annual provider education 2019 - caromont health · 2019. 4. 15. · when a fire is detected, all...

Annual Provider

Education 2019

Please review these educational topics that are important for patient and physician safety and may also be

requirements to maintain accreditation.

Emergency Management

Emergency Response

Physicians perform a vital role during an emergency response event (mass casualty event, hazardous

material incident, infrastructure failure, etc.). Whenever advised of an emergency response situation, all

available medical staff report to CaroMont Regional Medical Center or other designated site.

Four keys for Medical Staff emergency management response:

● Understand the overall Incident Command structure (see diagram 1).

● Know and follow the Medical Staff Branch of Incident Command structure.

● Receive assignment from Medical Staff Branch Director or one of the Medical Staff unit leaders.

● Perform duties based upon greatest need for medical staff response.

Incident Command structure facilitates the optimal response. The Chief of Staff is notified when Incident

Command is activated. The Chief of Staff will receive a situation briefing from Incident Command, then

communicate with Medical Staff and co-direct medical staff response with the Medical Staff Branch Director.

The Medical Staff Branch Director coordinates medical staff response and reports to the Operations Section

Chief in the Incident Command Structure (see diagram 2).

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Education 2019

Emergency Response (continued)

Four Roles in Medical Staff Branch (see diagram 3):

● Medical Staff Branch Director: coordinates medical staff response and assignments.

● Inpatient Medical Unit Leader: coordinates inpatient processing.

● Medical Support Services Unit Leader: prioritizes and expedites testing/treatment procedures

and coordinates support functions (Laboratory, Radiology, Respiratory, Infection Prevention, etc.).

● Mass Casualty Medical Care Unit Leader: works directly with Casualty Care Unit Leader in

Operations Section to coordinate the triage, treatment and management of casualties, including

on-the-scene physician communication, surgical case coordination physician, immediate care area

physician, alternate care area physician and other medical staff resources deployed to respond to

mass casualty incident.

The room assigned for the Medical Staff Branch is the Physician’s Conference Room.

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Education 2019

Emergency Response (continued)

Environment of Care

Environment of Care Basics

How should you handle safety risks in your work area?

● Remove/confine the safety hazard and call Housekeeping to assist in the cleanup.

● Work orders can be entered from the CHIP page under the Service Request link. If there is an

immediate need, Facility Services can be called to assist.

● For medical equipment that is broken or damaged, you can complete a CRT tag request on CHIP

under the Service Requests tab on the left side of the page.

● For acutely hazardous spills:

○ Isolate the area to prevent tracking and disturbing the spill.

○ Ensure affected persons are evacuated and receive medical treatment. Use personal

protective equipment.

○ Evaluate the need to evacuate or restrict access to the area. Notify your supervisor.

○ Contact the Nursing Shift Manager (ext. 2131)

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Environment of Care Basics (continued)

What should you do if you are injured at work?

● Report the injury to your supervisor, seek medical attention (if needed) through Employee Health

and complete a Quantros report after you are evaluated and treated by the Employee Health

Practitioner.

How should you report an incident involving a patient or visitor?

● Notify the Nursing Shift Manager (ext. 2131) and complete a Quantros Report as soon as feasible,

or within 24 hours of the incident.

What do you do if a visitor is involved in an accident?

● Notify Security immediately of all visitor incidents involving theft.

● If the staff member discovering the incident believes the visitor should go to the Emergency

Department, this information and reason must be noted on the Quantros Report.

Where can you smoke at CaroMont Health?

● Smoking is not permitted inside or on the campus of any CaroMont Health building, and there are

no exceptions.

Code RED

Code Red is the emergency page used to notify everyone of a fire related emergency.

Our building is constructed to withstand the spread of smoke and fire by using specific compartments that

can be sealed off. Fire and smoke doors are a major component of the compartmentalization concept. They

cannot be blocked or impaired from closing.

In areas where the fire is not located, all providers shall be able to:

1. Follow the directions of the Charge Nurse/Department Incident Commander.

2. Maintain oversight and direct measures for patients on life support.

3. Be ready to assist in the evacuation of patients, if required.

4. Stay alert for further information and direction on the emergency.

When a fire is detected, all staff and providers in the immediate area shall be able to carry out the following

steps at the point of the fire:

1. Remove everyone from immediate danger.

2. Pull handle of the nearest fire alarm station.

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Education 2019

Code RED (continued)

3. Dial “911.” The switchboard operator will answer “Emergency Line.” Provide the following

information:

a. Your name.

b. Say “Code Red.”

c. Give location of fire (department/unit and location). (Example: 4 South, Nursing Station)

d. The switchboard operator will sound the tones and page “Code Red” and the location of the

fire three times over the public address system.

4. Close all doors and windows in the area; this will contain the fire and smoke.

5. If appropriate, locate the nearest fire extinguisher and fight the fire.

a. To use a fire extinguisher, implement PASS:

Pull pin.

