- 1 -

Revised May 2016

2016 Non-Employee Training

(N.E.T)

- 2 -

TABLE OF CONTENTS Section I - NAMES TO REMEMBER

Who to call with questions and concerns ............................................................................... 3

Section II - THE FACILITY HOSPITAL SAFETY AND SECURITY Hospital Safety and Security ................................................................................................. 4 Medical Equipment Management .......................................................................................... 4 Hazardous Materials – Your Right To Know (Hazard Communication) ...............................4-5 Hazardous Materials MSDS/Spills /Chemical Labels ..........................................................5-6 Radiation Safety .................................................................................................................... 6 MRI Safety .........................................................................................................................6-7 Utility / Electrical Safety ......................................................................................................... 7 Violence ................................................................................................................................ 7 EMERGENCY MANAGEMENT Emergency Codes ............................................................................................................ 8-11 External Disasters ............................................................................................................... 11 Internal Disasters ........................................................................................................... 11-12

Section III - THE EMPLOYEE EMPLOYEE HEALTH Employee Health ................................................................................................................. 13 Back Injuries, safety and body mechanics ...................................................................... 13-15 INFECTION CONTROL Handwashing and PPE ....................................................................................................... 15 Safe Work Practices ............................................................................................................ 15 Bloodborne Pathogens and Exposure Control Plan ............................................................. 16 TB exposure plan ................................................................................................................ 16 Answers to Infection Control frequently asked questions ..................................................... 16 Infection Prevention Education ............................................................................................ 17

Section IV - COMPLIANCE Compliance and HIPAA ................................................................................................. 18-19 Information Systems Security ......................................................................................... 19-20 Employee Concerns .......................................................................................................... 20 Community Cares/S.A.F.E. ........................................................................................... 21-22 Employee Incident Reporting / Harassment and Workplace Violence ............................ 22-23 Employee Name Badge……………………………………………………………………………23

Section V - THE PATIENT PATIENT RIGHTS AND RESPONSIBILITES Patient Rights ...................................................................................................................... 24 Patient Responsibilities ....................................................................................................... 25 CARE OF THE PATIENT Patient Safety Tips .............................................................................................................. 25 Cultural Diversity ............................................................................................................ 25-26 Restraints ............................................................................................................................ 26 Pain Management .......................................................................................................... 26-27 Patient Education ................................................................................................................ 27 Rapid Response Team / CPR ........................................................................................ 27-29 Sexual Assault .................................................................................................................... 29 Non-Employee Incident Reporting ....................................................................................... 29 Center for Metabolic and Weight Loss Surgery .............................................................. 29-30 National Patient Safety Goals .............................................................................................. 30 National Quality Measures ............................................................................................. 31-33 Heart Attack Signs / Symptoms & ACS Education .......................................................... 33-34 Stroke Signs and Symptoms .......................................................................................... 35 36

- 3 -

Section I NAMES TO REMEMBER

Extension Suzanne Woods Chief Executive Officer 1100 Heath Phillips Chief Operating Officer 1100 Rodney Gaw Chief Financial Officer 1100 Dan Cumbie Chief Nursing Officer 1110 Joey Hester VP Professional Services 1100 Amy Butler Chief Quality Officer 1580 Donavan Leonard Assistant Chief Financial Officer 1100 Beth Hawkins Administrative Specialist 1100 Jason Sharp Director of Physician Recruitment 1100 Linda Terhark VP Physician Services 1100

Chris Pruitt Safety Officer and HazMat Coordinator 1770 Kimberly Helms Employee Health Nurse 8260 Darla Silavent Infection Control Practitioner 8265 Matthew Garrett Director of IS/Facility Security Officer 8150 Eric Marsh Training Specialist/Security Coordinator 8150 Dominique Steeves Facility Compliance Officer 8515 Sandra Rafferty Facility Privacy Officer 1574 Patti Hatcher Human Resources Director 1131

Marilyn McKissack Education Director 1950 Nathan Chase Chest Pain/Stroke Coordinator 1555 Barbara Spann HHS Food & Nutrition Services Director 1197 Brian Hanson HHS Environmental Services Director 8839

- 4 -

Section II THE FACILITY

HOSPITAL SAFETY/SECURITY - (Contact Person: Chris Pruitt – ext. 1770)

Safety is everyone’s responsibility.

All staff should wear ID badges when at work. Other than patient visitors, all non-employees should wear a “visitor”, “contractor” or “vendor” badge; it is your responsibility to question unauthorized visitors or call Security.

Accu-tech system is the name of the ID security band system that the Center for Women and Children uses for infant safety and security.

Report safety concerns or suggestions. A safety suggestion box is located in the employee hallway. The Environment of Care Committee reviews each suggestion on a bimonthly basis.

Do not admit strangers after doors are locked.

Do not give out information about patients or employees unless you have authority to do so.

Report any behavior that concerns you; you are the eyes and ears for Flowers Hospital.

MEDICAL EQUIPMENT MANAGEMENT - (Contact Person: Chris Pruitt – ext. 1770)

Clinical equipment that is not working appropriately should be taken to Bio-Med and labeled with the specific problem.

Clinical equipment should have a preventive maintenance (PM) sticker with a current date. It should be checked prior to use and if equipment is out of date, it should not be used and sent to Bio-Med for servicing.

Medical gas cylinders should never be unsecured or left lying on their side. Medical gas cylinders used for patient transport should be placed in a secure stand, such as a rolling stand or one that has been attached to a wheelchair or patient bed.

HAZARDOUS MATERIALS - (Contact Person: Chris Pruitt – ext. 1770)

YOUR RIGHT TO KNOW

The U.S. Department of Labor, Occupational Safety and Health Administration (OSHA) has established a Hazard Communication Standard, based on a simple concept - that employees have both a need and a right to know the hazards and identities of the chemicals to which they are exposed when working. They also need to know what protective measures are available to prevent adverse effects from occurring. The standard's design is simple. Chemical manufacturers and importers must evaluate the hazards of the chemicals they produce or import. Using that information, they must then prepare labels for containers and more detailed technical bulletins called material safety data sheets (MSDS). Material safety data sheets provide instructions and precautions on:

physical and health hazards;

handling and storage requirements;

- 5 -

personal protective equipment (PPE) needed;

signs and symptoms of exposure;

how to handle spills, fires and/or other emergencies.

This is also known as Hazard Communications!

MSDS (Material Safety Data Sheets) - (Contact Person: Chris Pruitt – ext. 1770)

Hard copies of MSDS’s are located in each department. You can also access this information by clicking on the Flowers MSDS Online icon located on your computer desktop.

Master copies of all MSDS’s are located in the Emergency Department. Safety regulatory agencies are OSHA, EPA, Joint Commission, and ADPH.

The purpose of MSDS is to identify materials and how to provide emergency care to the staff member, if exposed.

Labels on chemicals give the information needed.

Ask your supervisor if you have questions or concerns regarding any of the chemicals you may use.

Hazardous Materials Spill - (Contact Person: Chris Pruitt – ext. 1770)

Each department should have a copy of the MSDS sheets that are specific to their department. You can also access this information by clicking on the Flowers MSDS icon located on your computer desktop. You should call 1666 if there is an unknown chemical spill. Reference the Spill Policy for known chemical spills.

Mercury or Cidex Spills - (Contact Person: Housekeeping Supervisor – ext. 1996 or 796-4870)

In the event of a mercury spill, Housekeeping should be called immediately. You should never touch a mercury spill or try to clean it up. Housekeeping has personal protective equipment they wear along with a special kit that must be used when cleaning up a mercury spill. A designated bucket is located in Plant Operations for disposal of the mercury. Cidex will undergo a neutralization process prior to being collected and disposed of.

CHEMICAL LABELS - (Contact Person: Chris Pruitt – ext. 1770)

Colors: RED = fire hazard. BLUE = health hazard. YELLOW = reactivity hazard. WHITE = specific hazard or need for personal protective equipment (PPE). Words: Flammable Explosive Carcinogen Irritant Corrosive

Numbers: 0 – minimum hazard 1 – slight hazard 2 – moderate hazard 3 – serious hazard 4 – severe hazard

- 6 -

Picture symbols:

What is the degree of hazard? Danger: Risk of immediate serious injury or death. Warning: Risk of serious injury or death. Caution: Risk of moderate injury. RADIATION SAFETY - (Contact Person: Chris Pruitt – ext. 1770)

The sign identifying radiation is the purple propeller sign.

The 3 safety steps are time, distance and shielding.

Report pregnancy to supervisor.

In hospitals, ionizing radiation is produced by x-ray machines and the radioisotopes used in nuclear medicine. All nuclear medicine procedures at Flowers Hospital are considered “diagnostic”. This means that the level of radioactive dose the patient receives is very low and poses no threat to others in the hospital or the general public. There are no special precautions that must be taken for these patients. We have a written radiation protection program that is designed to keep exposures As Low As Reasonably Achievable (ALARA). This program is comprised of several policies and procedures developed to keep the radiation worker’s (x-ray, nuclear med, etc.) exposure ALARA. (Refer to the hospital’s Radiation Safety Manual for specific policies and procedures.)

All radioactive materials are used and stored in the nuclear medicine department. An area that is a potential risk for exposure is marked by a radioactive symbol.

