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Spring 2010 1
A.C.E.S. AAAAdvanced
CCCClinical
EEEEducation with
SSSSimulation
Spring 2010 2
ACES Policy and Procedure Review and Sessions
Week 1— Admission/Assessment/Codes Complete the worksheets for the a.m. session using the key points and/or handouts listed below
1. Admitting a Patient—Key points
2. Use of Free Float- Key Points
3. Nursing Assessment & Reassessment-Key Points
4. Patient Care Plans/Focus Problem Lists-Key Points
5. D.A.R. Charting Resource—Handout
6. Discharge of Patient from the Hospital Against Medical Advice (Form)
7. Rapid Response Team Protocol (RRT)-Key Points
8. Initiating a CODE BLUE-Key Points
9. Crash Cart Contents—Handout
10. AMBER ALERT-Key Points
11. CODE RED– Fire Policy-Key Points
12. CODE GRAY—Physical Assistance-Key Points
13. (Draft) Post Mortem Care-Key Points
14. Organ and Tissue Donation—policy
15. POLST FORM (Form)
16. Coroners Case—policy
A.M. Session - See Matrix
Teams will present on completed worksheets:
1-Emergency Codes
2-Code Cart and Code Team
3-Fire Evacuation Carries/Demonstration
4-AMA/AMBER Alert
5-Post-Mortem Organ Donation/Coroner Case
P.M. Session—Clinical simulation scenarios—rotations assigned day of class
Anaphylaxis Scenario
CHF Scenario
RRT Scenario
Quiz
Evaluation
Spring 2010 3
WEEK 1
SKILLS STATION MATRIX AND SIMULATION MATRIX
Time All Groups Together
0800-0830 Welcome/Intro/Expectations
0830-0915 Pretest
0915-0930 Break
0930-1000 Team Assignments/ DAR Charting Worksheet
TEAM Presentations
Group
1
1000-1030
Group
2
1030-1100
Group
3
1100-1130
Group
4
1130-1200
Group
5
1245-1315
Emergency
Codes (2)
Code Cart/
Code Team
Evacuation-
Carries (5)
AMA/
AMBER Alert
Organ Donation/
Coroner Case
1200-1245 Lunch on your own
1315-1345 Group Review—Kronos / Fire Drill
1345-1430 Group 1 Group 2 Group 3
1430-1515 Group 2 Group 3 Group 1
1515-1600 Group 3 Group 1 Group2
Anaphylaxis CHF RRT
1600 –1620 Quiz
1620 –1630 Evaluations
Spring 2010 4
Policy Title: Admitting a Patient
For complete policy, go to Policies and Procedures (Admission & Discharge) on Memorial’s Intranet
Purpose: To provide guidelines for admitting a patient
Key Points:
• All patients admitted to YVMH must have doctors orders for care
• If direct admit, the patient will be escorted to the floor by a Registration Service Represen-
tative.
• The nursing staff (nurse techs/RN) assists patient with changing into gown, weighs patient,
obtains current vital signs and assists patient with getting into bed. Patient is oriented to
use of bed, call lights, phone, bathroom, and visiting hours and visitation policy.
• An admission assessment is performed by the RN/LPNII (JCAHO requires an RN focused
assessment), who notifies the Physician as appropriate.
• The nurse must assess the patient within the first half hour after their arrival on the unit
for the chief complaint/focus problem and document as soon as possible.
• The Nursing Admission Assessment should be completed as soon as possible and docu-
mented completely within eight hours of admission.
• Documentation on the Home Medication Reconciliation Record will begin on admit and be
completed in Soarian within 24 hours– the unit Pharmacist may assist in completion.
• Do not provide water to a patient until there is a specific diet order
** Additional info: Patient may be admitted for:
Short Stay = patient here for less than 24 hours—time begins at end of procedure.
Observation = patient may remain for up to 48 hours—time begins when patient arrives to
unit/floor (or from end of anesthesia + 6 hours)
ACES
Policy and Procedure Review
Spring 2010 5
Free Float Responsibilities 2/2010
The Free Float's main responsibilities include assisting nurses when they are having difficulty completing their as-
signments in a timely manner. This may include items from the following list:
1. Respond to Rapid Responses/Code Blue (cover patients for the nurse involved in the code)
2. Assist with in-patient transfers
3. Pass medications
4. Assist with blood transfusions
5. Assist with RN skills: ex. dressing changes, catheter insertions
6. Double check insulin and heparin
7. Pick up a group of patients without notification (i.e. sick nurse)
8. Transport patients to CT/Radiology if requiring a nurse to monitor.
9. Assist with patient care and transfers
10. Call physicians for orders, clarification
11. Assist in consolidating patients to make room for surgeries and admits
12. Check in surgery patients returning to floor from PACU
13. Assist in Day Surgery to prepare patients for surgery
14. Assist physicians with procedures (i.e. chest tube insertion, biopsy, paracentesis, thoracentesis,
etc.)
15. Assist in ED as second pair of hands
16. Able to assist with all RN responsibilities when needed by floor staff
17. Assess, pass meds, and complete DAR note on one(1) patient from each nurse on days when staff-
ing is below Matrix
18. Admissions (history and physical assessments)
19. Discharges
20. Sign off orders
Free Floats are limited: 1 per shift to cover hospital wide, and can be reached by Vocera
Free Floats communicate DIRECTLY with the Primary Nurse prior to and following care of a patient.