Aim nozzle at base of the fire.

Squeeze handles together.

Sweep from side to side.

6. If instructed to do so by the Charge Nurse, turn off medical gases and electrical equipment in the

fire area.

7. Providers will also be ready to maintain oversight and direct measures for any patients on life

support.

Patient Care

Rapid Response

There are three types of Rapid Response Teams (RRTs) at CaroMont Regional:

● Adult Rapid Response Team (Hospitalist, Critical Care RN, Respiratory Therapist)

● Pediatric Rapid Response Team (ED Physician, ED RN and Respiratory Therapist)

● Obstetrical Rapid Response team (Birthplace Team Leader and other Birthplace staff as needed)

The Rapid Response policy identifies criteria for activating Rapid Response, but a patient does not have to

meet one of those specific criteria in order for the RRT to be called. Healthcare staff may summon the RRT

any time a patient’s condition suddenly changes and/or deterioration in status is noted.

Rapid Response Team

● Families may also activate RRT if they have a concern about the patient they feel is not being

addressed.

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Rapid Response Team (continued)

● RRTs are activated by dialing “0” (Switchboard) and requesting RRT assistance at stated location

and extension. RRTs are notified via the SpectraLink paging system.

● Upon arrival, the RRT will assess the situation and utilize approved protocols as necessary.

● The RRT physician will hand off information to the Hospitalist, the Attending Physician or

responsible consultant. Interventions are documented on the RRT Flowsheet in the EMR.

● For the triggers of deterioration in condition, refer to Policy #10312, Rapid Response Team Patient

Care Protocol. There is an “Adult Rapid Response Team Protocol” located as an order set in Epic

that can be utilized by the RRT members who arrive prior to the physician.

Assessing and Managing Pain

CMS and The Joint Commission dictate that all patients have a right to pain management.

At CaroMont Health:

● All admitted patients receive an initial screening regarding pain.

● Patients having invasive procedures in the outpatient setting will have their pain status addressed.

● Patients and/or families will be included in pain management.

● Pain is assessed with each nursing assessment and when reported by the patient.

● We use non-pharmacological and/or pharmacological interventions to address pain when

appropriate.

● The goal is for the patient’s pain level to be improving.

● There are multiple pain scales. The scale is selected based on the patient’s condition and/or

understanding. All scales are then converted to a 0-10 number, with 0-3 being mild pain,

4-6 being moderate pain and 7-10 being severe pain.

Restraint Management

● Restraints are used only to reduce risk of self-injury to others and only after non-physical, less

restrictive interventions have been considered and/or attempted and found to be ineffective.

● Restraints include the emergency or planned use of seclusion, physical or chemical restraint and

any combination of interventions.

● (Violent) Behavioral - Violent, aggressive or destructive behavior posing a danger to self or

others.

● (Non-Violent) Medical/Surgical - Protects from unintentional self harm/injury.

● Chemical - Drug or medication used as a restriction to manage the patient’s behavior or restrict

the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s

condition.

● Note: The type of restraint is NEVER determined by the equipment/medication being used. It is

ALWAYS determined by the reason the restraint is being used.

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Education 2019

(Violent) Behavioral Restraint

Patient must be seen within 1 hour after initiation of restraint.

Orders: Need to be renewed according to age- 18 and older: every 4 hours 9 to 17: every 2 hours 8 and younger: every 1 hour Patient 18 and older must be seen every 8 hours after initiation of restraint. Patient 17 and younger must be seen every 4 hours after initiation of restraint.

MD must document reason for restraint in progress notes every time you see patient in restraint. Restraint Progress Note can be utilized, if completed note meets all regulatory requirements.

If Restraint Progress Note is not used, documentation must include the reason for restraint, patient condition (both physical and psychological), patient response to restraint and justification to continue use of restraint.

(Non-Violent) Medical/Surgical Restraint

Patient must be seen within 24 hours after initiation of restraint.

Orders: Need to be renewed every 24 hours

MD must document reason for restraint in progress notes every time you see patient in restraint. It is highly

recommended that you use the Restraint Progress Template because the template meets all regulatory requirements.

If the Restraint Progress Template is not used, documentation must include the reason for restraint, patient condition

(both physical and psychological), patient response to restraint and justification to continue use of restraint.

Chemical Restraint

Example of a medication used inappropriately as a restraint:

A patient has Sundowner’s Syndrome. She gets out of bed in the evening and walks around the unit. The unit staff

find the patient’s behavior bothersome and ask the physician to order sedating medication to ‘knock out’ the patient

and keep her in bed. The patient has no medical or psychiatric symptoms or conditions that indicate that she needs

a sedative.

Example of a medication used that is not used as a restraint:

A patient is anxious, aggressive and becoming more agitated. The patient is given a PRN medication to address his

specific symptoms. It is best practice to utilize medication to manage an agitated condition to prevent further

escalation and possible restraints. The medication used for this patient is not considered a drug used as a restraint.