Limiting the time spent around a radioactive source will minimize any potential exposure. Also, you should increase the distance between you and the radioactive source. When handling radioactive material, always use shielding. Shielding is some kind of barrier (lead apron, leaded gloves, syringe shield) between you and the radioactive source.

Any employee who is exposed to Radiation and is pregnant should complete a DECLARED PREGNANCY FORM and meet with the radiation safety officer to discuss options available for the employee to minimize risk to the unborn fetus.

MRI SAFETY - (Contact Person: Chris Pruitt – ext. 1770)

MRI is a giant magnet and it is always on.

A keypad is used to control access to the area.

Zones are established for patient and employee safety.

Equipment used on the patient in the MRI has to be MRI compatible.

Patients are screened prior to procedure. (metal implanted, issues with confined spaces, etc.)

- 7 -

Because of the effects of the static magnetic field, all personnel and visitors are thoroughly screened for contraindications to MRI before entering the magnetic field area or magnet room. No one with a pacemaker or other implanted device or metal object is allowed to enter the restricted magnetic field area Zone IV.

UTILITY /ELECTRICAL SAFETY - (Contact Person: Chris Pruitt – ext. 1770)

Flowers Hospital has generators which automatically come on in case of a power failure. In an emergency situation, power is available only from the red switches and outlets. Be sure that only essential medical equipment is plugged into a red outlet. Red Plugs = emergency generator power. Bottled water to use during disaster situations can be obtained from Food and Nutrition. Emergency suction is available from portable suction. Oxygen is available from portable cylinders.

Personal electrical safety requires that you follow some basic safety precautions:

Never use equipment with damaged or frayed cords – take the equipment out of service and report it to Bio-Med.

Never use electrical equipment or switches with wet hands or while standing in water.

Do not try to repair electrical equipment yourself – take it out of service and report it to BioMed.

Do not overload outlets.

Any electrical equipment that “smells” hot or does not function properly – unplug it, take it out of service and report it to Plant Operations or BioMed.

Do not use “cheaters” (3-prong to 2-prong adapters).

When disconnecting, pull the plug; never pull on the cord.

Do not use extension cords. Exceptions may only be made by Plant Operations.

VIOLENCE - (Contact Person: Chris Pruitt – ext. 1770)

Can occur any time and any place.

Anyone can become violent (due to alcohol, drug abuse, head injuries, pain, altered mental status).

Warning signs may be verbal threats, restlessness, pacing, fighting, “in the face” confrontations, etc.

Recognize and always keep an escape path open.

How to prevent:

Respect and Respond.

Be Alert to Signs of Violence.

Page Code One.

Report Suspicious Behavior.

- 8 -

EMERGENCY MANAGEMENT - (Contact Person: Chris Pruitt – ext. 1770)

CODE SYSTEM

A system of codes has been developed to alert Flowers Hospital employees of potential or actual dangers. These codes help provide safety and protection to patients, visitors and staff. Every employee needs to know what to do in the event a code is called. Refer to Hospital and department policies or ask your Department Director/Manager what specific actions employees in your Department should take for each of the codes.

Dr. Red is the code for fire. You can report a fire by pulling a fire pull station or by

dialing 1666. The page is followed by the location of the fire. The fire plan then goes into effect. Review the fire plan located on your unit.

Remember the acronyms R.A.C.E. and P.A.S.S.

R-remove (everyone from immediate danger). A-activate (activate nearest fire alarm pull station, dial 1666). C-contain the fire (close all doors). E-extinguish or evacuate (use ABC-rated fire extinguisher).

Using the fire extinguisher:

P-pull the pin. A-aim at the base of the fire. S-squeeze the handle. S-sweep back and forth, front to back at base of the flame.

DR. RED TO THE OUTSIDE = This is never a drill. Must evacuate to the outside.

Code Blue is the alert for cardiac or respiratory arrest. The code is called as well as

the location. Trained healthcare providers respond.

Code Blue = age specific for adults 12 years of age or older/adult respiratory/cardiac

arrest.

Code Pink = age specific for under age 12/cardiac/respiratory arrest.

Dr. Dothan to Administration – Disaster:

Emergency Operations Plan goes into effect. This is called for either an internal or external disaster. Check with your Department Director/Manager – what is your role in case of a disaster? Do you have a pre-assigned task? If you are off campus and are called in because of a Code situation, enter the Hospital through the employee entrance. Clock in. You must wear your name badge.

- 9 -

Code One is the code called when security help is needed to de-escalate a potential

problem with an out of control visitor or patient. Trained personnel will respond.

Code Weather:

Code Weather to the Inside:

Code used for announcement by the Switchboard Operator over the hospital PBX system when a tornado warning possibly affecting our facility has been issued by the Emergency Management Agency. Emergency procedures are to be implemented. Patients will be moved away from windows to a safe location at this time.

Code Adam is called for an infant or pediatric patient abduction. Code

Adam is initiated by the staff person discovering the situation. When Code Adam is called, go to your assigned area. Many staff are asked to man the nearest exits. Be on the alert for anyone attempting to leave with an over-sized purse, backpack, large box or a large bulky coat. Visitors are asked to remain in the hospital until released. If an individual insists on leaving or behaves in a threatening manner, do not jeopardize your safety. Back off; be observant; note physical description, clothing and vehicle. Jot down the license plate number if you are able. Some staff members will conduct a search of the hospital in case the abductor does not leave the premises.

Code Cerner, HMS, PACS, PYXIS = Computer system failure has occurred.

Move to manual system for communication as required.

Code Six = A major trauma patient is expected to arrive in the Emergency

Department. Departments should respond according to policy.

Code Lockdown = Securing the facility in response to an external or internal threat.

Examples include civil disturbance, terrorism or threats on staff or visitors.

Code Orange = A facility code that signifies a person may be experiencing a stroke.

To activate a Code Orange call the operator and advise that you suspect a person is having a stroke, give the location and ask them to page a Code Orange. The operator will page Code Orange and the location overhead 3 times. When a Code Orange is called, a specially trained team will respond.

Code Silver = Response to an armed assailant. Remove/protect patients, visitors,

employees and other persons from areas of danger and assist law enforcement in bringing event to an end. Whatever the code, whatever the problem, when the emergency is over, the Switchboard Operator will announce, “Code All Clear” three times.

- 10 -

Safety Codes

Event

Audible Page

CARDIAC/RESPIRATORY ARREST

(Adult)

“CODE BLUE”

FIRE ALARM

“DR. RED”

TORNADO SPOTTED

“CODE WEATHER TO THE INSIDE”

CARDIAC/RESPIRATORY ARREST

(INFANT/CHILD)

“CODE PINK”

EXTERNAL DISASTER

“DR. DOTHAN TO

ADMINISTRATION”

EVACUATE TO THE OUTSIDE

“DR. RED TO THE OUTSIDE”

COMPUTER SYSTEMS FAILURE “CODE CERNER”

CHILD/INFANT ABDUCTION

“CODE ADAM”

VIOLENT PERSON

“CODE ONE”

MAJOR TRAUMA/ARREST IN

EMERGENCY DEPT (LAB, X-RAY, EKG,

RESPIRATORY, ANESTHESIA

RESPOND)

“CODE SIX”

LOCKDOWN FACILITY “CODE LOCKDOWN”

ARMED THREAT “CODE SILVER”

STROKE PATIENT “CODE ORANGE”

PATIENT FALL, ASSISTANCE NEEDED “CODE YELLOW”

CHANGE IN PATIENT CONDITION

(Nursing Supervisor, Respiratory, ICU

Nurse)

“RAPID RESPONSE”

- 11 -

Armband Alerts Color/Item Indication/Alert

YELLOW

Patient Armband, Communication Board

Magnet, Door Tag, Chart Label

FALL RISK

PURPLE

Patient Armband, Communication Board

Magnet, Dot on Door, Chart Label

DNR (Do Not Resuscitate)

HOT PINK

Parent/Guardian of Pediatric Patient

Armband

PEDIATRIC PATIENT

PARENT/GUARDIAN

EXTERNAL DISASTERS - (Contact Person: Chris Pruitt – ext. 1770) Dr. Dothan to Administration is the page alerting hospital staff to potential large numbers of patients coming to the hospital due to an external emergency. (Examples: school bus wreck, airplane crash, etc.) Staff responsibilities:

1. Retrieve safety manual. 2. Complete status report and fax to Nursing Administration. 3. Staff called back to work should enter through the employee entrance and report

to the Personnel Pool located in Nursing Administration. 4. Areas set up to handle the victims should be prepared with equipment,

staff and supplies.

Priority Treatment Areas are:

1. ER = Life Threatening (all patients go here until other areas are ready to receive patients).

2. Cath Lab = Emergent Care. 3. DDC/Endo Lab = Walking wounded. 4. Morgue = (Only holds 2 bodies, but State can provide refrigeration truck if area

funeral homes are not able to help.) 5. Family should wait in hospital cafeteria if possible. 6. Press should wait in the Boardroom for Administrative Representative to keep

them informed. 7. Children of hospital staff (area to be announced).