Assessments and charting:
The Primary RN completes: the Head to Toe chapter, Fall Risk chapter, and Braden Scale chapter. It
remains the responsibility of the Primary RN to complete the admit on their patient.
The Free Float can complete: the admission chapter, patient factor chapter, patient history chapter,
and the medication chapter. Time permitting the free float may fill in the Kardex and/or print off the
medication reconciliation sheet for the chart.
The Free Float can complete an admission for an LPN II, (including assisting with Kardex, medication
reconciliation, and completing a DAR note) if the Shift Coordinator or RN supervising the LPN II is un-
able to complete.
Spring 2010 6
Policy: Nursing Assessment and Reassessment
For the complete policy, go to Policies and Procedures –General Nursing, on Memorial’s Intranet
Purpose: To provide guidelines for assessment standards for patients at YVMH
Key Points:
• On Admit: Nursing Admission Assessment is performed by admitting nurse upon admis-
sion and must be documented as early in shift as possible or within (8) eight hours.
This also includes:
Patient History/ Fall Risk/Braden Scale
On Pediatric unit - include Growth and Development
Medication Reconciliation Form is completed within 24 hours
• The admission assessment evaluates physical, psychosocial, environmental, self-care, edu-
cational, spiritual, pain (including pain score/goal), cultural and discharge needs. This as-
sessment helps prioritize which interdisciplinary health care team members will assist
with the patient’s needs (i.e. referrals that may be needed).
• Each Shift:
1) Nurses complete and document a Head-Toe-Assessment (i.e. Shift Assessment)
which reviews all systems, including Braden Scale (Fall Risk)
2) Complete a DAR note ( D=Data, A=Action, R=Response) in Clinical Notes on each
problem that deviates from the patient’s normal state or baseline. The DAR should
paint a picture of the patient’s condition and should address the focus problems.
3) Review and update the focus problems on patient’s KARDEX (pain, falls, skin,
diagnosis, etc.). Documentation of Focus problems on the Kardex should include:
Date initated
Priority
Signature
Date resolved
• Reassessments are driven by the focus problem list and any changes inpatient condition
• Please see policy for unit specific assessment and reassessment requirements.
• Vital signs are obtained per unit protocol and based on patient’s condition.
ACES
Policy and Procedure Review
Spring 2010 7
Policy: Patient Care Plans/Focus Problem Lists
For the complete policy, go to Policies and Procedures on Memorial’s Intranet
Purpose: To show the purpose of the Patient Care Plans/Focus Problem Lists and
inform nurses of their responsibility to complete them.
Key Points:
• Care Plans/Focus Problem lists are based on the nursing process. It is the responsibility of
the nurse to document these on the Kardex.
• Care Plans/Focus Problem lists are individualized for each patient’s needs and communi-
cates the patient’s needs to all healthcare team members.
• Care Plans/Focus Problems are assessed and documented on admission and at least every
8 hours.
• Any unresolved focus problems at time of discharge require patient education, ie. wound
care, use of pain meds, potential for falls, and/or need for referrals.
• The Kardex, along with the Care Plans/Focus Problem lists are part of the patient’s perma-
nent record.
ACES
Policy and Procedure Review
Spring 2010 8
Policy: Multidisciplinary Documentation of Patient Care - Focus Problem Charting
For complete policy, go to Policies and Procedures (General Nursing) on Memorial’s Intranet
Purpose: To outline the standards expected for proper patient documentation.
Key Points:
• The patient’s record is private and confidential. Only Health Care Providers directly in-
volved in care will have access. Because of this, providers must sign off computer termi-
nals anytime they leave the terminal site
• All patients must have at least one problem documented on the Focus Problem List on ad-
mission. The admitting RN/LPNII initiates the focus problem list based on the Admit As-
sessment and patient care guidelines. As subsequent assessments are done by care team
members (i.e. Nursing, CRM, PT, RT etc.) the focus problem list will be added to, updated,
reassessed and reprioritized.
• Change of shift report is given from the Focus Problem List
• All Focus Problems must be addressed each shift both on the Kardex and as a Clinical Fo-
cus Note/DAR Note (using the Data, Action, Response format for charting).
• Vital signs and pain assessments/reassessments are obtained and documented per unit
policy into the patient’s chart. I& O is entered into the computer charting at 0600, 1400,
and 2200.
• Allergies are documented on admission and updated /corrected as additional information
is obtained.
• Physician Orders should be reviewed by the Primary RN throughout the shift and evalu-
ated to ensure correct processing comparing MAK, Soarian and the Kardex.
• 24 hour Chart Checks:
- An additional chart check is performed by the night shift RN, who reviews the last 24
hours of physician orders to ensure correct processing.
- The 24 hours chart check should not be completed by the same RN who signed off the
order originally. Another RN should review.
- Following review and correction of the orders, the nurse will draw a green line across
the order sheet and sign after the last order, including date and time. Document ‘24
hour chart check’ has been completed.
Continued following page -
ACES
Policy and Procedure Review
Spring 2010 9
Late Entries:
Additional documentation may be added to Soarian for the first 24 hours post discharge.
After 24 hours post discharge, any late entry may be made on the Progress Note and given to Health
Information Management (Medical Records dept.) to be scanned into the electronic Medical Record.
Late entry note must include:
1. Documenting “Late Entry “ at the beginning of note.
2. Date and time of actual note entry.
3. Date and time of event/occurrence being charted on.
4. Patient name and encounter number (eight digit account number).
Spring 2010 10
DAR is a form of focus charting and the DAR stands for Data-Action-Response. DAR documen-
tation is based upon the nursing process. Routine nursing tasks and assessment data is docu-
mented on flow sheets and check-lists.