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Documentation Requirements for Restraints

● Classification of Restraint

○ (Non-Violent) Medical/Surgical

○ (Violent) Behavioral

○ Chemical

○ Seclusion

● Reason/Justification for Restraint

○ (Non-Violent) Medical/Surgical

■ Threatens placement and/or patency of necessary lines/tubes

■ Is unable to follow directions to prevent self injury or support medical surgical healing

■ Other (describe)

○ (Violent) Behavioral/Seclusion

■ Is harmful to self as evidenced by hitting, pulling hair, self mutilating

■ Is harmful to others as evidenced by combativeness, hitting, pulling hair, striking at or

biting others

■ Has caused serious destruction to unit property

■ Other (describe)

● Type(s) of Restraint(s)

○ Mechanical

■ Freedom Splints

■ Closed Mitts

■ Soft Wrist

■ Twice as Tough (TAT)

○ Physical-Temporary Restraint (Hold) for Medication Administration

○ Chemical (medication orders on Physician Order Sheet)

○ Seclusion

● Appropriateness of Restraint

○ The above noted restraint is the least restrictive method and is appropriate to prevent harm,

intentional or unintentional to the patient or others

● Patient’s Behavior During Evaluation

● Patient’s Mental Status

● Patient’s Physical Condition

● Vital Signs

○ Temperature

○ Pulse

○ Respirations

○ Blood pressure

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Documentation Requirements for Restraints (continued)

● Other

○ Any other pertinent details

● Physician/Designee Signature, Date, Time

● If Designee: Physician Notified, Date, Time

Suicide Precautions

Suicide is the 10th leading cause of death in the United States. Although the vast majority of suicides occur

outside of the health care facility, many suicides do occur within health care facilities. The Joint Commission

(TJC) and the Centers for Medicare and Medicaid (CMS) have taken a no tolerance stance to self-harm

risks within a suicidal patient’s room.

As of July 1, 2019, TJC is requiring that all patients who are being evaluated or treated primarily for a

behavioral health condition be screened for suicidal ideation, and their overall level of risk, along with plans

to mitigate that risk, be documented. CRMC is working to mitigate the risk to suicidal patients who are not

placed in a designated psychiatric area by utilizing sitters to monitor the patients. We also utilize the room

safety checklist that guides the clinical team to remove anything from the room that the patient could

potentially use to cause harm to himself/herself or a staff member.

Anticoagulation Therapy

Anticoagulation therapy can be used as therapeutic treatment for a number of conditions, the most common

of which are atrial fibrillation, deep vein thrombosis, pulmonary embolism, and mechanical heart valve

implant. Anticoagulation medications are more likely than other medications to cause harm due to complex

dosing, insufficient monitoring, and inconsistent patient compliance.

To achieve better patient outcomes, patient education is a vital component of an anticoagulation therapy

program. Effective anticoagulation patient education includes face-to-face interaction to be sure that

patients understand the risks involved in anticoagulation therapy, the precautions they need to take, and the

need for regular monitoring. At CRMC, pharmacists perform patient education on initiation of anticoagulant

therapy and for patients that have experienced a complication. All other patients on anticoagulation therapy

are educated by nursing.

The following topics should be included when educating the patient/family on anticoagulation therapy:

● Adherence to medication dose and schedule

● Importance of follow-up appointments and laboratory testing (if applicable)

● Potential drug-drug and drug-food interactions

● The potential for adverse drug reactions

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Education 2019

Clinical Alarms

Clinical alarms are intended to alert caregivers of potential patient problems, but if they are not properly

managed, they can compromise patient safety. CaroMont policy states that all members of the care team

are responsible for management of, and response to, clinical alarms.

Biomedical Engineering is responsible for performing regular preventative maintenance and testing.

Appropriate staff members must ensure that the clinical alarms are set appropriately and audible with

respect to distance and competing noise. Monitor alarms should not be turned off or have the alarm

functions bypassed by patient care staff.

Use of Interpreters and American Sign Language

CaroMont Health provides language interpreting and translation services through LanguageLine Telephone

Services, interpreting iPad, CaroMont Spanish Interpreters, and LanguageLine Contracted Interpreters (live

person). American Sign Language is available through the interpreting iPad and LanguageLine Contracted

Interpreters.

Consider using the available resources on admission, at time of informed consent, at discharge, and with

any change in the plan of care. Document the use of these services in the patient’s medical record

each time.

We must always honor the patient’s preference for interpreting services. If the patient refuses to use the

interpreter services provided by CaroMont Health, the Informed Waiver of Medical Interpreter

Services must be printed from FormFast and signed by the patient.

Infection Prevention

Hand Hygiene

Healthcare-associated infections (HAIs) continue to be a serious problem for health care organizations, and

hand hygiene is the single most important action in helping to prevent HAIs.