INTERNAL DISASTERS - (Contact Person: Chris Pruitt – ext. 1770) Bomb Threat: Anyone receiving a bomb threat should obtain as much information as possible. A bomb threat checklist is included in the Environment of Care section of the Safety Manual. At the same time, you should be signaling to a co-worker to notify the Nurse Manager or Nursing Supervisor on nights, weekends and holidays. Listen carefully to the caller. Is there background noise; does the caller speak with an accent; is this person familiar with the Hospital buildings or procedures? Ask where the bomb is located and what type of bomb it is. You may be asked to conduct a search of your work area. Do not touch or move anything that looks suspicious or is out of place. Notify person in charge immediately so that qualified personnel can take over.

- 12 -

FIRE: In case of fire, a Dr. Red is called. Remember the acronyms R.A.C.E. and P.A.S.S. The fire extinguishers available in this facility are “all purpose” extinguishers; in other words they are “A B C” rated and can be used on any type of fire. Only the CEO (or designee), House Supervisor or Fire Department Shift Commander can authorize an evacuation. This building was designed with smoke and fire barriers to protect patients, visitors and employees. This is why doors with automatic closures should never be propped or wedged open. The ONLY exception to this rule is when the door is designed to be held open with a magnet, which automatically releases when a Dr. Red is called. Do not block fire alarm pulls, fire extinguishers, or exits. All staff should know the location of the Oxygen shut off valves on their unit. In case of emergency, the oxygen shut off valve is turned off only after patients on oxygen have been assessed and/or relocated. Emergency egress corridors are hallways that lead all building occupants from one area to “a way out”. Do not leave items like medical equipment, WOW computers, or furniture in the means of egress. Fire Drills:

Know the location of red safety manual and have available/open during drill.

Know the location of the nearest fire extinguisher and the steps for use (i.e. P.A.S.S. = pull, aim, squeeze, sweep).

Close doors in area.

Know the location of the oxygen shut-off valves in your area. Shut off only after providing portable oxygen to dependant patients and after being told to do so by person in charge.

Do not use elevators.

Know who can order the evacuation of the hospital. (CEO or designee/Fire Captain).

The Evacuation Plan is in the red Safety Manual. Summary: 1. Be familiar with resources and equipment available to assist with

evacuation. 2. Maintain continuity of care during an evacuation. 3. Move patients in the following order: Ambulatory, Non-ambulatory, Critical. 4. Ensure proper tracking of patients is maintained (see policy).

- 13 -

Section III THE EMPLOYEE

EMPLOYEE HEALTH – (Contact Person: Kimberly Helms – ext. 8260)

Use good ergonomics. Prevent back injuries by lifting with legs, push and pivot, keep load close to body and get help.

Take care of yourself by eating right, being active, adequate rest and managing stress.

Observe hospital caution signs for wet floors.

Flowers Hospital is a drug free work environment. If you are aware of a co-worker’s problem or you have a concern, discuss with appropriate chain of command or call Human Resources.

BACK INJURY AND BODY MECHANICS - (Contact Person: Kimberly Helms – ext. 8260)

Back injury is one of the most common forms of injury in the hospital setting. Improper lifting and bending, poor posture when sitting, standing or reaching will increase your risk of injury. Utilizing the following pointers will help you avoid damaging your back.

Principles of Body Mechanics:

Balance is maintained and muscle strain is avoided as long as the line of gravity passes through the base of support.

Start any movement with proper alignment.

Stand as close as possible to the object being moved.

Avoid stretching, reaching and twisting, which may place the line of gravity outside the base of support.

The wider the base of support and the lower the center of gravity, the greater the stability.

Before moving objects, increase stability by widening stance and flexing knees, hips and ankles.

Objects that are close to the center of gravity are moved with the least effort.

Adjust working area to waist level; keep body close to the work area.

Elevate adjustable beds and over-bed tables; lower the side rails of beds to prevent twisting and reaching.

Balance is maintained with minimal effort when the base of support is enlarged in the direction in which the movement will occur.

When pushing an object, enlarge the base of support by moving the front foot forward.

The greater the preparatory tensing of muscles before moving an object, the less energy required to move it, and there is reduced likelihood of musculoskeletal strain and injury.

Before moving objects, contract your gluteus maximus, abdominal, leg and arm muscles to prepare them for action.

- 14 -

The synchronized use of as many large muscle groups as possible during an activity increases overall strength and prevents muscle fatigue and injury.

To move objects below your center of gravity, begin with hips and knees flexed. Use your gluteus maximus and leg muscles rather than the lower back muscles to exert an upward thrust when lifting the weight.

Distribute the workload between both arms and legs to prevent back strain.

Always face the direction of the movement to prevent twisting the spine and ineffective use of major muscle groups.

The closer the line of gravity to the center of the base of support, the greater the stability.

When moving or carrying objects, hold them as close as possible to your center of gravity.

The heavier an object, the greater the force needed to move it.

Encourage patients to assist as much as possible by pushing or pulling themselves to reduce the muscular effort.

Use arms as levers whenever possible to increase lifting power.

Use own body weight to counteract the weight of the object. For example, lean forward when pushing an object and rock your body weight backward when pulling an object or patient toward you.

When mobilizing bariatric patients obtain the appropriate assistance of staff and/or mechanical devices.

For determining the limits of the mechanical device of bariatric equipment, rated at 500 pounds or more, look for the lighthouse decal indicating the safe handling capacity of the device.

All other equipment will be labeled in a sensitivity manner using FH followed by the .100 of the maximum weight capacity. For example, if the equipment only holds 400 lbs. the label will read “FH4.0” or if it holds 1,050 lbs. it will read “FH10.5.”

Bariatric equipment is located in the 6th floor equipment room, and patient lifting devices are located on 4th, 5th, 6th floors, as well as in the Emergency Department.

Obtain the assistance of other persons or use mechanical devices to move objects that are too heavy.

Moving an object along a level surface requires less energy than moving an object up an inclined surface or lifting it against the force of gravity.

Avoid working against gravity.

Pull, push, roll or turn objects instead of lifting them.

Lower the head of the patient’s bed before moving him/her up in bed.

Continuous muscle exertion can result in muscle strain and injury.

To prevent fatigue, alternate periods of rest and work.

- 15 -

Teamwork is very important when lifting. Plan ahead; think through what you want to do and GET HELP! Make your life easier. Save your back.

If your job requires that you lift or transfer patients, always call for assistance, if needed, and use good body mechanics.

INFECTION CONTROL – (Contact Person: Darla Silavent – ext. 8265)

Flowers Hospital assumes that all people have the potential to harbor organisms that can cause infection. This includes employees, patients, volunteers and visitors. Because everyone has this potential, there are certain things that we must do to protect others and ourselves from the risk of infection. These things include:

Wash hands with soap and water before eating, after using the bathroom, and if visibly dirty.

Clean hands with alcohol based hand rub or wash hands with soap and water between patients and after wearing gloves. Use soap and water, not alcohol based hand rub, if the patient has Clostridium difficile.

Use Standard Precautions on all patients. Personal Protective Equipment (PPE) such as gloves, gowns, masks, shoe covers, and eye protection should be worn whenever necessary.

Safe Work Practices should include (but are not limited to):

Hand Hygiene performed before and after patient care (explained above).

Discard isolation-required PPE inside the patient’s room, except for the N95 respirator used for Airborne Precautions.

Post patient door signage when applicable for Airborne Precaution, Contact Precaution, Contact/Enteric, Droplet Precaution or Neutrapenic Precaution. (Signs are available in each patient care department.)

NO recapping of needles. If absolutely necessary, use the one handed scoop method.

No eating, drinking, smoking or applying cosmetics, lip balm or contact lenses in patient care areas or any area of potential exposure.

Do not put food or drinks where blood and infectious waste may be placed.

DO NOT transport a specimen if not contained and labeled properly. Specimens should be placed in a leak-proof bag that is labeled Biohazard.

Keep clean and dirty items separated.

Check expiration dates on medicines and food before use.

Store all linens covered.

Clean all reusable equipment between each patient. Use approved germicidal wipes or disinfectant spray. (If germicidal wipes are used leave on surface for 5 minutes for PDI Super Sani-Cloth and 5 minutes for PDI Wipe with Bleach before removing; if disinfectant spray is used, leave on surface for 10 minutes before removing.)

Report infectious and/or communicable diseases to the Infection Control Nurse or the Employee Health Nurse.

Store patient and staff items separately.

- 16 -

BLOOD BORNE PATHOGENS/EXPOSURE CONTROL PLAN - (Contact Person: Darla Silavent – ext. 8265 or Kimberly Helms – ext. 8263)

Personal Protective Equipment is provided for all persons involved in patient care services in any department to aid in preventing a potential exposure. Standard precautions are to be used for care of all patients (i.e. wear gown, gloves and/or face shield as appropriate). Safety engineering controls to aid in preventing an exposure include, but are not limited to: sharps containers, needleless IV system, safety needles and IV catheters. Contaminated waste is contained by using a Red Bag for trash and Yellow Bag for laundry.

The bloodborne pathogens of most concern to Healthcare workers are Hepatitis B and C and HIV.

Signs and symptoms include, but are not limited to:

HEPATITIS B and C - fatigue, loss of appetite, mild fever, muscle and joint aches, nausea and vomiting, diarrhea, jaundice (yellowing), itching skin, dark urine and/or light colored feces.