Your focus is a nursing diagnosis, or in place of a nursing diagnosis you can use
a problem, sign or symptom (nausea, pain, etc), behavior, special need, an
acute change in the patient's condition or a significant event. Your progress
note is written in the DAR form.
D (Data) - includes subjective and objective information that describes the fo-
cus problem or describes observations at the time of significant events.
A (Action) - includes immediate and future nursing interventions performed,
and/or protocols and procedures initiated, based on your assessment of the
patient's condition and any changes to the care plan you deem necessary based
on your evaluation.
R (Response) - describe the patient's response to nursing or medical care. The
response is a statement that the Action Plan of Care outcomes have been at-
tained or are progressing toward attainment.
Here are examples of DAR charting related to a focus problem:
Focus: Risk for infection related to surgical incision sites
D (data): Incision site in front of left ear extending down and around the ear
and into neck--approximately 6 inches in length--without dressing. Site without
redness or swelling, bluish discoloration below left ear. Jackson-Pratt drain in
left neck below ear secured in place with suture. J-P drain half full.
A (action): J-P emptied (40 ml serosanguinous fluid). Instructed patient on S&S
of infection (redness, swelling, pain, green/foul drainage).
R (response): J-P drain suction reestablished. Patient states understands signs
and sx of infection.
Focus: Delayed surgical recovery
D (data): Patient reported dizziness after trying to get OOB to use the bath-
room.
A (action): Assisted patient back in bed and placed on bedpan. Reviewed use of
call light and to call for assistance to get up. Taught patient how to dangle legs
and get OOB slowly. Also taught coughing and deep breathing exercises, turning
in bed, and use of antiembolism stockings.
R (response): Patient voided 200ml in bedpan. Coughing and deep breathing
appropriately. Lungs clear bilaterally. Antiembolism hose in place.
D. A. R.
Charting
Spring 2010 11
Focus: Acute pain related to surgical incision
D (data): Patient reports pain at surgical incision as 7/10 on 0 to 10 scale.
A (action): Incision assessed. Sutures intact, no redness swelling or drainage
noted. Morphine 2mg IV given at 2335 per post op orders.
R: (response) Patient reports pain as 3/10 at 2400. Pt. resting with eyes closed.
from page 678 of Portable RN: The All-in-One Nursing Reference, third edition, published by
Lippincott, Williams & Wilkins, 2007
Examples of DAR notes related to patient condition or significant event:
D (data): Patient reports vaginal bleeding started yesterday and passing clots. –Four maxi
pads saturated with dark red drainage and 8 quarter clots in 60 minutes. BP 102/68, P 108, R
24, T 34.1C, SpO2 98%RA
A (action): Status reported to Dr. Miller. IV started with 18g. angiocath, 1000 ml of 0.9% Nor-
mal Saline hung @ 200 ml/hr per orders. Continue to monitor bleeding and pad count and
vital signs. Dr. Miller will see the patient in one hour.
R (response): Patient understands rationale for IV fluids and continuous monitoring. BP
120/72, P 88, R. 20, T. 34, SpO2 99% RA.
D (data): Bladder distended 2 fingers above pubis. Patient has not urinated since foley cathe-
ter removed @ 1800. Patients reports abdominal discomfort above pubis 8/10 when pal-
pated.
A (action): Patient assisted to toilet but remains unable to void. Dr. Johnson notified and or-
ders received. # 14 straight catheter inserted without difficulty per orders.
R (response): Drained 700 mL of clear yellow urine per straight cath. No distention noted
above pubis. Patient reports no bladder discomfort when palpated.
D (data): Patient's temperature at 1305 was 101.5 (oral). B/P 120/80, P-88, R-20. Patient in no
acute distress.
A (action): Dr Smith contacted and orders received: blood cultures X 2, CBC and portable
chest X-ray. After blood cultures drawn, patient given Tylenol 500 mg p.o.at 1400.
R (response): 1500 patient's temperature was 99.8 (oral). Awaiting lab and X-ray results . Will
continue to monitor .
Spring 2010 12
A patient has had cholecystectomy this morning and is now admitted to your floor for pain
control:
D (data): Pt is sitting at edge of bed grimacing, c/o pain in mid-abdominal region and right up-
per quadrant. Pt is crying, describes pain as “sharp” and rates pain as 9/10 on the 0-10 pain
scale. Pt relates “I need something for pain now.” Pt denies nausea but complains of feeling
“bloated and full of gas.” Incision evaluation: wound edges red with dime sized serosangi-
nous drainage noted. Hypoactive bowel sounds all 4 quadrants. V/S: Bp-145/93, HR-102, R-
14, T-98.7
A (action): Pt given medication for pain: Demerol 75 mg IM left ventral gluteal muscle. Pt re-
positioned on right side with pillows to help splint wound. Encouraged to take slow deep
breaths to relax and move legs to help move gas.
R (response): Rechecked patient at 30 minutes. Pt states pain is “much better” and rates pain
at level 3/10 on 0-10 pain scale. Pt resting with eyes closed. Call light within reach. Pt in-
structed to call for assistance if she needs to get up to bathroom (commode). Will continue to
monitor for changes.
So:
The Data portion is what is going on...(and sometimes what is not going on, to show that you
are checking the whole patient).
Action: What you did about it.
Response: What was the response of your action?