Please remember these facts about Hand Hygiene:

● Hand Hygiene includes the use of alcohol based hand rubs (ABHR) or washing with soap and

water:

○ Before and after each patient contact.

○ After contact with blood, body fluids, secretions, excretions or non-intact skin.

○ After contact with equipment, environmental surfaces, devices or removing gloves.

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Hand Hygiene (continued)

● Hand hygiene should be performed between tasks and procedures on the same patient to prevent

cross-contamination from different sites. (e.g., An IV site should not be manipulated by a

healthcare worker after a Foley catheter has been secured, unless hands have been cleaned.)

● If hands are visibly soiled, hand washing with soap and running water is recommended for a

minimum of 15 seconds. Turn the faucet off with a dry paper towel to avoid re-contamination of

hands.

● ABHR is the most effective and preferred method of hand hygiene except when hands are

visibly soiled and after caring for patients with Clostridiodes difficile or Norovirus. ABHR

does not kill spores or certain viruses, so decontamination with alcohol may not be as effective in

these patients.

○ ABHR dispensers are located in all patient care rooms, clinics and primary care sites.

○ Dispensers are accessible outside of patient rooms as an additional reminder to sanitize

hands prior to entry and contact with any patient.

○ Per CaroMont Health Hand & Skin Antisepsis Policy, ABHR should be used on the way into

each patient’s room and on the way out, regardless of whether or not you touch the patient or

the patient’s environment.

CaroMont Health has a comprehensive Hand Hygiene Audit Program. Hand hygiene audits are tabulated

into monthly results and shared with all staff. The observations are collected, reported and posted monthly

on the hospital’s intranet (CHIP).

Auditors observe healthcare personnel in the hospital, clinics and primary care sites looking for

opportunities to “clean in” and “clean out.” It is important to remember that contact with environmental

surfaces between patients prompts the necessity to clean hands prior to contact with the patient. If you are

observed or coached about inappropriate hand hygiene practice, please respond with, “Thank you for

reminding me.”

In 2019, hand hygiene audits will continue throughout the CaroMont Health system with data reported to

providers and personnel. Hand hygiene compliance will be monitored for all personnel, and compliance data

is available for all staff to see on the hospital intranet (CHIP) under the Infection Control Department page.

Reports on hand hygiene compliance are provided to certain committees such as the Infection Prevention

and Control Committee.

Catheter Associated Urinary Tract Infections (CAUTI)

CAUTI occurs when germs (usually bacteria) enter the urinary tract through the urinary catheter and cause

infection. CAUTIs have been associated with increased morbidity, mortality, healthcare costs and length of

stay. Proper insertion, care and maintenance of Foley Catheters can prevent CAUTI.

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CAUTI (continued)

This includes:

● Cleaning patient’s perineum prior to Foley insertion.

● Using sterile technique when inserting Foley.

● Using a securement device to secure Foley to upper leg.

● Maintaining closed drainage system.

● Keeping drainage bag below level of bladder.

● Emptying drainage bag when ⅔ full and whenever patient leaves unit.

● Using Foley removal protocol and promptly removing Foley catheters when patient no longer

meets the criteria to keep a Foley catheter.

Other methods for urinary management, such as female urinals, condom catheters or in-and-out

catheterization should be considered before indwelling catheters are used. Bladder ultrasound scanners

accurately measure even relatively small urine volumes. These devices may reduce the need for urinary

catheterization to assess residual urine volume. Fewer catheterizations, even in-and-out catheterizations,

mean fewer changes to introduce bacteria to the urinary tract.

Central Line Associated Blood-Stream Infections (CLABSI)

● Promptly remove unnecessary central lines.

● Follow proper insertion practices:

○ C.L.I.P. - Central Line Insertion Practices

○ Perform hand hygiene before insertion.

○ Adhere to aseptic technique.

○ Use maximal sterile barrier precautions (i.e., mask, cap, gown, sterile gloves, and sterile full

body drape).

○ Perform skin antisepsis with >0.5% chlorhexidine with alcohol, allow to dry.

○ Choose the best site to minimize infections and mechanical complications.

○ Avoid femoral site in adult patients. If femoral site is used, document the reason.

○ Cover the site with sterile gauze or sterile, transparent, semi-permeable dressings and

BioPatch.

● Handle and maintain central lines appropriately:

○ Comply with hand hygiene requirements.

○ Scrub the access port or hub for 15 seconds immediately prior to each use with an

appropriate antiseptic (e.g., chlorhexidine, povidone iodine, an iodophor, or 70% alcohol).

○ Access catheters only with sterile devices.

○ Replace dressings that are wet, soiled or dislodged.

○ Perform dressing changes under aseptic technique using sterile gloves and mask.