HIV - swollen lymph glands, recurrent fever or night sweats, rapid weight loss, constant fatigue, diarrhea and decreased appetite, yeast infections and other blemishes of the mouth, other opportunistic illnesses like Kaposi's Sarcoma, or Pneumocystic Pneumonia.

TB EXPOSURE PLAN – (Contact Person: Darla Silavent – ext. 8265)

How often are employees required to have the TB skin test? (Tuberculin Skin test)

You are required to have a TB skin test upon employment, annually or after exposure to an active case of infectious tuberculosis, unless you have tested positive in the past. If you have had a positive reaction, you must provide Employee Health with a copy of your health records from the health department to assure you have received follow-up investigation and/or prophylactic treatment. Any new exposures will be investigated thoroughly and reported appropriately.

YOU ARE RESPONSIBLE FOR KNOWING THE ANSWERS TO THE FOLLOWING QUESTIONS:

Who do you contact for infection control issues?

Contact the Infection Control Practitioner, your Immediate Supervisor or the Nursing Supervisor (after hours, weekends, and holidays).

What must you do if you get a needle stick or other type of exposure?

Thoroughly rinse/wash the exposure site and immediately report the incident to your Supervisor. Next, you should report to Employee Health. After hours, the Nursing Supervisor should be contacted. If necessary, you will be instructed to report to the ER for evaluation and treatment of the incident. A follow-up investigation of the incident, paperwork, and lab work will need to be completed as quickly as possible.

Where can you find Infection Control Policies and Procedures?

The Infection Control Manual is located in every department.

- 17 -

At Flowers Hospital we are dedicated to patient safety and will continue to make every effort to prevent adverse events in the healthcare setting. Our aggressive infection prevention strategies follow evidence-based guidelines. The key components of our prevention policies include:

Hand Hygiene

Hand hygiene is the single most important means to prevent transmission of infectious agents

Hands should be sanitized upon entry and exit of patient rooms

For hand sanitization you may use alcohol-based hand rub or wash hands with soap and water

Wash hands with soap and water when hands are visibly soiled, before you eat, after using the restroom, or when exposed to C.difficile

Prevention of Ventilator Associated Pneumonia (VAP)

Hand hygiene

Oral care every four hours

Head of bed elevated minimum 30 degrees at all times to prevent aspiration, unless medically contraindicated

Deep venous thrombosis prophylaxis

Stress ulcer prophylaxis

Daily sedation vacation

Prevention of Intravascular Catheter Related Blood Stream Infections (CLABSI – Central Line Associated Blood Stream Infection)

Hand hygiene – wash with soap and water prior to insertion

Use maximum barrier precautions for every central venous catheter insertion (large sterile drape; provider wears surgical mask, sterile gloves, hair/head covering, and sterile gown)

Chlorhexidine skin prep before insertion

Subclavian vein is the preferred site for non-tunneled catheters in adults

Avoid use of femoral site unless absolute necessity

Daily review of line necessity and discontinue as soon as medically possible

Prevention of Catheter Associated Urinary Tract Infections* (CAUTI)

Strict adherence to aseptic insertion technique, with appropriate hand hygiene and sterile gloves

Use indwelling catheters only when medically necessary*; remove catheters when no longer needed

Maintain closed sterile drainage

Maintain strict adherence to proper catheter care

Foley Catheter Protocol: Assessment for removal by nursing staff

Educate patient regarding Catheter Associated Urinary Tract Infections

Prevention of Multi-Drug Resistant Organisms** (MDRO)

Hand Hygiene – before and after patient/environment contact

Gown and gloves at time of entry to patient’s room

Decontamination of the environment and equipment

Active Surveillance screening for designated high risk populations

Contact Precautions for all colonized and infected patients

Antimicrobial Stewardship Prevention of Surgical Site Infections (SSI)

Appropriate use of prophylactic antibiotics

Appropriate Hair Removal

Controlled postoperative serum glucose for cardiac surgery patients

Immediate postoperative normothermia for colorectal surgery Patients

Individual hand sanitizer for post op patients

Educate regarding Preventing Surgical Site Infections

**MDRO as defined at FLOWERS HOSPITAL:

Methicillin Resistant Staphylococcus aureus (MRSA)

Vancomycin Resistant Enterococcus (VRE)

Extended-spectrum beta-lactamases (ESBL)

Carbapenem Resistant Enterobacteriaceae (CRE)

Clostridium difficile

Additional SSI prevention measures at Flowers Hospital: Pre-op screening for MRSA prior to high risk procedures

Pre-op bathing with CHG and Bactroban Intranasally if MRSA Screen is positive

Bathing patients in the ICU daily with CHG

Additional SSI prevention measures at Flowers Hospital: Hand Washing -Initial Scrub of the day and after smoking or meals-

full 5 min - Surgical scrub, including nails

Surgical Gel may be used between cases, must have contact with the

skin for 3 min and air dry OR 5 min surgical scrub Attire-Scrubs should be donned fresh on arrival and changed if: Worn

from home, Involved in isolation/dirty case, Soiled with blood and body

fluids. Head Covering- covers ALL head and facial hair. Cloth caps should

be worn only if laundered daily

Warm-up jackets (cotton fabric preferred) may not be worn outside of

the department, laundered if soiled or at least weekly

Shoe Covering – Off when leaving, on when entering restricted areas

INFECTION PREVENTION EDUCATION

*Indications for Indwelling Urinary Catheter:

Critically ill patients requiring accurate urine volume

measurements

KEY POINT: Strict I&O is not an absolute indication for an

indwelling urinary catheter for the alert and continent patient

Urinary retention, obstruction, neurogenic bladder

dysfunction

Sacral or perineal wounds (Stage III or IV pressure ulcers)

Palliative care for end of life/comfort care

Extreme dyspnea with exertion

Specific use for surgery patients:

Urological, Gynecological or Perineal surgeries

Required continuous bladder irrigation

Large-volume infusions or diuretics during surgery

Continuous Epidural pain management post op

Prolonged immobilization (e.g., potentially unstable thoracic

or lumbar spine, multiple trauma injuries such as pelvic

fractures)

Specific physician order for Foley Catheter insertion

Central Line Maintenance Care Scrub the Hub with alcohol pad prior to IV meds Swab Cap placed over connector/injection port Replace IV tubing set every 96 hrs or less Place Date Change Stickers on IV tubing Dressing change every Tuesday and PRN CHG Sponge with each dressing change Educate regarding Central Line Infections

- 18 -

Section IV COMPLIANCE

COMPLIANCE PROGRAM – (Contact Person: Dominique Steeves – ext. 1570 or 8515) The primary focus of the Compliance Program is to ensure that internal policies and controls, training and education, and auditing and monitoring are in place to help prevent, detect and resolve instances of conduct that do not conform to applicable laws, rules and regulations or the Code of Conduct. Code of Conduct Intended to foster ethical behavior in our day-to-day business operations. Open channels of communication to help avoid unethical as well as illegal activities. Responsibility of each employee to report violations or suspected violations of the

Code of Conduct or other hospital policies.

o Speak with a member of management or Administration. o Contact Flowers Hospital’s Compliance Officer at 334-794-5000, extension

1570. o Contact the Confidential Disclosure Program Hotline at 1-800-495-9510.

HIPAA Privacy–Confidentiality (Contact Person: Sandra Rafferty – ext 1574) Each individual providing services at Flowers Hospital has an obligation to protect the privacy and confidentiality of our patients according to the Privacy Regulations. Access, use and disclose Protected Health Information (PHI) only when it is

necessary for the performance of your job.

Release of patient information is conducted by the Medical Records Department, where appropriate patient identification and verification can be confirmed.

Discuss patient information only in appropriate clinical settings and appropriate to your involvement in that patient’s care.

Always keep your voice and tone to a minimum when discussing patient information.

To ensure the security of patient information, log out of the WOW each time you walk away from it. When you are logged into a WOW and leave it unattended, anyone can access patient information.

Facility Directory: Patients must be given the opportunity to agree or object to being listed in the facility directory. The facility directory is sometimes referred to as the patient census. When a patient chooses to be included in the directory, the patient’s location within the facility and general condition (good, stable, fair or poor) may be provided to callers or visitors. When a patient chooses not to be listed in the directory, or opts out, Flowers Hospital cannot acknowledge the patient is in the facility or provide information concerning the patient to anyone who calls or requests the patient by name. When a search for a patient name is performed within the

- 19 -

HMS computer system, the name of a patient who opts out of the facility directory will not appear. However, when a search for a patient name is performed within the clinical documentation system, Cerner, the names of all patients will appear, regardless of whether the patient chose to be in the directory or opt out of the directory. Therefore, when employees are asked whether a patient is here and a search is performed in Cerner, employees should always review the blue banner bar in the patient screen to determine whether the patient is in the directory or opted out. (See below) If the patient opted out of the directory, employees must respond that they have no information on the patient.

Cerner- blue banner bar of the patient screen Patients Opted Out of Directory will show: Opted in the Directory: No Patients in the Directory will show: Opted in the Directory: Yes

PHI - Patients must be given an opportunity to agree or to object to having other individuals in the room when a caregiver speaks with the patient or provides care instructions. The patient’s decision must be documented on the Privacy Disclosure Form that will be part of the electronic medical record.