If the situation warrants add— "will monitor or continue to monitor" to show that you intend
to stay on top of the situation.
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Spring 2010 21
Policy: Rapid Response Team (RRT) Protocol
For complete policy, go to Policies and Procedures (General Nursing) on Memorial’s Intranet
Purpose: Provide guidelines for calling RRT and the protocol to implement when an RRT is
activated.
Key Points:
The RRT is called when a patient begins to deteriorate and the nursing staff feels they need assistance by resource staff to evaluate and stabilize the patient or reverse a de-teriorating condition. It is important for nurses to recognize the s/s of a deteriorating patient which may include:
• Staff concern or worry
• HR <40 or >130
• SBP <90
• O2 sat <90%
• O2 sat declining with supplemental O2 • Increased work of breathing • Change in LOC / mental status (including agitation & restlessness) • Urine output to < 50 ml in past 4 hours • Physician request
• An RRT can be called when a patient’s primary nurse wants help in evaluating a patient by dialing 8123 and stating Rapid Response and Pt. Room #.
• Primary Nurse should stay with patient and give report to RRT team on arrival at patient bedside .Primary RN will be knowledgeable of the patient and have the chart at the bed-side including current labs, EKG, study reports, and H&P .
• Primary RN will notify the physician of the patient’s status, treatment, and response using the SBAR tool.
• The RRT is a multidisciplinary team (Critical Care Nurse, Resp.Therapy, Pharmacist, Nrsg
Supervisor, etc) that responds ASAP to assist the primary care nurse with patient evalua-
tion and treatment.
• Documentation following an RRT includes 2 forms: The Primary Nurse RRT Form, filled out by the patient’s primary nurse, and the RRT Team Form, filled out by the RRT Team members (found in Memorial Forms Catalog). Specific documentation is outlined in the policy.
ACES
Policy and Procedure Review
Spring 2010 22
Documentation:
• Primary RN will document date, location, time called, time arrived, situation, code status, current VS (including O2 sat, supplemental O2, pain level) on the Rapid Response form.
• RRT nurse will complete the rest of the Rapid Response Form every time the RRT is activated, routing the completed sheet to the RRT PI leader and physician for review and forwarded to the Performance Improvement office where data will be abstracted .
• RT will document on a respiratory DAR sticker with interventions and chart on the respiratory flow sheet if applicable.
• Primary RN - An interdepartmental transfer form will be completed by the Pri-mary RN.
• Peer Review Tool will be given to persons involved in the response by the RRT. These will be completed and sent to the Performance Improvement Depart-ment
The RRT will accompany the primary RN to assess the patient. and:
A. Stabilize the patient’s airway and administer oxygen.
B. Place patient on heart monitor if not already in place.
C. Begin ACLS protocol if a symptomatic arrhythmia detected.
D. Establish IV access if one not in place. Consider placing second line and drawing blood for lab if possible
E. Follow RRT protocol regarding basic interventions (see below)
F. Transfer patient to ACU or CCU as indicated by patient’s condition.
RRT PROTOCOLS:
1. Arrhythmia
• Ensure IV access EKG
• Supplemental oxygen Treat according to ACLS guidelines
• Initiate Code Blue if appropriate
2. Hemodynamic Consider if post-op or potential for bleeding • Trendelenburg position (if no head injury) CBG CBC • Ensure IV access & Consider 2nd IV line EKG INR • Supplemental oxygen Aptt • Consider fluid bolus according to medical hx: 250ml-1000ml
3. Respiratory • RT to assess & treat per RT protocol CBG • Ensure IV access Consider ABG and/or PCXR • Supplemental oxygen Consider bipap • If on opiate analgesia: Stop continuous PCA & administer Narcan 0.4mg IVP x1
4. Neurological • Glasgow Coma Scale CBG • Ensure IV access Consider ABG • Supplemental oxygen
5. Urinary Output • Bladder scan • Foley catheter and/or Irrigate pre-existing Foley
Spring 2010 23
6. Febrile • Tylenol 650mg PO or PR PRN fever >101F (38.3C)
7. Acute Seizures • CBG • Maintain airway • For adults only: Lorazepam (Ativan) 1mg IV x1 for clonic-tonic seizure activity
lasting longer than 2 minutes (if not allergic) ** Call Code Blue if seizure activity continues longer than 2 minutes after giving
Lorazepam **
8. Chest Pain
• Ensure IV access & Consider 2nd IV line
• Supplemental oxygen
• EKG
• Aspirin 325mg PO/PR x1 (if not contraindicated: allergy, surgery this admission, warfarin
• or aspirin ordered, or active bleeding)
• Nitroglycerin 1 spray or 0.4mg tablet SL PRN chest pain – may repeat every 5 mins x 2
• Consider Troponin and/or CPK
9. Anaphylaxis: - Ask physician about: • Diphenhydramine (Benadryl) 50mg IV x1 Epinephrine 0.3mg SQ x1 • Cimetidine (Tagamet) 300mg IV over 20mins x1 • Methylprednisolone (Solumedrol) 125mg IV x1
10. Hypoglycemia • If CBG less than 60 or symptomatic of hypoglycemia: • Able to take PO: 1. Give 1 tube of Instaglucose, ½ cup juice or regular pop 2. Re-
check CBG in 15 mins. • NPO w/ IV access: 1. Give ½ amp D50W IV & recheck CBG in 15 mins. • NPO w/o IV access: 1. Give Glucagon 1 mg IM & recheck CBG in 15 mins.