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CLABSI (continued)

Importance of Preventing CLABSIs:

● National estimates indicate the cost of a bloodstream infection around $45,814 per episode and

$58,614 for CLABSI with MRSA. CLABSIs with MRSA resulted in the highest attributed excess

LOS of 23 days.1

● CLABSIs happen when pathogens are introduced into the bloodstream from the skin around the

insertion site or from the hub or connector of the catheter. Following proper insertion,

maintenance practices and removal of lines are key in CLABSI prevention.

CLABSI Prevention Activities include:

● Daily alerts to nursing units of a patient with central lines (CL) that have been assessed by the IV

Team and are recommending removal. Nursing should communicate with the physician to see if

CL can be removed. It it’s determined that the patient continues to have a need for CL, it is

important to complete daily maintenance including documentation (CHG bathing and Scrub the

Hub).

● Use of chlorhexidine for bathing of patients with central lines (CL) is a recommendation from the

CDC for prevention of CLABSI (excluding NICU). This practice has been approved and was placed

into practice for all inpatients with CL (excluding NICU) at CaroMont Health in July 2012.

● CUROS caps placed on all CL ports, TEGOS high-flow needleless connectors with White CUROS

caps for TEGOS for dialysis catheters.

● CLABSI surveillance has been extended to include hemodialysis catheters.

Clostridioides difficile (C.diff)

● C.diff is a bacteria that causes the most common infectious healthcare-associated gastrointestinal

illness. It usually presents with diarrhea, along with other accompanying symptoms such as

leukocytosis, elevated temp and abdominal pain.

● 500,000 infections occur annually in U.S. with 29,000 deaths.

● Complications (shock, colectomy, perforation, megacolon, death) developed in 11% with first

recurrence.

● C.diff can form spores, which makes it very hardy and difficult to kill. It can live up to five months in

the environment. Hands or equipment that come in contact with the spores can then be carried to

patients who become colonized with it in their gut.

● Patients exposed to antibiotics, proton-pump inhibitors, chemotherapy or gastrointestinal surgery

are at a higher risk for developing a C.diff colitis, especially patients 65 years and older.

● C.diff prevention activities implemented at CRMC include antibiotic de-escalation, enteric contact

isolation (for duration of stay), use of dedicated equipment, and use of bleach to terminally clean

rooms.

1. Health Care-Associated Infections: A Meta-analysis of Costs and Financial Impact on the U.S. Health Care System. JAMA Intern

Med. 2013;173(22):2039-2046.loi:10.1001/jamainternmed.2013.9763 Published online September 2, 2013.

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Multi-Drug Resistant Infections (MDRO)

● Per the 2018 CaroMont Health Antibiogram (included on the final two pages of this document),

about 60% of CaroMont Health Staphylococcus aureus isolates are MRSA, resistant to nafcillin,

cephalosporins and beta-lactamase inhibitors (e.g., ampicillin/sulbactam, piperacillin/tazabactam).

The antibiogram is published annually and is available on the Infection Prevention and Control

Department page located on the hospital intranet (CHIP>Departments and Services>Infection

Prevention and Control).

● Patient risk factors for MDRO include stays in critical care, devices present including central lines

and Foley catheters, antibiotic therapy, surgical procedures and immuno-compromised status.

● Regardless of admission diagnosis, patients with prior MRSA/VRE/CRE/ESBL colonization or true

infection will be readmitted on Contact Isolation Precautions, unless there is documentation of

clearance through the IP&C Department. Patients arriving from other facilities who are known to be

positive for MRSA/VRE/CRE/ESBL are also placed in Contact Isolation Precautions.

● Please reference the CaroMont Health MDRO policy (located on CHIP) for the process of

discontinuation of isolation precautions for MRSA/VRE/CRE/ESBL.

● Only an Infection Preventionist is allowed to discontinue Contact Precautions for MDROs.

● Contact Isolation Precautions, including appropriate hand hygiene, is used for patients known to be

infected or colonized with MDROs.

● CaroMont Health follows CDC recommended cleaning, disinfection and sterilization guidelines for

maintaining patient care areas and equipment. Bleach is used for terminal and isolation cleaning.

Vancomycin Resistant Enterococcus (VRE)

● Enterococcus resides in our intestines as normal flora. It concerns us when it develops resistance

to Vancomycin.

● VRE has the potential to cause urinary tract infections, bloodstream infections or surgical site

infections. VRE can live for hours, and up to days, on surfaces such as cotton and polyester

(scrubs and privacy curtains for instance). VRE can be carried on our hands or contaminated

equipment.

Carbapenem-Resistant Enterobacteriaceae (CRE)

● Enterobacteriaceae resides in our intestines as normal flora. It concerns us when it develops

resistance to antibiotics, including carbapenems.

● CRE primarily cause urinary tract infection and bloodstream infections and can be carried on our

hands or contaminated equipment.