Privacy complaints should be reported to the Privacy Officer. The Privacy Officer will be responsible for managing complaints received by the facility.

Disciplinary action will be enforced for failure to follow Flowers Hospital’s privacy policies and procedures.

All fax transmissions of confidential information should include a fax cover sheet.

Medical Identity Theft Program (RED FLAG RULES) Implemented to detect, prevent, and respond to identity theft. Identity Theft Indicators or “RED FLAGS” include but are not limited to:

Alerts, Notifications or Warnings from a Consumer Reporting Agency.

Suspicious Documents.

Suspicious Personal Identifying Information.

Suspicious Activity Related to an Account. Report concerns to your manager or supervisor.

INFORMATION SYSTEMS SECURITY - (Contact Person: Eric Marsh – ext. 8150)

We consider the security and confidentiality of protected health information a high priority. Each employee who accesses data and resources holds a position of trust relative to such information and must recognize the responsibilities in preserving the security and confidentiality of the information. The purpose of HIPAA Security is to ensure the integrity, confidentiality and availability of electronic protected health information. It is each employee’s responsibility to protect such information against reasonably anticipated threats or hazards, improper use or disclosure of PHI. The best way to prevent unauthorized access is to refrain from using anyone else’s authentication code or device and to not allow anyone to utilize your authentication code or device. The key to HIPAA Security is respecting the confidentiality of all reports and data which are a part of our information network. These reports and data contain sensitive and confidential patient, business, financial and employee information and

- 20 -

should be handled, stored and disposed of appropriately by only disclosing such information to those authorized to receive it.

Proper Usage You are not allowed to seek personal benefit or permit others to benefit personally from any confidential information or use of equipment available through your work assignment. Responsible, incidental personal use is acceptable provided it does not violate any of the following three conditions: First, it does not interfere with the performance of your job duties or the duties of another employee. Second, the resources are not used in a manner that limits or impedes their use or access for legitimate business purposes. Finally, it does not violate any company policies. Obtaining or using an unauthorized pass code to access e-mail or other internet communications intended for other individuals may subject you to disciplinary action, up to and including termination. If you are provided access to the internet and e-mail services owned exclusively by CHS for its own benefit and that of its affiliates, there should be no expectation of privacy. You expressly waive such rights when using these systems, or with respect to anything that you the user creates, stores, sends or receives using a computer, e-mail or internet services provided by CHS. Subject to other applicable policies (e.g., patient confidentiality or access to proprietary information), all usage, data and information contained within or generated in connection with the use of these facilities are subject to review and monitoring. CHS or the facility may utilize monitoring software and other techniques to ensure that users adhere to this policy. Such monitoring will be conducted without prior notice to users. CHS and the facility shall have the right to block transmission or access by users; for example, access may be blocked to all Internet websites that display or link to pornographic material. Employees should understand that the activities in connection with monitoring usage and access are exclusively the rights of CHS and the facility and do not create any duty to or right of the user. Electronic Media There are several different types of electronic media - cd-roms, DVDs, floppy disks, USB “Flash Drives”, SD Cards, Hard Drive (Internal and External), and Back Up Tapes. These types of media must be destroyed properly and should always be taken to Information Systems for destruction. Intechra has been contracted to destroy all electronic media and out dated systems. EMPLOYEE CONCERNS Employees who have concerns about the safety or quality of care provided at Flowers Hospital may report their concerns to their supervisor, administration, Compliance Officer or The Joint Commission.

Flowers Hospital will take no disciplinary action because an employee reports safety or quality of care concerns to their supervisor, administration, Compliance Officer or The Joint Commission.

You may contact The Joint Commission at 630-792-5000.

- 21 -

COMMUNITY CARES – (Contact Person: Patti Hatcher - ext. 1131)

Community Cares is a culture of service and operational excellence. Excellent patient care is the key to achieving better quality outcomes. We demonstrate our COMMITMENT to professionalism by adhering to the following Standards of Behavior:

Attitude – It all begins with a positive attitude about the customers we serve. Our goal is to exceed our customers’ expectations. We are committed to providing the highest quality of service and meeting our customers’ needs with the utmost kindness, care, compassion, courtesy, empathy, respect and friendliness.

Appearance – We should take pride in our personal appearance, our facility and its surroundings.

Commitment to Co-Workers – We are linked to one another by a common purpose: serving our patients and our community. Your co-workers, our physicians and volunteers are our team members. They deserve our respect and support.

Communication – The goal of communication is mutual understanding. We must be committed to listening attentively to our customers in order to fully understand their needs. Close attention should be given to both verbal and non-verbal messages. We are committed to exceed our customers’ expectations and provide more than what is expected.

Customer Waiting – Our customers’ time is very valuable to them. From the moment they enter our hospital, we will provide them with prompt service. We will keep them informed regarding the time service will be provided and make them comfortable while waiting.

Privacy – We will always maintain customer privacy and confidentiality. It is the personal responsibility of every staff member to protect the privacy and confidentiality of every customer encountered. We will treat patient information with confidentiality according to the HIPAA Privacy Rule.

Responsiveness – Every patient or family member who approaches a staff member should be acknowledged. We will respond in a way that demonstrates the care, courtesy and respect our customers deserve.

Safety Awareness – It is the responsibility of all employees to ensure an accident-free environment.

Service Recovery – If a customer complains, do not be defensive; their perception is their reality. To reverse a potentially negative situation use ACT (Apologize, Correct and Thank).

Sense of Ownership – Every staff member must feel a sense of ownership toward his or her job. We will take pride in what we do and how we do our job. We will feel responsible and be in control of the job that needs to be done.

- 22 -

Why do we need to use Key Words at Key Times?

To provide a consistent message to our patients.

To provide consistent care to our patients.

To reduce anxiety for our patients.

It is our goal to hardwire the AIDET principle for excellent customer service, which will help to move the satisfied customer to very satisfied.

A = Acknowledge the customer. I = Introduce yourself to the customer. D = Duration – give the customer a time expectation. E = Explanation - keep customer informed by explaining all processes and procedures. T = Thank You – thank the customer.

Community Cares – Safety Behaviors and Error Prevention Techniques S.A.F.E. Toolbox

What we believe in… What we do…

S Support the Team • Practice Team Checking and Team Coaching

A Ask Questions • Speak Up for Safety Using ARCC - Ask a question, Request change, voice a Concern, use the Chain of command

• Practice with a Questioning Attitude: Validate and Verify

F Focus on Task • Use STAR – Stop, Think, Act, Review

E Effective Communication Every Time

• Use Read and Repeat Backs • Ask Clarifying Questions • Effective handoffs • Notifications using SBAR –

Situation, Background, Assessment, Recommendations/Request

Employee Incident Reporting – (Contact Person: Patti Hatcher – ext. 1131)

1. When an accident injurious in nature to an employee occurs, or when an incident that may cause an injury or illness to an employee occurs, it is the employee's responsibility to report the incident to his/her supervisor or manager immediately. The employee should complete the Employee Incident Report immediately and fax it to the Human Resources Department, seeking assistance from the supervisor or manager, as needed.

2. An incident that is not reported immediately could result in disciplinary action. 3. An employee who needs medical treatment should take the pink copy of the

Employee Incident Report to the Employee Health Office during normal business hours and to the Emergency Department after hours. The employee should have the required report completed prior to treatment, if possible. The employee should submit the white and yellow copies of the Employee Incident Report to his/her

- 23 -

supervisor or manager. If an employee is unable to complete the Employee Incident Report due to the seriousness of the accident or illness, the supervisor or manager should ensure the report is completed during the time treatment is being given.

4. An employee should not seek treatment or medical attention from anyone other

than the Employee Health Office or the Emergency Department, unless he/she is referred to another physician or specialist by either the Employee Health Nurse or the Workers’ Compensation Representative. Exceptions made without specific approval from the workers' compensation carrier and the Human Resources Department may not be covered under the Workers' Compensation Program and may become the responsibility of the employee.

5. The employee is responsible for providing a work status report, doctor’s excuse or

doctor’s release to his/her supervisor or manager as soon as possible after treatment.

6. If an employee is admitted to the hospital or loses time from work, the employee is

responsible for notifying his/her supervisor or manager immediately and should provide a doctor’s excuse from the authorized treating physician.

7. When a non-injurious employee incident occurs and treatment is not needed, the

employee should still report the incident to his/her supervisor or manager and complete an Employee Incident Report and fax it to the Human Resources Department immediately.