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Policy: Initiating a Code Blue
For complete policy, go to Policies and Procedures (General Nursing) on Memorial’s Intranet
Purpose: Provide guidelines to be followed for a Code Blue event
Key Points:
• The Code Blue is initiated when staff assesses the need for emergency interventions
(Airway, Breathing, Circulation) to save the life of a patient. There are 4 phases to a Code
Blue with each phase and team duties carefully outlined in the policy.
• 1- Initial Response: To call a Code Blue dial: 8123 (the priority emergency line in the hos-
pital) and tell the Operator “Code Blue, Room #____, or location.” Basic Life Support
(CPR) is begun by staff and continues until directed by the Code Team.
• 2- Unit Response: The first person available brings the Crash Cart and the patient records
to the room. Primary RN remains with pt. providing care (CPR), and history/report until
excused by Code Team. Other duties of Primary Nurse include: clears room of second pa-
tient as needed, checks O2/suction, notifies physician/family/clergy when released by
Code Team—Shift Coordinator/Nurse Supervisor can assist as needed.
• 3- Code Team Response: The Code Team consists of: a Team Leader (Critical Care Shift
Coordinator/or Physician Responder)- Nursing Supervisor/Chaplain (provide emotional
support and communication), Emergency Department RN (defibrillation/meds), Critical
Care Shift Coordinator (may be team leader/assigns scribe), IV Therapy nurse (IV insertion/
assist with medication administration), Medical Technician (lab draws/ISTAT) Respiratory
Therapist (airway/O2), Pharmacist (assist/or administer meds), Primary nurse (see above),
Security Guard (as directed by Team Leader), and Transport Tech (duties as directed by
Team Leader).
• 4- Post Code Activities: Code Blue Record (on top of code cart) is completed by the Criti-
cal Care Coordinator or assigned staff. Respiratory Care are notified to replace resuscitator
mask in patient room. Crash Cart is taken to the pharmacy for replacement by the Trans-
port Tech.
ACES
Policy and Procedure Review
Spring 2010 27
ACTIVATION OF CODE BLUE AND RAPID RESPONSE DURING
SYSTEM FAILURE
EMERGENCY CELL PHONES AVAILABLE IN UNIT LOCK BOXES
Person identifying Code Blue or RRT identifies a person
to activate emergency cell phone tree, in the following order:
ED 952-68892-
Respiratory 952-08333-
Nursing supervisor 961-18864-
Coordinator ICU 969- 00535-
Pharmacy 952-9195
Lab 952-31117-
Security (If needed send runner to
operator to page them via 2 way radio)
Give the location of the event
Personal identifying
Code Blue or RRT
yell5”Code Blue, I
need help.” NAC or
Unit Secretary is
designated to be:
Runner #1
Runner #1...goes to
the ED to report the
location of the event.
EMERGENCY CELL PHONES NOT AVAILABLE
Runner #1...goes
to ICU to notify
coordinator of
event location.
Runner # 1..locates
the nursing
supervisor and they
both report to the
event.
ED shift coordinator designates
Runner #2 to notify the following
Staff in the order listed.
1. Pharmacy
2. Laboratory
Runner #2... returns to ED
The coordinator designates
Runner #3 then reports to the
event.
Runner #3...goes to the
operator to have them page
security via 2-way radio.
ALL TEAM MEMBERS PRESENT
The Nursing Supervisor makes the decision when runners # 1 and # 3 and Security are no longer
needed.
The RN calls the family and physician as soon as phone available.
Note: A copy of this policy is kept on all Code Blue carts and in the Disaster Manual.
Spring 2010 28
What’s Inside the Crash Cart?
DRAWER CONTENTS
1
Pharmacy
Medications
Adenosine, Epinephrine
Amiodarone, Glucagon
Atropine Midazolam
Calcium Chloride Magnesium Sulfate
Dextrose Naloxone
Sodium Bicarbonate
Diphenahydramine Vasopressin
2
IV Equipment
500ml bag of NS, 5 saline flushes, 10ml &12ml syringes, IV
pump tubing, sterile towel & sterile gloves, assorted IV
catheters, tourniquet, blood tubes for lab draw, tegaderm
dressing, 2x2 gauze, povidone-iodine & chlorseptic swab-
sticks.
3
Nursing
Equipment
Yankhauer suction, Salem Sump NG tubes, tubing, NG con-
nector & strips, Suction catheter kits, Yellow face masks,
Yellow isolation gown, ECG pads, Defibrillation pads, Blood
pressure cuff, Stethoscope, water soluable lube, 60ml cathe-
ter-tip syringe (cone tip)
4
Respiratory
Infant, Pediatric & Adult Ambu bags, Towel roll, Adult non-
rebreather mask, Infant & Pediatric O2 masks, Oxygen tub-
ing/connectors, Oral airways in assorted sizes, Wrapped intu-
bation tray & blades for intubation
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Policy: AMBER ALERT: For Missing Infant or Child
For complete policy, go to Policies and Procedures (Administrative) on Memorial’s Intranet
Purpose: To outline YVMH staff protocol in the event an infant or child is ab-
ducted from the hospital
Key Points:
• Amber Alert is announced to alert all hospital personnel that an infant/child is discovered
to be missing—this also requires an immediate coordinated hospital response with Yakima
Police Dept.