● CRE became a reportable event to the North Carolina Department of Health in October 2018. For

CRE, as well as any MDRO, it is important to follow the hospital policies and procedures for

appropriate isolation and use of personal protective equipment when caring for patients in which

these pathogens have been identified.

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Extended Spectrum Beta Lactamase (ESBL)

● The most common ESBL producing organisms include Klebsiella sp, Enterobacter sp,

Acinetobacter sp and Escherichia coli.

● The bacteria develop resistance to beta-lactam antibiotics, including penicillins and

cephalosporins, and can also be resistant to other antibiotics such as aminoglycosides (e.g.,

gentamycin and tobramycin) and quinolones (e.g., ciprofloxacin).

● ESBL producing bacteria can be carried on our hands or contaminated equipment.

Surgical-Site Infections (SSI)

● National estimates indicate the cost of a surgical site infection around $20,785 and those with

MRSA more than doubled the cost to $42,300.1

● Order sets are used for all procedures.

● Whenever possible, identify and treat all infections remote to the surgical site before elective

operations and postpone elective operations until the infection has resolved.

● Hair should not be removed pre-operatively; if it interferes with the procedure, remove immediately

prior to incision with electric clippers. Hair should be removed in a location outside of the OR or

procedure room.

● Adequately control serum blood glucose levels and avoid hyperglycemia perioperatively.

● Encourage tobacco cessation; at a minimum, instruct patients to abstain for at least 30 days.

● A pre-op application of CHG to the skin is recommended for high risk, high volume, problem-prone

procedures.

● Patients going through PSS will receive instructions for showering with an antiseptic soap,

chlorhexidine gluconate (CHG), for a specified period of days prior to, and on, the day of the

operation.

● Thoroughly wash and clean at and around the potential incision site to remove gross

contamination before performing antiseptic skin preparation. Chloroprep is the recommended skin

prep; a 30-second friction scrub with a back and forth motion is necessary; a 120-second scrub is

required for the groin. Allow to dry three minutes before draping; avoid pooling.

● Post-operative incision care includes keeping the sterile dressing intact per the physician orders

and not removed. If the dressing is manipulated prior to day two, use sterile technique.

● Staph aureus nasal screening should be done for certain surgical procedures (i.e. total hip and

knee replacement) and per surgeon order.

● Preoperative antibiotics should be administered within 60 minutes of initial cut time, agent

appropriate for the anticipated pathogens, dosed and re-dosed per the CaroMont Health Antibiotic

grid. Surgical prophylaxis should be stopped at 24 hours.

● Urinary catheters are removed on POD 1 or POD 2, with day of surgery being day zero.



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Ventilator-Associated Events

● National estimates indicate the cost of a ventilator-associated pneumonia to be around $40,144

and increased length of stay of 13.1 days.1

● Physicians coordinating care and standardizing patient care protocols.

● Physical Therapy protocol for progressive mobility.

● IP&C Department performs active surveillance for VAEs, bundle compliance and protocol

compliance.

Antibiotic Stewardship Program

According to the Centers for Disease Control and Prevention (CDC), an Antimicrobial Stewardship Program

is a hospital-based program dedicated to improving antibiotic use to optimize the treatment of infections and

reduce adverse events associated with antibiotic use.

Antimicrobial Stewardship Programs are heavily supported by the CDC, The Joint Commission, and

Centers for Medicare and Medicaid. Antimicrobial Stewardship Programs help clinicians improve the quality

of patient care, as well as patient safety, through increased infection cure rates, reduced treatment failures,

and increased frequency of correct prescribing for therapy and prophylaxis. Antimicrobial stewardship

reduces hospital rates of Clostridioides difficile infections and reduces antibiotic resistance, as well as saves

the hospital money.

At CaroMont Regional Medical Center, we utilize an electronic program, TheraDoc®, to pull in real-time

culture information in order to follow sepsis patients and identify any drug-bug mismatches.

Recommendations are made by the Antimicrobial Stewardship Pharmacist either by leaving a sticky note in

the medical record or by directly contacting the provider.

Facility Ebola Plan

CRMC has an Ebola Plan located on CHIP. This plan is reviewed and revised annually, and when any

changes occur. It includes infection prevention and control considerations per guidance of the CDC and

World Health Organization (WHO). CRMC collaborates directly with the North Carolina Department of

Health and other local health care agencies such as the Gastonia Emergency Management Services

(GEMS) to develop and maintain the plan.

Initial triage of patients is routine across all entities of CaroMont Health to aid in the quick identity, isolation,

and notification to the appropriate personnel, including public health authorities, about patients who may

have communicable infections.



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The Bloodborne Pathogens Plan and TB Plan

The Bloodborne Pathogens (BBP) Plan and the Tuberculosis (TB) Plan are both located on CHIP.

The BBP Plan includes the following information:

● Signs and labels used in the hospital (biohazard signs).

● BBP are microorganisms that are carried in the blood and body fluids of infected people and

include HIV, HBV and HCV.