Harassment and Workplace Violence – (Contact Person: Patti Hatcher – ext. 1131)

Every employee has a right to a work environment free of harassment or discrimination because of gender, age, race, ethnicity, religion, creed, national origin, sexual orientation or any other attribute or characteristic protected under federal or state law. All colleagues shall treat one another with courtesy, fairness and respect. We will not tolerate any sexual, racial, ethnic, religious or other forms of harassment of colleagues or applicants. The organization will take action to fairly and objectively address any complaints of harassment or inappropriate behavior. If you experience or witness such behavior, contact the facility Human Resources Department, the Facility Compliance Officer (FCO), the Corporate Compliance and Privacy Officer or the Confidential Disclosure Program. Workplace violence, such as stalking, robbery, assault (verbal or physical), battery, vandalism and other crimes committed by current or former employees or their associates is not acceptable and will not be tolerated. Colleagues must not bring firearms, explosive devices or other weapons or dangerous materials onto any hospital or affiliate’s property. Colleagues who witness any form of violence or harassment are required to report the conduct to the Facility Compliance Officer (FCO), the Corporate Compliance and Privacy Officer or the Confidential Disclosure Program. Employee Name Badges: – (Contact Person: Patti Hatcher – ext. 1131)

Employee name badges must be worn at all times while on duty. Name badges should be worn where they can be visibly seen. Please notify your manager immediately if you lose your name badge. Your manager will need to have your building access revoked as quickly as possible. This will prevent someone from obtaining access to the building after hours utilizing your name badge.

- 24 -

Section V THE PATIENT

PATIENT RIGHTS AND RESPONSIBILITES – (Contact Person: Marilyn McKissack – ext. 1950) Each patient has a right to:

expect a reasonable response to their request.

participate in decisions related to their care.

be informed of the medical consequences in choosing to accept or refuse care.

formulate advance directives and appoint a surrogate to make decisions should the need arise.

pain management.

receive considerate and respectful care, including confidentiality, privacy, security and communication.

maintain personal dignity (i.e. cubicle curtains closed during procedures, doors closed during exams, etc.).

obtain from his/her physician current information concerning diagnosis, treatment and prognosis in terms the patient can understand.

know medically significant alternatives of care and treatment.

know if they are part of an educational or experimental research project that may affect care and for which they have the right to refuse or accept to participate.

expect reasonable continuity of care.

explanation of their bill, regardless of source of payment.

reasonable access to care regardless of race, creed, sex, national origin or source of payment.

participate in ethical questions that arise in the course of care.

be informed about the outcome of care, including unanticipated outcomes.

pastoral counseling and spiritual services.

be free from mental, physical, sexual and verbal abuse, neglect and exploitation.

voice complaints and recommend changes without fear of discrimination, reprisal or unreasonable interruption of care or treatment.

access protective services.

file a complaint with regulatory agencies.

obtain information about any relationship of this hospital to other healthcare and educational institutions as far as care is concerned and any professional relationship among individuals, by name, who are treating them.

be provided with a Notice of Privacy Practices which includes information about how we may use and disclose medical and billing information and rights regarding medical and billing information.

- 25 -

Each patient has the responsibility to:

provide to the best of their knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, family history and other matters relating to the patient’s health.

report unexpected changes in their condition to the responsible practitioner.

clearly understand the course of healthcare treatment and what is expected of him or her.

respect the rights and property of others.

keep staff advised of transportation issues at discharge.

assist in safeguarding personal property.

participate in health care choices.

treat our staff with respect and courtesy.

notify us right away of complaints or questions concerning the care and treatment received.

request information or clarification about their health status or treatment when not fully understood.

CARE OF THE PATIENT - (Contact Person: Marilyn McKissack – ext. 1950)

Patient Safety Tips

ALWAYS use patient name and date of birth as identification prior to procedures or medication administration.

ALWAYS confirm/clarify verbal physician orders and document as “read back” on patient record if a verbal order is taken.

Avoid use of high risk abbreviations in the medical record.

Use free flow protected infusion pumps and time strip fluids and monitor rates closely.

Keep clinical alarms on, set parameters appropriately and maintain audible levels in clinical areas.

Comply with the Fall Protocol as identified by yellow patient identification bracelets and door tags. Ensure bed alarm and chair alarm device is activated when leaving the bedside of a patient identified at risk for fall.

CULTURAL DIVERSITY - (Contact Person: Marilyn McKissack – ext. 1950)

Avoid being judgmental about patient’s beliefs and practices.

Ask questions to assist you in learning about the patient’s view of their condition.

Find out what treatments the patient has been using.

Ask the patient to bring all medications, including herbs, etc.

Explain procedures carefully before an examination, especially when they may be embarrassing or uncomfortable for the patient.

Assure the patient that all attempts will be made to preserve modesty.

Avoid touching the patient’s head unless it is necessary and then explain reasons before touching.

Ask the patient who they want to be involved in discussions about diagnosis, treatment and prognosis.

- 26 -

Allow patients to lead the way in shaking hands.

Beware that some ethnic groups will answer yes and smile the entire time because they are not allowed to say no.

RESTRAINTS - (Contact Person: Marilyn McKissack – ext. 1950)

The use of restraints is a LAST RESORT and should not be considered until alternative methods have been exhausted.

Know the alternatives to restraints, such as patient education and redirection, decreasing patient stimulation (lighting, noise, etc.). Ask family to stay with the patient or provide one-on-one staffing for patient, when available.

The Restraint band documentation tool in the electronic medical record should be used to document circulation checks, toileting, hydration, time restraints were initiated and time removed.

Nurses should document patient/family education regarding the need for and use of restraints in the electronic medical record under the Interactive View and I&O section in the Adult Education Band.

Restraints should be ordered using the Flowers Restraint powerplan within the electronic medical record. The physician or Licensed Independent Practitioner (LIP) responsible for the care of the patient is authorized to order a restraint. In an emergency application situation, an RN, who has documented Restraint and Seclusion competency, may initiate the application of restraint or seclusion prior to obtaining an order from a LIP. In this event, the order must be obtained either during the emergency application of the restraint or seclusion or immediately (within a few minutes) after the restraint or seclusion has been applied. Orders for restraints should not be written as standing orders or PRN orders. Each episode of restraint or seclusion must be initiated in accordance with an order by a physician or other LIP. If a patient was recently released from restraint or seclusion, and exhibits behavior that can only be handled through the reapplication of restraint or seclusion, a new order is required. Staff cannot discontinue restraint or seclusion as a trial and then re-start it under the same order.

There are two types of Restraints available for patient care: Non-Violent, Non-Self-Destructive and Violent Self-Destructive.

If patient and/or family refuse the use of restraints or safety devices, a release of safety devices form should be signed by patient and/or family and nurse and placed in patient’s medical record. This should also be written on the dry erase board in the patient’s room to notify the other caregivers.

PAIN MANAGEMENT - (Contact Person: Marilyn McKissack – ext. 1950)

Pain management is a patient right.

Patients should be educated regarding the pain scale and their pain management plan.

Pain should be assessed based on the patient’s perceived level of pain and scored accordingly.

The pain scales used are the Numeric Pain Intensity Scale, FLACC, and Wong Baker Faces. Pain is assessed as part of the hourly rounding process as well as once a shift.

- 27 -

Once a pain intervention is made then the nurse should recheck patient in 30-60 minutes for results of intervention. Pain assessment scale is documented in the MAR and under frequent documentation in Cerner (Electronic Medical Record).

PATIENT EDUCATION - (Contact Person: Marilyn McKissack – ext. 1950)

Patient education should be documented in the electronic medical record under the Interactive View and I&O section in the Adult Education band. When new medications are given, the patient/significant other should be informed about potentially adverse reactions and side effects along with any other concerns related to new medications. Patient medication education should be documented in the electronic medical record under the Interactive View and I&O section in the Adult Education band. Rapid Response Team (RRT): The Rapid Response Team (RRT) consists of the Nursing Supervisor, Critical Care Nurse and Respiratory Therapist. The RRT may be initiated in the event of a patient status change (example: Chest pain, signs and symptoms of a heart attack, stroke, etc.) and if additional help is needed to manage the patient. The beeper number is: 719-0310. When you dial beeper # -, you will hear a series of beeps - immediately type in your room number, Flowers extension or cell phone number, whichever is accessible to you while caring for the patient. If the Nursing Supervisor does not recognize the room number or extension, he/she will return your page to the number you entered. If you do not get a response within one minute, dial "0" for the operator. This number is also located on the back of the employee identification badge. If patients and/or family members/significant others have a question or concern regarding the patient’s condition, they may notify the patient’s primary nurse or they may dial “0” for the operator and ask for a Rapid Response to be activated. CARDIOPULMONARY RESUSCITATION: - (Contact Person: Marilyn McKissack – ext. 1950)

Calling for HELP 1. Dial 1666. 2. Ask co-worker to page 1666. 3. Utilize Code button in areas that have the buttons on the wall.

The 4 Cs of a Code - Bring the following equipment to patient’s room. 1. Chart. 2. Cart. 3. Cables. 4. Computer

Team Members 1. ER staff (physician, nurse and PCT). 2. Nursing Supervisor. 3. Ancillary Department (Lab, Radiology, Respiratory and Cardiac Testing). 4. Charge Nurse and Primary Nurse.

- 28 -

Age Specific Criteria for CPR:

One person CPR

Infant - 12 months of age and under - 30 compressions and 2 ventilations in series of 5 sets (exception is the neonate).

Children - 1 year of age to puberty (signs of puberty: girls breast buds and boys hair under arm pits) - 30 compressions and 2 ventilations in series of 5 sets.

Adults - puberty and above - 30 compressions and 2 ventilations in series of 5 sets.

Two Person CPR

Infant - 2nd rescuer comes in to assist - compression/ventilation ratio changes to 15:2. Reason for change is that infants usually have respiratory issues, not cardiac.