• Dial 8123– state “AMBER ALERT”, (Location/Room Number) and age of child if over one
year of age/ Operator notifies Nursing Supervisor and calls 911
• Each staff member and the Yakima Police Department response is outlined in the policy
• When a “AMBER ALERT” is called, it is the responsibility of all employees to stop and de-
tain, if possible, any individual with an infant/child, large bag, box / backpack or other large
object within the hospital, or attempting to leave the hospital.
• When detained, escort to Admitting Main Lobby to meet with Security.
• If unable to detain, then obtain and document a description of the individual(s) and vehi-
cle—and direction heading and notify Security, person in charge and /or YPD—911.
ACES
Policy and Procedure Review
Spring 2010 34
Policy: Fire Policy
For complete policy, go to the Red Emergency/Disaster Binder in your Department
Purpose: To provide the safest care to both patients, visitors and staff in the
event of a fire within the hospital setting
Key Points:
• If you see smoke, smell something burning, or suspect there is a fire, follow the
R.A.C.E. plan: R- Remove, A - Alarm, C - Contain, E - Extinguish/Evacuate
• Call the hospital switchboard to report fire – Dial 8123
• Remain calm – Do not yell “Fire.” Alarms frighten patients, be sure to reassure patients/
persons in the immediate area and explain procedure for evacuation (or drill).
• In the event of a fire, there are two points of evacuations:
1) Point of Origin (those in the immediate vicinity of fire) -see algorithim
2) Away from the Point of Origin (those away from the vicinity of fire)-see algorithim
• In the event of an evacuation, complete a Transfer form for each patient and attach it to
the patient’s gown.
• Once room evacuated, close door and place pillow, upside down garbage can, or mark X on
door to indicate evacuation.
• Remember to account for patients/visitors and staff once evacuation of department com-
plete. Check in with Incident Command upon evacuation to report patient/visitor status.
• There are 3 types of extinguishers. Each extinguisher is labeled—use the appropriate ex-
tinguisher for the type of fire.
• If the fire can be extinguished, use the P.A.S.S. acronym:
P—Pull, A—Aim, S—Squeeze, S— Sweep
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Policy: CODE GRAY: Physical Assistance Needed
For complete policy, go to Policies and Procedures (General Nursing) on Memorial’s Intranet
Purpose: To maintain control of a patient or visitor who becomes threatening to
others or themselves
Key Points: 4 phases to the policy
• 1- Initial Response: The calling of the “Code Gray”: Dial 8123 ( the priority emergency line
in the hospital) and telling the Operator “Code Gray, Room #___, or location.”
• All trained personnel shall respond immediately
• 2- Planning: Forming of strategy while other staff members arrive. Identify a “Person in
Charge”(primary communicator) and a “Traffic Control Person”(directs those arriving)
• 3- Crisis Management: Only one person actually talks to the individual. Statements are
direct, to the point, but not rude. Expectations and consequences are made clear. Physi-
cal interventions are executed quickly and without excess force.
• 4- Debrief: Immediately after event a concise ‘debrief’ should take place to see what was
effective or not and check –in with staff involved to be sure they are able to return to
work.
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Policy: Post-Mortem Care (DRAFT ) Page 1 of 2
For complete policy, go to Policies and Procedures (General Nursing) and (Emergency) on Memorial’s
Intranet
Purpose: Guidelines for notification of family/healthcare professionals after
death of a patient with steps for preparation and transport of a body.
Key Points:
Notify Nursing Supervisor (Vocera: state, “Nursing Supervisor”) who will notify or ask the
nurse to notify the following individuals:
• Call the attending physician (inquire if there is to be an Autopsy).
• Notify significant family member as designated in the patient record.
• Call the funeral home (family choice or funeral home on-call).
• Notifies the organ procurement agency of all deaths within one hour.
• Will notify Coroner when appropriate (see policy on Coroner cases).
• Information desk (during business hours) so they are removed from the inpatient list.
• Radiation oncologist if patient has radio active implant.
• All consulting physicians on the case at the earliest appropriate time.
The Nurse should provide the Nursing Supervisor with:
- Patient’s weight (Funeral Home needs this for transport of body).
- Whether patient was in a RESTRAINT anytime during the 24-hours preceding
death. This must be reported to the Department of Health.
If possible, determine if an autopsy is planned, prior to patient’s death. (Complete Form
#0264: Authorization for Autopsy) Original goes into chart, copy to Mortician or morgue and
copy to Pathologist. Notify Nursing Supervisor for assistance to transfer the body, unobtru-
sively to the hospital morgue if an autopsy is to be performed.
Note: It is preferable for the physician to discuss an autopsy with family and to secure the au-
thorization signatures. If the physician is not available, a registered nurse may witness the au-
thorization. The Nursing Supervisor will notify the Pathologist on weekends and holidays of a
pending autopsy.
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Policy: Post-Mortem Care (DRAFT) Page 2 of 2
Key Points (continued):
• Determine if the necessary legal paperwork is complete for tissue or organ donation.
(Form #0273: Consent for Organ and Tissue Donation and Form #0105: Organ Tissue
Donor Information to Funeral Home/Donor Inquiry).
• Determine if there are any cultural, religious, or ethnic beliefs that will influence the
postmortem care of the body
• Gently close the eye lids. Wash body parts soiled by blood, urine, feces, or other drain-
age. The mortician will provide a complete bath. Place an absorbent pad under the pa-
tient’s buttocks, clean gown on the patient, and brush or comb the patient’s hair. Place a
clean sheet over the body leaving the arms exposed at the side for family to touch if they
would like. Keep the patient's head elevated at all times with the hands placed naturally
at the sides or resting on the abdomen. Patient's dentures: should be placed in patient’s
mouth if preparing the body for the family—otherwise not required.
