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New Provider Orientation

VISION To be our communities most trusted healthcare partner

MISSION To provide compassionate, exceptional and highly reliable care

High Reliability Organization CaroMont Health is working to become a HRO. A highly reliable standardizing systems that support humans, reducing the variability and likelihood of errors. It means identifying errors before they cause harm and using that information to avoid errors in the future, therebyMore information about HROs and our journey may be found on the intranet.

The medical staff documents which include the bylaws, medical staff policies, and the organizational manual can be found

on www.caromonthealth.org by clicking on the healthcare professionals tab and then selec

Patient safety is important at CaroMont Health. For this reason, we have implemented and monitor compliance to the National Patient Safety Goals. Several of these goals are defined below:

Patient identification ▪ At least two patient identifiers are to be used whenever providing treatments or procedures.▪ Patient name and date of birth are recommended. The patient’s room number is never to be used as a patient

identifier.

Unapproved Abbreviations For patient safety, these unapproved abbreviations MUST NOT be used:


Organization Overview

To be our communities most trusted healthcare partner.

To provide compassionate, exceptional and highly reliable care

CaroMont Health is working to become a HRO. A highly reliable organization achieves the correct outcome by standardizing systems that support humans, reducing the variability and likelihood of errors. It means identifying errors before they cause harm and using that information to avoid errors in the future, thereby resulting in Zero Patient Harm. More information about HROs and our journey may be found on the intranet.

Medical Staff Documents


by clicking on the healthcare professionals tab and then selecting the medical staff office.

Patient Safety

Patient safety is important at CaroMont Health. For this reason, we have implemented and monitor compliance to the National Patient Safety Goals. Several of these goals are defined below:

At least two patient identifiers are to be used whenever providing treatments or procedures.Patient name and date of birth are recommended. The patient’s room number is never to be used as a patient

For patient safety, these unapproved abbreviations MUST NOT be used:

1

Organization Overview

organization achieves the correct outcome by standardizing systems that support humans, reducing the variability and likelihood of errors. It means identifying errors

resulting in Zero Patient Harm.

Medical Staff Documents


ting the medical staff office.

Patient Safety

Patient safety is important at CaroMont Health. For this reason, we have implemented and monitor compliance to the

At least two patient identifiers are to be used whenever providing treatments or procedures. Patient name and date of birth are recommended. The patient’s room number is never to be used as a patient


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Verbal or Telephone Orders (including reporting of critical test results)Verbal or telephone orders or telephone reporting of critical test results: person receiving order must “readcomplete order or test results. Person who gave the order or test result confirms it was read back.

▪ Must be authenticated within 48 hrs. ▪ Are limited to emergent situations or during procedural interventions. ▪ May be taken by a pharmacist, dietician, RN/LPN, or respiratory therapist.▪ If present, the physician must enter the orders into the EHR

Universal Protocol ▪ Improves patient safety and prevents procedural errors by following established procedures. ▪ Implemented in all locations where operative and other invasive procedures are performed that expose patients to

more than a minimal risk. ▪ Three primary components:

o Pre-Procedure: documents/equipment available and correctly identifiedo Procedure Site Marking: identify intended siteo Time Out: final pre-procedure assessment (correct patient, site, procedure)

Patient Safety & Risk Management ProgramThe Patient Safety and Risk Management program provides a systematic, coordinated and continuous approach to the maintenance and improvement in patient safety issues and provide proactive risk assessment to control losses related to healthcare general, professional and employment practice liability and property damage, in every department and entity throughout the organization. An anonymous Patient Safety Hotline is also available to patients and/or families, physicians and staff by calling 834SAFE (834.7233).

Reporting Concerns If you have a safety concern, follow-up with someone who can help

▪ If it is regarding equipment or an environmental issue that needs repair, ask the UCC to enter a work order to get it fixed.

▪ If you have a patient safety or risk management iscontact the Manager, Patient Safety @ 704.834.

▪ For any other issue, discuss with any supervisor or manager, who will raise it to the Environment ofCommittee for further review and follow

If your concern is not adequately addressed by CaroMont Health, you are free to report your concern to The Joint

Commission. To support this culture of safety, no formal disciplinary actions (for example,

change in working conditions or hours) or informal punitive actions (for example, harassment, isolation, or abuse) will be

threatened or carried out in retaliation for reporting concerns to The Joint Commission.


