor and was asked to Delivery. revise policy and re-submit to MEC for approval. Medical Record New Policy N/A 3 Years Bernice Zander To describe the Changes: • Ambulatory Admin Delinquency and (Dir., HIM), Steve process for Operations Council Medical Staff Kilgore (DON- suspension of New Policy (8/2017) Suspension: Ambulatory), Palav provider privileges for • Medical Records 1 Title of Policy Last BOT due Next review Policy Purpose Summary of History of Review Type Approved date date after Owner/Author/ Changes Committee Date from last BOT approval Reviewer approval Ambulatory Babaria, MD (CAO- delinquent medical Committee Ambulatory), Dave records. Timely (8/2017) Cox (CFO) completion of • Medical Executive ambulatory medical Committee records is essential (10/2017) for ensuring patient safety, continuity of care and appropriate clinical care, especially when outpatients are seen in other locations subsequent to their outpatient visits. Medication Kit/ New Policy N/A 3 Years Doug Del Paggio Different Changes: • Pharmacy and Dept Transport Boxes for (Director, departments/division Therapeutics Specific Departments Pharmacy), Diana s store boxes or kits New Policy (10/2017) and Divisions (HH Thamrin (System to get access to Only) Director, mediations in their Pharmacy), John specific areas, where Chapman (CAO) Automated Dispensing Machines (ADM, e.g. Pyxis) are not accessible and/or certain specific drugs are not included in crash cart. These departments/ divisions include Allergy Clinic, Anesthesiology, Cardiology, Diagnostics, Oral Surgery, Operating Room and Radiology. Medications: Look- New Policy N/A 3 Years Priya Patel To ensure Alameda Changes: • Pharmacy and Clinical Alike, Sound-Alike (Medication Safety Health System (AHS) Therapeutics (AHS 2 Title of Policy Last BOT due Next review Policy Purpose Summary of History of Review Type Approved date date after Owner/Author/ Changes Committee Date from last BOT approval Reviewer approval (System) Officer), Diana has a system in place New System-Wide Core, 2/2017, AH Thamrin (System to eliminate Policy 4/2017, SLH Director, medication errors 3/2017) Pharmacy), John caused by the • Clinical Practice Chapman (CAO) procurement, storage, Council (6/2017) dispensing and • PCLT (7/2017) administration of look alike, sound alike medications. Medications: 2/2011 2/2017 3 Years Doug Del Paggio The formulary Changes: • Pharmacy and Dept Prescribing and (Director, system improves Therapeutics Ordering (AHS Core) Pharmacy), Priya patient care by Minor revisions (3/2017) Patel (Medication promoting rational Safety Officer), and discriminate Diana Thamrin drug therapy, (System Director, providing Pharmacy), John medications in a Chapman (CAO) timely manner and generally at a lower cost to the patient because of the contractual prices. Scope of Service – 7/2014 7/2017 3 Years Bernice Zander To ensure adequate Changes: • Health Information Health Information (Director, HIM), information is Management ( Management (System) Dave Cox (CFO) available to the Minor revisions members of the healthcare team and other health care providers and when necessary to provide effective patient treatment. To process and maintain patient care information for the continuity of patient care research, legal 3 Title of Policy Last BOT due Next review Policy Purpose Summary of History of Review Type Approved date date after Owner/Author/ Changes Committee Date from last BOT approval Reviewer approval purposes, and justification for reimbursement, service utilization and other administrative purposes. Vancomycin Pharmacy 9/2014 9/2017 3 Years Matt Labreche To enhance the safe Changes: • Pharmacy and Dept Dosing Protocol (HH (Clinical Pharmacy and effective use of Therapeutics Only) Specialist) (Doug vancomycin and to Minor revisions Committee Del Paggio increase antibiotic (11/2017) (Director, stewardship for this Pharmacy), Diana medication with a Thamrin (System pharmacist dosing Director, and monitoring Pharmacy), John protocol. Chapman (CAO) PLANS Infection Prevention 9/2016 9/2017 Annually Deborah Ellis This document is a Changes: • Infection Control Admin and Control Annual (Interim System comprehensive Committee Plan: 2016 Assessment Director, Infection evaluation, risk Annual Plan (8/2017) 2017 Plan (AHS Core) Prevention and assessment, • Quality and Safety Control), Adrian prevention and Committee Smith (Interim VP, control plan (11/2017) Quality) completed annually. This document may be revised at any time based on significant changes in the healthcare setting and infection control field. 