• Remove unneeded equipment from the room—exception = following Code/Trauma may
leave equipment for family to see that everything possible was done for patient.
• Offer to call hospital or other chaplain for family members.
• Do not remove indwelling catheters, IVs—may tie off, mortician /coroner will remove
• Keep patient identification band in place.
• Do not delay providing postmortem care and notifying the family so they may begin
funeral arrangements.
• A focus note is required to record event and specific observations (quality of pulse, respi-
ration, etc.) prior to patient’s death. Nursing documentation after death should include:
• Name of Physician notified
• Funeral home called and WHO requested it
• Detailed accounting of disposition of personal effects
• Record of support offered to family
• Enter Discharge by Death into the Soarian system.
• The Nursing Supervisor will notify the County Coroner of any death that meets criteria as
a Coroner’s Case.
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General Nursing Policy and Procedure Manual
Admission & Discharge
Organ and Tissue Procurement
PURPOSE:To identify individuals for organ and tissue donation.
POLICY:
1. In compliance with Washington State and Federal Laws, it is the policy of Yakima Valley
Memorial Hospital to honor voluntary consent for organs and tissues for transplantation
and to secure appropriate informed consent.
2. The Hospital recognizes the importance of allowing those who wish to have the maximum
opportunity to give, providing solace to the grieving family by giving life and happiness to
others at the time of tragedy. The principles of voluntary giving are upheld while allowing
autonomy to families of potential donors.
3. Yakima Valley Memorial Hospital recognizes LifeCenter Northwest, Northwest Tissue Cen-
ter, and Sight Life as the designated regional organ and tissue procurement agencies.
PROCEDURE:
1. The Nursing Supervisor will notify the procurement agency on all deaths or imminent
deaths to determine donor suitability.
• Non-ventilated patients: 1-888-266-4466
• Ventilated patients: 1-888-543-3287
• On all coroner cases, release for donation must be pursued prior to fam
ily approach. The donation agency will contact the coroner regarding
release for donation. The legal next-of-kin should then be provided with
the appropriate donation options. Individuals who may approach the
donor family must be trained by the Donation Agency. The staff will ex
ercise discretion and sensitivity of the circumstances, beliefs, and de
sires of the families of potential donors.
2. A determination is to be made regarding necessity of notifying the coroner if the cause
of death could result in a criminal action per hospital policy (if injury occurred outside of
Yakima County, coroner of county in which injury occurred must be notified as well as
Yakima County Coroner):
•Homicide l Unknown or doubtful causes
•Suicide l Drug related incident
•Trauma l Death within 24 hours of admission
•Accident (unless seen by MD within last 36 hours)
3. It is solely the responsibility of the donation agency to obtain release from the coroner
for donation. Hospital staff should contact the coroner per hospital policy in reference to
all cases that fall under that jurisdiction. However, all discussions with the coroner regard-
ing donation will be pursued by the donation agency.
Spring 2010 43
4. These requests shall be documented on the Organ/Tissue Donor Information to the Fu-
neral Home/Donor Inquire Form. If a patient is not a designated donor, a consent form for
organ and tissue donation shall be signed by the legal next-of-kin. In the case of solid organ
donation, LifeCenter will be responsible for completing either a witnessed telephone con-
sent or a written consent with the family. This disclosure form along with a copy of the le-
gal document attached to it will be placed in the patient's chart. A signed donor card,
driver's license legal document or donor registry entry is a legal document of documenta-
tion of donation wishes may also be used as a legal document
1. LifeCenter Northwest Organ Procurement Agency; Ventilated patients; meeting imminent
death criteria.
2. A LifeCenter Northwest coordinator will facilitate the organ donation process in all phases.
The coordinator will travel to Yakima Valley Memorial Hospital to evaluate patient suitabil-
ity for donation.
3. Organ donation will be limited to all medically suitable patients (as determined by LifeCen-
ter) who have been declared brain dead in accordance with the "Declaration of Brain
Death Policy" approved by the Medical Staff, or who will probably suffer cardiac arrest
within 60 minutes after withdrawal of life support.
4. In the case of a brain dead donor, the time brain death is declared is the official time of
death.
5. In the case of tissue or cornea donation, all tissues to be donated are to be specified on
the consent form. The original signed consent is to be kept with the chart. In the case of
solid organ donation, LifeCenter Northwest will be responsible for completing either writ-
ten consent or a witnessed telephone consent with the family.
6. Washington State Law identifies the following persons (in descending order of priority) as
legal next-of-kin:
• Legal Guardian
• Durable power of attorney of health care
• Spouse
• Adult son or daughter 18 years or older
• Parent
• Adult brother or sister 18 years or older
• Any other person authorized to do so
7. The Nursing Supervisor and Spiritual Care is to be notified that donation is being consid-
ered so that emotional and spiritual support may be given.
ORGAN DONORS:
Spring 2010 44
5. In the case of donation after cardiac death (DCD), the time of cardiac death will be the offi-
cial time of death. For withdrawal of life support in a DCD case, the hospital staff should
follow Yakima Valley Memorial's policy for "Withholding and Withdrawing Treatment."
LifeCenter staff members will not participate in the process of withdrawal of life support.