Verbal or Telephone Orders (including reporting of critical test results)Verbal or telephone orders or telephone reporting of critical test results: person receiving order must “readcomplete order or test results. Person who gave the order or test result confirms it was read back.

rs. Are limited to emergent situations or during procedural interventions. May be taken by a pharmacist, dietician, RN/LPN, or respiratory therapist.

enter the orders into the EHR.

Improves patient safety and prevents procedural errors by following established procedures. Implemented in all locations where operative and other invasive procedures are performed that expose patients to

Procedure: documents/equipment available and correctly identified

Procedure Site Marking: identify intended site

procedure assessment (correct patient, site, procedure)

Patient Safety & Risk Management Program Safety and Risk Management program provides a systematic, coordinated and continuous approach to the

maintenance and improvement in patient safety issues and provide proactive risk assessment to control losses related to d employment practice liability and property damage, in every department and entity

is also available to patients and/or families, physicians and staff by calling 834

up with someone who can help If it is regarding equipment or an environmental issue that needs repair, ask the UCC to enter a work order to get

If you have a patient safety or risk management issue or question, discuss with any supervisor or manager, or contact the Manager, Patient Safety @ 704.834.2874 or Manager, Risk Management @ 704.834.For any other issue, discuss with any supervisor or manager, who will raise it to the Environment ofCommittee for further review and follow-up.


Commission. To support this culture of safety, no formal disciplinary actions (for example, demotions, reassignments, or


threatened or carried out in retaliation for reporting concerns to The Joint Commission.

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Verbal or Telephone Orders (including reporting of critical test results) Verbal or telephone orders or telephone reporting of critical test results: person receiving order must “read-back” the complete order or test results. Person who gave the order or test result confirms it was read back.

Improves patient safety and prevents procedural errors by following established procedures. Implemented in all locations where operative and other invasive procedures are performed that expose patients to

Safety and Risk Management program provides a systematic, coordinated and continuous approach to the maintenance and improvement in patient safety issues and provide proactive risk assessment to control losses related to

d employment practice liability and property damage, in every department and entity

is also available to patients and/or families, physicians and staff by calling 834-

If it is regarding equipment or an environmental issue that needs repair, ask the UCC to enter a work order to get

sue or question, discuss with any supervisor or manager, or or Manager, Risk Management @ 704.834.2074.

For any other issue, discuss with any supervisor or manager, who will raise it to the Environment of Care


demotions, reassignments, or



The Joint Commission

Office of Quality & Patient Safety One Renaissance Boulevard Oakbrook Terrace, IL 60181 Toll Free: (800) 994-6610 Fax: (630)792-5636 Website: [email protected] Division of Health Services Regulation Complaint Intake Unit 2711 Mail Services Center Raleigh, NC 27699-2701 Toll Free: (800) 624-3004 Fax: (919) 715-7724 Website: www.ncdhhs.gov

Sentinel Events

▪ A sentinel event is an unexpected occurrence involving death

▪ These events are reviewed as educational opportunities and are not used to place blame. ▪ Each sentinel event is investigated through the Patient Safety/Risk Management Department and

ALL the patient’s caregivers. ▪ The Joint Commission requires case reviews be completed within 45 days of notification of the event.▪ If a physician’s practice of care could have contributed to a sentinel event, the case is referred to CPI and a

review is performed. Findings from the actual event are shared with the peer reviewer to assist in a thorough evaluation. All Sentinel Event peer review cases are discussed at Performance Improvement departmental medical staff meetings. Sp

Unanticipated Outcome Disclosure▪ All staff members are expected to report an unanticipated negative outcome.▪ The CaroMont Health Unanticipated Outcome Disclosure Policy

families shall be promptly informed about the outcomes of care, including unanticipated outcomes, and shall be assured that appropriate clinical measures have been taken to respond to the unanticipated outcome

▪ The Licensed Independent Practitioner (LIP) involved in the care of the patient will initiate the disclosure conversation with the patient, surrogate decision maker and/or family.

▪ This disclosure shall occur as soon as practically possible after it has patient’s condition is stable and/or the patient is able to comprehend the information.


occurrence involving death, permanent harm or severe temporary harm.

These events are reviewed as educational opportunities and are not used to place blame. Each sentinel event is investigated through the Patient Safety/Risk Management Department and

The Joint Commission requires case reviews be completed within 45 days of notification of the event.If a physician’s practice of care could have contributed to a sentinel event, the case is referred to CPI and a review is performed. Findings from the actual event are shared with the peer reviewer to assist in a thorough evaluation. All Sentinel Event peer review cases are discussed at Performance Improvement departmental medical staff meetings. Specific cases may be discussed at the Board Safety and

Unanticipated Outcome Disclosure All staff members are expected to report an unanticipated negative outcome.

