Alameda Health System CPC Executive Summary to Medical Executive Committee Policies and Procedures June 2021 Chair: Dr. Felicia Tornabene TOPIC or Last Next review Document Owners Purpose Summary of Changes History of Review TITLE OF POLICY Approved date after Committee Date BOT approval AHS System Wide Policies & Procedures VISITING 03/2020 05/2024 Janet McInnes, Chief Revisions to Purpose P&T: 5/24/21 HOURS/VISITORS Administrative and Policy paragraphs CPC: 06/03/2021 Officer/Nurse Executive 06/15/21 eVote Approval after revisions made MEC: Sedation/Analgesia for the 05/2024 Theresa Cooper - Patient Protocol updated to CPC 06/03/2021 Mechanically Ventilated Care Services – Highland address our TJC fallouts 06/15/21 eVote Approval surrounding the titration after revisions made Patient Violeta Luna-Jones of analgesic and MEC: sedation drips on the ventilated patient in ICU. System Medication 10/2019 07/2024 Priya Patel PharmD Minor revision to include System P&T approval language that samples 6/28/2021 Samples are only allowed if CPC: 07/01/2021 approved by P&T MEC: Sedation Medications on NA 07/2024 Violeta Luna System P&T approval 6/28/2021 the Vent Policy Jones/Theresa Cooper CPC: 07/01/2021 MEC: COVID-19 Vaccine Policy 05/2021 07/2024 Priya Patel PharmD Minor revision to add System P&T approval language on process for 6/28/2021 procuring federally CPC: 07/01/2021 funded vaccine, HRSA MEC: 2/62 Pharmaceutical Waste 12/2017 07/2024 Priya Patel PharmD No changes. Triennial System P&T approval review for JC 6/28/2021 CPC: 07/01/2021 MEC: Medication Area 08/2020 07/2024 Jackie Ho PharmD Revisions to Inspection System P&T approval List for pharmacists 6/28/2021 Inspections Policy CPC: 07/01/2021 MEC: Discharge Medications 01/2020 07/2024 Priya Patel PharmD Add language to align System P&T approval with new State Board of 6/28/2021 Policy Pharmacy Requirements CPC: 07/01/2021 for discharge medication MEC: counseling Highland Hospital Policies & Procedures None San Leandro Hospital Policies & Procedures None N/A N/A N/A N/A N/A N/A John George Psychiatric Hospital Policies & Procedures None N/A N/A N/A N/A N/A N/A Alameda Hospital Policies & Procedures None N/A N/A N/A N/A N/A N/A 3/62 VISITING HOURS/VISITORS Effective Date Not Set Date Revised 06/11/2021 Document Owner CHIEF ADMIN Next Scheduled Review 06/11/2024 OFCR/CHIEF NURSE EXEC Executive Responsible BOT, QPSC Printed copies are for reference only. Please refer to electronic copy for the latest version. PURPOSE To provide support for patients during their stay by accommodating visitors and encouraging visitation. To ensure that all visitors enjoy full and equal visitation privileges that are consistent with patient preference and our ability to provide patient and family centered care. POLICY It is the policy of Alameda Health System (AHS) to uphold patients’ rights to designate visitors of his/her choosing and to allow patient visitation, as authorized and in accordance with the provisions set forth below. DEFINITIONS: A. “Patient and family-centered care” is based on the assumption that “family” is the primary source of strength and support. Family-centered providers recognize that family members hold essential information that enhances the patient’s care. B. Family – “Family” is defined by the patient as the group of significant people that normally provide physical, psychological, or emotional support. C. “Visitors” are defined as any individual who presents to the health care facility for the purpose of visiting a patient. RESTRICTED VISITATION During flu season and public health situations/emergencies such as pandemic these practices may be amended to reflect infection control safety concerns. Patients who are symptomatic PUI or Covid19+ and continue to be on transmission-based precautions (on isolation) will not be allowed visitors. When time permits a consensus statement will be issued by the infectious disease department. Emergent situations will be handled by each site’s Infection Control department and administrative leaders. PROCEDURE Visitor identification enforcement policy: All in-patient visitors that come into any of the AHS campuses are required to check-in and receive a visitor pass while at AHS. Badges are one day Page 1 of 5 4/62 self-expiring badges that expire approximately 15 hours after activation. When red lines have appeared the visitor badge is not valid and must be replaced immediately. Badges will be color coded for Highland Hospital ONLY. Emergency Department Red Visitor Badge ICU Yellow Visitor Badge 4th Floor Purple Visitor Badge 3rd Floor ISSU White Visitor Badge 5th Floor Yellow Visitor Badge 6th Floor Dark Blue Visitor Badge 7th Floor Green Visitor Badge 8th/9th Floor Blue Visitor Badge Visiting hours are from 9 a.m. to 10 p.m. except in FBC