● HIV symptoms include: fever, loss of appetite, fatigue, weight loss and skin rash. There is no

vaccine to protect against HIV.

● HBV symptoms include: jaundice, abdominal pain, loss of appetite, fatigue, nausea or vomiting.

● The hepatitis B vaccine will help protect you from getting HBV. This vaccine is offered free of

charge at CaroMont Regional to personnel working in a job that puts them at risk for exposure to

HBV. This vaccine is given as a series of three injections over a six-month period and is safe and

effective. Hepatitis B titer should be checked following the third injection to ensure protection.

● HCV symptoms are the same as HBV. There is no vaccine to prevent HCV.

● BBP are transmitted through direct contact with infected blood or body fluids which enter through

mucous membranes via sharps injuries, puncture wounds and/or non-intact skin.

● The best protection is always practicing standard precautions , which includes using appropriate

personal protection equipment (mask, gloves, gowns, face shields).

● Use standard precautions with all patients every time that you anticipate contact with blood, body

fluids, non-intact skin and mucous membranes.

● If you are exposed to blood or body fluids, perform first aid by washing the area with soap and

water or flushing your eyes with water immediately following a splash. Report the exposure

incident to the Blood Exposure Line at ext. 4848 during Employee Health business hours or the

Shift Manager at ext. 2131 and complete an occurrence report.

The TB Plan includes the following information:

● Administrative controls, environmental controls and details on the respiratory protection program.

● Tuberculosis is a disease caused by the bacteria Mycobacterium tuberculosis. It is spread through

the air when people with active TB cough, sing, speak or sneeze.

● TB may be active or inactive (also called latent TB infection). Inactive infections cannot be spread

to others.

● Symptoms include: persistent cough for more than three weeks, fever, weight loss, loss of

appetite, night sweats and weakness.

● TST: TB Skin test placed intradermally and read after 48-72 hours is the test provided at CaroMont

Regional. A positive reaction means you’ve probably been exposed to the TB germ and will need

further follow-up with Employee Health Services and/or Department of Health. Personnel are

screened prior to employment and annually thereafter.

● Early detection, isolation and treatment is key to controlling the spread of TB.

Annual Provider

Education 2019

TB Plan (Continued)

● At CRMC patients who are suspected or known to be infected with TB are placed on Airborne

Isolation Precautions.

● Airborne Isolation Precautions means the patient is placed in a negative pressure room (checked

by nursing each day); the door is kept closed and personnel are required to wear a fit tested

respirator mask to enter.

Please contact Infection Prevention and Control at ext. 2913 or Employee Health Services at ext. 2179 if

you need additional information or have questions about either of these plans.

Medical Staff

Physician Health Policy

CaroMont Regional Medical Center (the “Hospital”), CaroMont Medical Group (“CMG”) and their respective

medical staffs are committed to providing patients with quality care and are aware of their obligation to

protect patients from harm. It is recognized that the delivery of quality care could potentially be

compromised if a member of the Medical Staff, a physician employed by CMG or an advanced practitioner

is suffering from a medical, behavioral or substance abuse related illness.

The focus of the Physician Health Policy is assistance and rehabilitation, rather than discipline, with the goal

being to aid physicians or other practitioners in retaining or regaining optimal professional functioning, while

at the same time ensuring that patients are protected from a provider who may not be able safely to perform

the privileges s/he has been granted.

Signs of impairment that may be observed include physical state and behavior in the hospital.

Examples are as follows:

● Deterioration in personal hygiene

● Frequent Accidents

● Emotional crises

● Making rounds late or displaying inappropriate, abnormal behavior during rounds

● Inappropriate orders or over-prescriptions of meds

● Reports of behavioral changes from other personnel

● Unavailability or inappropriate responses to telephone calls

● Hostile, withdrawn, unreasonable behavior to staff and patients

● Unusual complaints by patients to staff about doctor’s or practitioner’s behavior

Hospital staff may report practitioners to the CEO, CMO, CLO, VPMA or direct supervisor. The identity of

the person submitting the report will remain confidential. Practitioners may self report to the Physician

Health and Behavior Committee. The complete policy is on CHIP.

Annual Provider

Education 2019

Written Orders

All orders and physician notes are to be entered into Epic; however, in rare circumstances where a written

order or note may be required, all entries must have both a signature by the provider who wrote the order,

and a date and time with the entry.

Verbal Orders

Verbal orders must be signed off within seven days of the order given and should be done through the Epic

Worklist.

Computer Downtime

When electronic information systems are unavailable for either planned or unplanned downtime, staff will be

notified. If the downtime is planned (i.e. monthly maintenance scheduled), notification to end users will go

out in advance of the planned event. Overhead paging will be included as part of the notification during

daytime hours.