Children - 2nd rescuer comes in to assist - compression/ventilation ratio changes to 15:2. Reason for change is that children usually have respiratory issues, not cardiac. It is also acceptable to use either one hand or two hands to complete compressions.

Adults - 2nd rescuer comes in to assist - compression/ventilation ration remains the same as 1 - man - 30:2.

Steps to Complete CPR 1. Establish unresponsiveness. 2. 2015 Adult BLS Algorithm a. Activate emergency response system (dial 1666, press Code Blue Button). b. Get Defibrillator. c. Lone rescuer to initiate chest compressions before giving rescue breaths

using C-A-B rather than A-B-C. The lone rescuer begins with 30 compressions rather than 2 ventilations to reduce delay to first compression. After delivery of 30 compressions, the lone rescuer opens airway and delivers 2 breaths.

d. Continuous compression rate of 100-120/minute. e. Compression depth for adult is at least 2 inches.

f. As soon as defibrillator is available and shock is indicated perform without delay.

g. Healthcare providers who treat cardiac arrest in hospitals and other facilities with on-site AEDs or defibrillators should provide immediate CPR

and should use AED/defibrillator as soon as it is available. AED is now acceptable to use on infants if a manual defibrillator is not available. The AED used on infants must be a pediatric dose attenuation capable.

Children 2015 AHA guidelines a. Check for responsiveness b. activate emergency response system (dial 1666, press Code blue button but call is Code Pink) c. Compressions: 1 rescuer 30:2 2 rescuer 15:2 d. Continuous Compression rate is 100-120/min e. 1 breath every 6 seconds f. compression depth is about 2 inches or 1/3 diameter of chest

- 29 -

4. Infant 2015 AHA guidelines a. excluding newborns b. depth 4 com-1/3 depth of chest for compressions c. positions: 1 Rescuer 2 fingers center of chest just below nipple line 2 Rescuers 2 thumbs encircling hands in the center of chest Just below nipple line

Once CPR is started, only the physician can stop. SEXUAL ASSAULT - (Emergency Department – ext. 1125) The Emergency Department will screen and perform appropriate treatment for the injury and involve other disciplines as necessary.

Non-Employee Incident Reporting - (Contact Person: Amy Butler– ext. 1580)

Any deviation from the expected course of events should be entered into the Electronic Reporting System (ERS), utilizing the link on the desktop or the Flowers Hospital Intranet page. An event report is a protected document for internal use only. Examples include but are not limited to:

Medication error/near-miss

Adverse drug reaction

Equipment malfunction

Patient fall/visitor fall

Mislabeled/unlabeled specimens

Misidentification of a patient

Patient leaving AMA

Allegations of abuse

Lost or stolen items

Delays in care Please keep these tips in mind when completing an event report:

Demographic information is critical

What is reported- anything not routine

Should be a factual account of the event

Description/summary of the incident is critical

Must be completed as close to the event as possible, prior to end of shift

It is the responsibility of the person who finds or is part of the event to complete the event report

The actual event report SHOULD NOT be referenced in the EMR

Documentation of the event SHOULD be entered in the EMR as applicable

- 30 -

CENTER FOR METABOLIC AND WEIGHT LOSS SURGERY - (Contact Person: Jane Skeen – ext. 7433 SENSITIVITY TRAINING

Overweight individuals often encounter discrimination in all areas of life including healthcare.

Obese persons are blamed for their condition and are not afforded the same considerations as others who suffer from a disease or disability.

Obese people often shy away from healthcare providers and hospitals because they are afraid of being embarrassed or humiliated.

What can you do? o Show all patients that you are sensitive to their needs. o Use appropriate equipment and supplies such as beds, stretchers,

wheelchairs, blood pressure cuffs, tourniquets, etc. o Avoid derogatory words and actions. Do not stare at the patient or whisper

and point to others about the patient. o Communicate genuine interest. Use AIDET principles. Actively listen. o Eliminate personal judgments and bias. Listen to the patient. o Bariatric sensitivity training is required for all employees on Advanced

Learning Center. SAFE TRANSFER / CAREGIVER SAFETY

Staff should recognize the challenges with the obese population. o May require specialized equipment with proper in-servicing. o A lighthouse on the equipment designates that the equipment holds up to 500

lbs. o Maintaining patient privacy. o Adequate training in body mechanics. o Before you lift: Remember the three “R’s”:

Right number of people Right equipment Right position

o Transporting: Appropriate size transport vehicle. o Use correct size stretcher or bed. o Push, don’t pull.

Goals: o Reduce and prevent back injuries. o Reduce patient anxiety and discomfort.

CARE OF THE BARIATRIC PATIENT

RNs and LPNs should be familiar with the Care of the Bariatric Patient section with special consideration for complications of weight loss surgery.

Helpful tips o Location of Bariatric Equipment Room is 6th floor breezeway. o Glides and Lifts are available in the equipment room as well as ER and OR. o Call the Center for Metabolic and Weight Loss Surgery with ANY

CONCERNS AT EXTENSION 7432.

- 31 -

NATIONAL PATIENT SAFETY GOALS - (Contact Person: Marilyn McKissack – ext. 1950)

PATIENT IDENTIFIERS = a) NAME AND DATE OF BIRTH, b) make sure get correct blood when get a transfusion

IMPROVED STAFF COMMUNICATION = Get important test results to the right staff person on time.

USE MEDICINES SAFELY = a) label medicines not labeled. (syringes, basins, cups), b) take extra care with patients who take medicines to thin their blood, c) complete correctly patient medication history and provide discharge information on what meds to continue.

USE ALARMS SAFELY = on and audible with appropriate timely response.

PREVENT INFECTION = a) Hand washing guidelines, b) use proven guidelines to prevent infections that are difficult to treat, c) use proven guidelines to prevent infection of the blood from central lines, d) use proven guidelines to prevent infection after surgery, e) use proven guidelines to prevent infections of the urinary tract that are caused by catheters.

IDENTIFY PATIENT SAFETY RISKS = Find out which patients are most likely to commit suicide. Patients presenting with a diagnosis of Drug Overdose, Suicide Attempt, Psychiatric Disorder, Drug or Alcohol Withdrawal/Detox or other Emotional or Behavioral Disorder should be screened for risk of suicide in the hospital.

PREVENT MISTAKES IN SURGERY = a) correct surgery, correct patient, correct location, b) mark the correct place on the patient’s body where the surgery is to be done, c) pause before the surgery to make sure that a mistake is not being made.

NATIONAL HOSPITAL QUALITY MEASURES (CORE MEASURES) - (Contact Person: Carol Gordon-Brantley – ext. 1580)

Flowers Hospital is committed to ensuring evidence-based healthcare practices and processes are utilized for the patients we are privileged to serve. We would like to acknowledge our outstanding physicians and dedicated employees for their contribution and collaboration leading to our quality and patient care performance. The teamwork and strategies employed to achieve top performance in core measures are also being utilized to make improvements in other patient care conditions and services. Flowers Hospital’s culture of quality improvement reflects our goal to provide every patient with the right health care services every time.

The National Hospital Quality Measures are sets of indicators for specific patient groups meant to decrease morbidity and mortality, decrease length of stay, decrease readmissions, improve overall quality of care and provide hospital quality information to consumers. Organized by the Centers for Medicare and Medicaid (CMS) and the Joint Commission, the Measures promote the best evidence-based medical practices associated with certain clinical conditions.

Flowers Hospital consistently performs in the top 10% of all hospitals nationwide for our Quality Measures. We have implemented processes for patient identification, concurrent review, creation and implementation of tools for frontline staff, quality improvement teams, and performance oversight and accountability.

- 32 -

ACUTE MYOCARDIAL INFARCTION

ASA at Arrival.

ASA at Discharge.

ACEI or ARB for LVSD.

Beta Blocker at Discharge.

Time to Thrombolysis < 30 minutes.

Time to PCI < 90 minutes.

Statin at Discharge.

CONGESTIVE HEART FAILURE

LVF Assessment.

ACEI or ARB for LVSD.

PNEUMONIA

Blood Culture within 24 hours for patients admitted to ICU.

Appropriate Antibiotic Selection within 24 hours of Hospital Arrival.

STROKE

Venous Thromboembolism Prophylaxis (VTE).

Discharged on Antithrombotic Therapy.

Anticoagulation Therapy for Atrial Fibrillation/Flutter.

Thrombolytic Therapy (t-PA).

Antithrombotic Therapy by End of Hospital Day 2.

Discharged on Statin Medication.

Stroke Education.

Assessed for Rehabilitation.

SURGICAL CARE IMPROVEMENT PROJECT

Antibiotic Received within 1 hour Prior to Surgical Incision.

Appropriate Antibiotic Selection.

Antibiotic Discontinued within 24 hours after Surgery End Time (48 hours for CABG, VALVE).

Cardiac surgery patients with controlled post-op glucose ≤180 in the timeframe of 18- 24 hrs after Anesthesia end time

Surgery patients with appropriate hair removal.

Urinary Catheter removed by Postop Day 2 (day of surgery is 0).

Surgery patients on Beta Blocker therapy prior to admission to receive a Beta Blocker during the Perioperative Period.

Surgery patients with recommended Venous Thromboembolism Prophylaxis.