Determination of the location of withdrawal of life support is the responsibility of the hos-
pital and/or the donor family members. For pronouncement of death in a DCD case, it is
important to keep the warm ischemic time of the organs to a minimum. Therefore, a phy-
sician must be available at the bedside at the time of withdrawal of life support, in order to
pronounce the cardiac death as soon as cardiac death is evident.
6. Notify admitting department of time of brain death (all charges from that point on go to
the procurement agency). Notify admitting department to make a new face sheet, chip,
and ID bracelet, with new admission number.
7. The LifeCenter Northwest coordinator will remain on site to assist with the donor manage-
ment and the recovery of the organs for transplant.
8. For brain death donors, the hospital will provide (at minimum) the following staff to assist
with the donor case:
ICU
a.Bedside Nurse
b.Physicians
OR
a.Anesthesiologist (Anesthesia will not be needed in DCD cases)
Northwest Tissue Services & Sightlife Eye Bank - All deaths
Families that are unable to make a decision about cornea or tissue donation while on site
are encouraged to go home and discuss donation with additional family members, etc. Ex-
plain to them that a Donor Coordinator will contact them by phone later to further discuss
their options. If the family wished to donate, a witnessed telephone consent will be ob-
tained by the recovery agency. Get a phone number from the family where they can be
reached.
Organ and Tissues Procurement Agencies Phone Numbers:
LifeCenter Northwest Organ Procurement - (ventilated) 1-888-543-3287Northwest Tissue
Services and Sihtlife Eye Bank - (non-ventilated) 1-888-266-4466
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Effective Date: 08/31/1982
Prepared by:
Approved by: Nursing Policy and Procedure Committee Date: 08/01/1982, 09/23/2008
Reviewd by: Nursing Policy and Procedure Committee Date: 09/19/2003, 08/22/2006, 09/23/2008
Revised by: Nursing Policy and Procedure Committee Date: 05/05/1988, 08/02/1993, 12/02/1994, 12/05/1997, 01/05/1998, 02/05/1999, 08/01/2000, 06/01/2005, 10/19/2007, 09/23/2008
Approved by: Nursing Policy & Procedure Committee Date: 06/01/2005, 10/19/2007, 09/23/2008
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Emergency Department
Emergency
Coroner Cases
PURPOSE:
To notify the Yakima County Coroner of all suspected coroner cases.
POINTS OF EMPHASIS
All suspected coroner cases (see attached sheet) shall be reported to the Yakima County
Coroner at the time of death in the Emergency Department (ED). This can be done by the
Nursing Supervisor, ED Physician, or the Shift Coordinator in the ED.
1. Contact Coroner at his office, 575-4369, or call Sheriff's Department at 575-4080 and ask
that he be paged.
2. Coroner will decide if autopsy is needed and at what facility it will be done, at YVMH or
one of the funeral homes. Body will be transported to appropriate facility.
3. Contact the House Supervisor regarding organ donation. Nurse Supervisor or Chaplain
requests permission from the family.
4. If an organ donation is to be made, House Supervisor/Chaplain will contact Northwest
Organ Procurement Agency (N.O.P.A.) for further arrangement and patient management
requirements
Under existing State Law, the County Coroner has jurisdiction of bodies of all deceased
persons, as follows:
1. Who come to their death SUDDENLY WHEN IN APPARENT GOOD HEALTH WITHOUT
MEDICAL ATTENDANCE WITHIN THE THIRTY SIX HOURS PRECEDING DEATH.
2. Where the circumstances of death indicate death was caused by UNNATURAL OR UNLAW-
FUL MEANS.
3. Where death occurs under SUSPICIOUS CIRCUMSTANCES.
4. Where a Medical Examiner's (Coroner's) autopsy or post mortem or inquest is to be held.
5. Where death results from UNKNOWN OR OBSCURE CAUSES.
6. Where death occurs WITHIN ONE YEAR FOLLOWING AN ACCIDENT.
7. Where death results from a KNOWN OR SUSPECTED ABORTION, whether self-induced or
otherwise.
Where a death is caused by ANY VIOLENCE WHATSOEVER.
CORONER CASES (REPORTABLE DEATHS):
Spring 2010 48
9. Where death apparently results from:
A.DROWNING
B.LIGHTENING
C.HANGING
D.STARVATION
E.TETANUS
F.BURNS
G.RADIATION
H.STRANGULATION
I.ELECTROCUTION
J.EXPOSURE
K.SUFFOCATION
L.GUNSHOT WOUNDS
M.ALCOHOLISM
N.SMOTHERING
O.STABS
P.CUTS
Q.NARCOTICS
R.OTHER ACCIDENTS
10. Where death is due to PREMATURE OR STILL BIRTH.
11. Where death is due to a violent CONTAGIOUS DISEASE OR SUSPECTED CONTAGIOUS DIS-
EASE WHICH MAY BE A PUBLIC HEALTH HAZARD.
12. Where death results from:
A.ALLEGED RAPE
B.CARNAL KNOWLEDGE SODOMY
13. Where death occurs in a jail or prison.
14. When a body is FOUND DEAD, OR IS NOT CLAIMED BY RELATIVES OR FRIENDS.
Effective Date: 09/30/1991
Prepared by: Julia Patten
Approved by: Date: 09/01/1991
Reviewd by: Alan Collinsworth/Interim ED Director/Memorial Date: 09/09/1996, 01/10/2002, 05/10/2003, 12/15/2003, 11/27/2006
Revised by: Betty Baird/ED RN/Memorial Date: 11/27/2006
Approved by: ED Policy & Procedure Committee Date: 11/27/2006
Spring 2010 49