Alternative procedures to follow during downtime include:

● Epic: Access to Epic’s Shadow environment is available by clicking the icon for EpicRPT on any

computer. This is a “Read Only” version of Epic for current patients. Downtime forms, including

Physician Order Sheets and Progress Notes are available via FormFast and/or in each patient

care unit in the downtime drawer or bin. For issues impacting or delaying patient care, the Clinical

Help Desk can be reached at ext. 3700, option 1, option 4.

● PACS: Exams will continue to be ordered in Epic. Studies will be performed and saved at the

modality until PACS is operational. Studies will be printed from the modality until PACS is

operational. Once PACS is operational, each modality will use their downtime log book to

determine the patients that need to be sent to PACS and transfer those studies.

● Voice Dictation: When the voice dictation system is down providers should create their notes

using Epic Native Notes, Dragon, Speech, or handwritten notes until the system is back up.

Progress Notes forms can be obtained from FormFast.

● Dragon Dictation: Physicians should document in Epic without the use of Dragon during an Epic

downtime. Downtime forms, including Physician Order Sheets and Progress Notes are available

via FormFast and/or on each patient care unit in the downtime drawer or bin.

Annual Provider

Education 2019

Medical Examiner and Death Certificate Information

When reviewing Medical Examiner Criteria, be aware that criteria #10 states: “Poisoning or suspicion of

poisoning (includes drug or alcohol overdose).” This means that every drug or alcohol overdose should be

called to the Medical Examiner per state regulations.

Per DHHS, the physician in charge of care may sign the death certificate EXCEPT when the death falls

under ME jurisdiction.

Safety Event Reporting, Unanticipated Outcomes, and Patient Complaints

You may report patient, employee, or visitor safety events (actual or “near misses”) via Quantros or

by calling the Safety Hotline and leaving a voicemail with details at 704-834-SAFE (7233).

If you have an Unanticipated Patient Outcome that warrants a disclosure, you may contact the

Manager of Patient Services at 704-834-2682 for disclosure guidance and support.

You may direct patient and/or family complaints to the Patient Representative department by

calling 704-834-2694.

In the event of an unexpected, serious, or catastrophic patient event, please contact the Patient Safety

Department at ext. 3856 or the Risk Management Department at ext. 2074. After-hours, you should contact

the Shift Manager at ext. 2131.

Reporting Concerns to The Joint Commission

Any individual who provides care, treatment, and services can report concerns about safety or the quality of

care provided at CaroMont Health to The Joint Commission. CaroMont Health will take not take any

disciplinary or punitive actions because an employee, physician, or other individual who provides care,

treatment or services reports a concern to The Joint Commission.

CaroMont Health and its medical staff are committed to providing patients with quality care and is aware of

its obligation to protect patients from harm. Medical staff leadership encourages providers to report

concerns about safety or quality to the Chief Medical Officer or the Vice President of Medical Affairs before

contacting The Joint Commission.

You may report your concern to:

The Joint Commission

Office of Quality & Patient Safety

https://www.jointcommission.org/report_a_complaint.aspx

One Renaissance Boulevard

Oakbrook Terrace, IL 60181

Toll Free: (800) 994-6610

Fax: (630) 792-5636

Annual Provider

Education 2019

Cumulative Antimicrobial Susceptibility Data

2018 Edition

CaroMont Regional Medical Laboratory

Based on tests performed in 2017

Top Ten 2017 Urinary Incidence

Top Ten 2017 Non-Urine Incidence

Staph. Coag negative 8110 Staph. aureus 1749

Escherichia coli 4665 Staph. coagulase negative 1631

Kleb pneumoniae 970 Streptococcus Group A 428

Streptococcus Group B 926 Streptococcus Group B 357

Enterococcus faecalis 498 E. coli 351

Staphylococcus aureaus 444 Candida albicans 245

Yeast, not C. albicans 444 Pseudomonas aeruginosa 141

Proteus mirabilis 429 Kleb pneumoniae 139

Pseudomonas aeruginosa 244 Streptococcus pneumoniae 99

Candida albicans 239 Enterococcus faecalis 99

Duplicates excluded

Chart Notes:

(1) This data was compiled based on the approved guidelines from Clinical and Laboratory Standards

Institute (CLSI), MA39-A3, 2009

(2) Duplicate isolates from a given patient are included only once per year regardless of specimen source

(per CLSI). Previously only “repeats” within 7 days were eliminated.

(3) % susceptible does not include isolates which tested as Intermediate.

(4) For Streptococcus pneumoniae isolates, susceptible breakpoint for penicillin is <=0.06 ug/mL. 10% of

2015 and 19% of 2016 isolates tested as intermediate and these might be effectively treated with high-

dose penicillin.

(5) Nitrofurantoin is not recommended in patient with estimated creatinine clearance of <60ml/min. With

renal impairment, there is an increased risk of toxicity and decreased efficacy.

annual provider education 2019 - caromont health · 2019. 4. 15. · when a fire is detected, all...

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