4 Page 1 of 7 Alameda Health System LABOR AND DELIVERY TRIAGE Department Maternal Child Heath Effective Date New Policy Campus Highland Date Revised 2/2017 Unit Labor and Delivery Next Scheduled Review 2/2020 Manual Maternal Child Health Author Director of Nursing – MCH Replaces the following Policies: Responsible Person Chief Nurse Executive Chair, Maternal Child Health Printed copies are for reference only. Please refer to electronic copy for the latest version. Purpose Establish parameters for obstetric triage, including admission, transport and discharge criteria, acuity assignment and standardization of nursing documentation for all patients who present to Labor and Delivery. Policy Alameda Health System Family Birthing Center will provide comprehensive professional nursing care to all patients presenting to Labor and Delivery under the guidelines of the Emergency Medical Treatment and Active Labor Act (EMTALA) and the AHS EMTALA policy. Use of a maternal fetal triage index and standardized criteria for ongoing assessment and dispensation will facilitate the highest quality care delivery. Admission to Labor and Delivery Triage 1. Labor and Delivery (L & D) triage services will be available 24 hours per day, seven days per week. 2. Patients less than 20 weeks gestation or with a non-obstetric emergency will be triaged in the Emergency Department. If patient’s condition warrants, fetal monitoring or obstetric clearance may be provided in the Emergency Department by Labor and Delivery RN and/or OB physician. 3. Obstetric patients at 20 weeks of gestation or greater will be evaluated on the labor and delivery unit. Patients may present to L & D Triage in the following ways: self present, brought in by ambulance, referred or brought in from an outpatient setting, brought from the Emergency Department, transported from another medical facility or from an out-of-hospital birth attendant. 4. Patient with the following conditions will bypass L & D Triage and be either directly admitted or placed in observation status: a. Patients scheduled for cesarean delivery, induction of labor, cerclage placement, external cephalic version, or other conditions as determined by provider. b. Patients directly admitted to the postpartum or antepartum unit. Page 2 of 7 c. Patients who present as born out of asepsis. d. Patients with imminent delivery. 5. All patients will be interviewed in a private location by an RN to determine evaluation priority. Patient acuity will be categorized according to the Maternal Fetal Triage Index (Appendix A). 6. Initial and ongoing assessment and documentation will occur per Labor and Delivery RN Triage Protocol (Appendix B). 7. An in-house OB provider will be notified of each patient’s chief complaint and acuity index on patient arrival depending on assigned acuity level. Ongoing Evaluation Following Medical Screening Exam by Qualified Medical Personnel (QMP): 1. Orient patient to nurse call light, restroom and fetal surveillance. 2. Re-assess vital signs per protocol or as ordered. 3. Document all interventions including start and stop times of infusions and injections. 4. Complete triage re-evaluation within 2 hours to determine if patient will be discharged, admitted or placed on observation status. 5. When it is determined that the pregnant patient is not in labor and does not have an emergency medical condition, the woman may be transferred to another health care facility, be referred for outpatient services, be discharged, or be seen in the Emergency Department as determined clinically appropriate by a physician or Certified Nurse Midwife (CNM) or other Qualified Medical Personnel (QMP). The medical record will reflect the basis of the determination. Acceptance of Maternal Transports to Labor & Delivery 1. Requests for maternal transport should be from the attending physician at the referring hospital to the triage attending and/or perinatologist at the transport hospital to assess medical need. 2. Request for maternal transport from an out of hospital birth site may