and ICU. From 10 p.m. to 9 a.m. is designated hospital quiet time. A security officer is posted at the fourth-floor elevator area 24 hours a day to screen all persons entering the acute care hospital. It is recommended that only two people should visit any patient at one time. 1. Children visiting must be supervised by responsible adults, other than the patient at all times. Children visiting must be supervised by responsible adults, other than the patient at all times. Children under 12 are not permitted in the ICU and NICU (see document) Special arrangements may be made through the Nurse Manager or designee for visits for pre-op patients. Limiting the number of family members and/or visitors in a room may be necessary due to space and patient access issues. There may be special circumstances when staff may request families/visitors to leave the patient’s bedside for a limited time. Staff will explain to visitors the clinical rationale for the request, when visitors may return, and where they may wait. Examples of circumstances which may necessitate restrictions or limitations on visitors might include (but are not limited to), when: • When there might be an infection control issue • Visitation might interfere with the care of other patients • The hospital is aware of an existing court order restricting contact • The patient is undergoing care interventions; however, if possible, the patient request that at least one visitor be allowed to remain in the room to provide support and comfort will be accommodated. • During a resuscitation process we will do everything possible to accommodate family request to be present if desired. Page 2 of 5 5/62 Only 1 visitor may stay overnight in private rooms. Arrangements must be made with the charge nurse. Minors (under 12) are not permitted to stay overnight except for exclusive breastfeeding babies under the age of 6 months if accompanied by a caregiver other than the patient. (See infant border policy) Individuals who are disruptive to patient care or operations of the facility will be asked to leave. Acts or threats of violence, intimidation, vandalism, or verbal abuse will not be permitted or tolerated under any circumstances. Anyone engaging in these behaviors will be asked to leave. Visitors should refrain from sitting or lying on patient's bed. 1. POST ANESTHESIA CARE UNIT Visiting patients in the PACU is not allowed unless permission is granted by the PACU nurse. 2. ICUs Visitors for the CRITICAL CARE units may visit patients for 30 minutes in an hour. Visiting hours are not restricted. No one under 12 years of age is allowed in the ICU's unless special arrangements are made through the Charge Nurse. 3. EMERGENCY DEPARTMENT The Emergency Department allows for the presence of a support individual (visitor) of the patient’s choice unless the individuals presence infringes on safety or is medically or therapeutically contraindicated. If a visitor is already with a patient and the patient is agreeable the visitor may stay during rounds. Security will bring visitors back at the scheduled time after checking with the patient’s nurse. The Emergency Department Charge Nurse has the authority to suspend visiting anytime that there is a situation where visitors would be a safety issue, i.e., multiple GSW traumas. Visiting would resume as soon as the situation has resolved. 4. FAMILY BIRTH CENTER A. Family and friends should refrain from visiting if they are febrile, have diarrhea, or have symptoms of an upper respiratory infection. Cold sores should be covered with a mask until lesion is dry and scabbed. Anyone exposed to a known communicable disease (such as chickenpox or influenza) is not allowed in the birthing center. All visitors must clean their hands and forearms when entering the mother’s room, and before handling the infant. B. Each mother will be asked to designate her primary support person. This support person will have unlimited access to the mother and her infant(s). A mask will be provided to the support person if he/she has any signs of illness. C. All visitors will sign in and obtain a designated visitor badge to wear at all times while in the birthing center. Visiting hours are as follows: L&D unrestricted; PP unrestricted for designated primary support person, 9 a.m. – 10 p.m. for all others; NICU 9 a.m. – 10 p.m. Page 3 of 5 6/62 Visitors are allowed in the mother’s room or in the waiting room. They may not wait in the hallways or by the doors. D. A member of the health-care team may request that the number and timing of visitors be limited at certain times to facilitate adequate patient access for care. Requests by staff members to limit the number of visitors and/or length of visit should include information that helps the family and friends understand the patient’s needs.