- 33 -

SEPSIS BUNDLE PROJECT

Early Management Bundle, Severe Sepsis/Septic Shock

CHILDREN’S ASTHMA CARE

Use of Reliever.

Use of Corticosteroid.

Home Management Plan of Care to include: Physician follow-up, environmental triggers/control, methods and timing of rescue actions, use of controllers and use of relievers.

EMERGENCY DEPARTMENT

Time from ED arrival to ED departure (admission).

Time from Admit Decision to ED departure (admission).

IMMUNIZATION

Influenza Immunization rate.

VENOUS THROMBOEMBOLISM PROPHYLAXIS

VTE Prophylaxis ICU VTE Prophylaxis VTE Warfarin Therapy Discharge Instructions Hospital Acquired Potentially Preventable VTE

OP MEASURES

OP Pain Management for Long bone fractures

AMI

CP

STROKE

ED Throughput

SCIP

Please make sure the Quality Measure Section of the Discharge Planning Summary Checklist is completed prior to discharge. This is our last opportunity to verify applicable quality measures have been met. HEART ATTACK SIGNS / SYMPTOMS & ACS EDUCATION- (Contact Person: Nathan Chase – ext. 1555)

Your heart muscle needs oxygen to survive. A heart attack occurs when the blood flow that brings oxygen to the heart muscle is severely reduced or cut off completely. This happens because coronary arteries that supply the heart with blood can slowly become thicker and harder from a buildup of fat, cholesterol and other substances that together are called plaque. This slow process is known as atherosclerosis. When a plaque in a heart artery breaks, a blood clot forms around the plaque, this blood clot can block the artery and shut off blood flow to the heart muscle. When the heart muscle is starved for

- 34 -

oxygen and nutrients, it is called ischemia. When damage or death of part of the heart muscle occurs as a result of ischemia, it is called a heart attack or myocardial infarction (MI). About every 34 seconds, someone in the United States has a heart attack. If you encounter a visitor in our facility you suspect may be having a heart attack, you should call for help and escort them to the ER. If a patient is having chest pain or signs of a heart attack, you should call a Rapid Response by dialing 719-0310.

COMMON SIGNS AND SYMPTOMS OF A HEART ATTACK

Chest discomfort: Most heart attacks involve discomfort in the center of the chest that lasts for more than a few minutes, or goes away and comes back. The discomfort can feel like uncomfortable pressure, squeezing, fullness or pain.

Discomfort in other areas of the upper body: Can include pain or discomfort in one or both arms, the back, neck, jaw or stomach.

Shortness of breath: Often comes along with chest discomfort. But it also can occur before chest discomfort.

Other symptoms: May include breaking out in a cold sweat, nausea or light- headedness. WOMEN AND HEART ATTACK

If you're a woman, you may not believe you are as vulnerable to a heart attack as men–but you are. Women account for nearly half of all heart attack deaths. Heart disease is the number one killer of both women and men. There are differences in how women and men respond to a heart attack. Women are less likely than men to believe they're having a heart attack and more likely to delay in seeking emergency treatment. Further, women tend to be about 10 years older than men when they have a heart attack. They are more likely to have other conditions, such as diabetes, high blood pressure, and congestive heart failure–making it all the more vital that they get proper treatment fast.

Women should learn the heart attack warning signs. These are:

Pain or discomfort in the center of the chest.

Pain or discomfort in other areas of the upper body, including the arms, back, neck, jaw, or stomach.

Other symptoms, such as a shortness of breath, breaking out in a cold sweat, nausea or light-headedness.

As with men, women's most common heart attack symptom is chest pain or discomfort. But women are somewhat more likely than men to experience some of the other common symptoms, particularly shortness of breath, nausea/vomiting, and back or jaw pain.

If you feel heart attack symptoms, do not delay. Remember, minutes matter! Do not wait for more than a few minutes–5 minutes at most to seek medical treatment. Your family and/or friends will benefit most if you seek fast treatment.

- 35 -

HEART ATTACK SYMPTOMS IN PERSONS 65 OR OLDER

Over the past few decades, medical research has shown that women, as well as older people of either gender, often have heart attack symptoms that are very different from the so-called “classic” chest pain and/or pressure that middle-aged men tend to experience.

These different symptoms often include shortness of breath, weakness, and fatigue. Other possible symptoms include nausea, vomiting, sweating, palpitations, or pain in the jaw, neck, arm, or upper belly. Some women and older men even have poor sleep for a few days before their heart attack. And although many do get chest pain or chest discomfort, at least 30-40 percent may not have any chest pain at all.

The trouble is there are lots of things that can make an older person feel weak and tired. For instance, even though heart attacks are common, it’s far more common to find their weakness and fatigue is due to something like a cold, a medication side effect, or a urinary tract infection. And for the many older people who live with chronic shortness of breath (due to ongoing health problems such as chronic obstructive pulmonary disease or congestive heart failure), it can be hard for a caregiver or doctor to distinguish a bad day in the life of a chronic disease from a new urgent problem like a heart attack. Finally, it’s of course even trickier to evaluate the symptoms of someone who has Alzheimer’s or another dementia. Memory and thinking problems often make it hard for the person to describe symptoms accurately. People with dementia are also particularly likely to develop delirium (a state of worse than usual mental confusion), which can make them either more agitated or quieter than usual when a heart attack is stressing the body.

- 36 -

STROKE SIGNS AND SYMPTOMS WHAT IS A STROKE? Stroke is a disease that affects the arteries leading to and within the brain. It is the No. 4 cause of death in the United States, behind diseases of the heart and cancer. A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts. When that happens, part of the brain cannot get the blood (and oxygen) it needs, so it starts to die. COMMON SIGNS AND SYMPTOMS OF A STROKE

Sudden numbness or weakness of the face, arm or leg, especially on one side of the body

Sudden confusion, trouble speaking or understanding

Sudden trouble seeing in one or both eyes

Sudden trouble walking, dizziness, loss of balance or coordination

Sudden, severe headache with no known cause

WHAT DO I DO?

For visitors, immediately call Rapid Response at 719-0310 or take them to the Emergency Department.

For Inpatients, call Rapid Response Team: 719-0310.

Also, check the time so you'll know when the first symptoms appeared. It's very important to take immediate action. If given within 3 hours of the start of symptoms, a clot-busting drug t-PA may reduce long-term disability for the most common type of stroke.

Think FAST:

· Face: Does the face look uneven? Ask the person to smile.

· Arm: Does one arm drift down? Ask the person to raise both arms.

·Speech: Does their speech sound strange? Ask the person to repeat a simple phrase.

· Time: If you observe any of these symptoms, call Rapid Response @719-0310.

- 37 -

FLOWERS HOSPITAL NON EMPLOYEE TRAINING ACKNOWLEDGMENT

I HAVE READ AND REVIEWED THE NON EMPLOYEE TRAINING INFORMATION RELATED TO SAFETY, CODE OF CONDUCT, HIPAA PRIVACY, AND OTHER FLOWERS HOSPITAL POLICIES AND PROCEDURES AND AGREE TO ABIDE BY THESE.

__________________________________________ Print Name __________________________________________ _____________________ Signature Date

Please complete the POST TEST questions below before submitting this acknowledgment.

1. The acronym R.A.C.E. stands for Remove, Activate, Contain, and Extinguish.

a. True b. False

2. The 3 radiation safety steps are time, distance and shielding.

a. True b. False

3. Hand Hygiene should be performed before and after patient care.

a. True b. False

4. The 2 patient identifiers used at Flowers Hospital are the patient’s name and room

number. a. True b. False

5. Code Orange is paged when you suspect a person may be experiencing a stroke.

a. True b. False

6. The Code Orange is paged overhead by the operator three times.

a. True b. False

7. Do not leave items like medical equipment, WOW computers, or furniture in the

______________ ____ egress.

8. Privacy complaints should be reported to the _______________ _______________.

- 38 -

9. List out what the below acronyms for A.I.D.E.T. stands for: A ________________________ I ________________________ D ________________________ E ________________________ T ________________________

10. With respect to cultural diversity, avoid being __________________________________ regarding a patient’s beliefs and practices.

11. The primary focus of the _______________ ______________ is to ensure that internal

policies and controls, training and education, and auditing and monitoring are in place to help prevent, detect and resolve instances of conduct that do not conform to applicable laws, rules and regulations or the Code of Conduct.

12. ___________________ __________________ is the Chief Executive Officer.

13. ___________________ __________________ is the Employee Health Nurse.

14. ___________________ __________________ is the Safety Officer.

15. An employee can contact the Joint Commission about concerns about the safety or

quality of care provided at Flowers Hospital? a. True b. False

16. Employees who have concerns about the safety or quality care provided at Flowers

Hospital may report their concerns to their supervisor, administration, Compliance Officer or may contact The Joint Commission at 1-630-792-5000?

a. True b. False

___________________________________________ Print Employee Name

__________________________________________ __________________ Employee Signature Date

___________________________________________ __________________ HR Signature Date

A test score of 16 out of 16 is required, or the manager must remediate the employee.

Post Test Score ____ out of ____. (If the employee scored below 16, my signature below confirms that I have remediated the employee on all incorrect answers.)

Remediation date: __________________

_______________________________________________ __________________ Manager Signature Confirming Remediation (if applicable) Date