Unanticipated Outcome Disclosure Policy states: patients and, when appropriate, their families shall be promptly informed about the outcomes of care, including unanticipated outcomes, and shall be assured that appropriate clinical measures have been taken to respond to the unanticipated outcomeThe Licensed Independent Practitioner (LIP) involved in the care of the patient will initiate the disclosure conversation with the patient, surrogate decision maker and/or family. This disclosure shall occur as soon as practically possible after it has occurred or has been identified and/or the patient’s condition is stable and/or the patient is able to comprehend the information.

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, permanent harm or severe temporary harm.

These events are reviewed as educational opportunities and are not used to place blame. Each sentinel event is investigated through the Patient Safety/Risk Management Department and may involve

The Joint Commission requires case reviews be completed within 45 days of notification of the event. If a physician’s practice of care could have contributed to a sentinel event, the case is referred to CPI and a peer review is performed. Findings from the actual event are shared with the peer reviewer to assist in a thorough evaluation. All Sentinel Event peer review cases are discussed at Performance Improvement Council and

Safety and Quality Committee.

states: patients and, when appropriate, their families shall be promptly informed about the outcomes of care, including unanticipated outcomes, and shall be assured that appropriate clinical measures have been taken to respond to the unanticipated outcome. The Licensed Independent Practitioner (LIP) involved in the care of the patient will initiate the disclosure

occurred or has been identified and/or the


Hospitalists/Intensivists/Consults▪ Hospitalists, CaroMont Inpatient Physicians, are available for the admission and consultation of your patients. ▪ Intensivists, CaroMont Critical Care Specialists, supervise the critical care units. They must be consulted for

critical care management of any patient admitted to an intensive care unit. o They are also available to serve as the admitting physician to a critical care unit for your patients if you

speak with them directly. o They are also considered to be Critical Care Medicine Consultants.

Consults ▪ All medical staff members are required to respond to consultation requests from their colleagues in a timely

manner. ▪ Consultations may be emergency/urgent, routine/non urgent, off▪ Critical care or pulmonary consults to ICU, SICU, CVRU, CCU

o Critical Care Units are ‘Open Units’ and appropriately credentialed and privileged practitioners are allowed to admit patients.

o Consultations on patients destined for admission to or admitted to one of the Critical Care Unconsidered Emergency/Urgent Consultations and the request by the Attending/Admitting Physician must comply with the Medical Staff consultation Policy

o All patients admitted to a Critical Care Unit bed must have a Critical Care Consult with the exceptions:

▪ overflow patients admitted to Critical Care unit bed or PICS because of lack of availability of a bed on a lower acuity unit

▪ Uncomplicated patients admitted to a Critical Care Unit with a primary cardiac problem without significant respiratory compromise.

Acceptance of Patients from Other Facilities▪ Admissions from other hospitals, clinics, or agencies can be accepted if the patient meets the criteria of the service

to which they are admitted. ▪ The patient must be accepted by a physician on staff.▪ If you receive a call from another facility regarding the transfer to CRMC, please refer the caller to the Bed

Planning Department.

Emergency Medical Treatment and Labor Act (EMTALA)When an individual presents or is brought to the Emeindividual’s behalf for examination and treatment of a medical condition, a physician or advanced care practitioner will


Patient Care

Hospitalists/Intensivists/Consults Hospitalists, CaroMont Inpatient Physicians, are available for the admission and consultation of your patients. Intensivists, CaroMont Critical Care Specialists, supervise the critical care units. They must be consulted for

ny patient admitted to an intensive care unit. They are also available to serve as the admitting physician to a critical care unit for your patients if you

They are also considered to be Critical Care Medicine Consultants.

All medical staff members are required to respond to consultation requests from their colleagues in a timely

mergency/urgent, routine/non urgent, off-hours/non-urgent, or courtesy listingconsults to ICU, SICU, CVRU, CCU

Critical Care Units are ‘Open Units’ and appropriately credentialed and privileged practitioners are

Consultations on patients destined for admission to or admitted to one of the Critical Care Unconsidered Emergency/Urgent Consultations and the request by the Attending/Admitting Physician must comply with the Medical Staff consultation Policy All patients admitted to a Critical Care Unit bed must have a Critical Care Consult with the

overflow patients admitted to Critical Care unit bed or PICS because of lack of availability of a bed on a lower acuity unit Uncomplicated patients admitted to a Critical Care Unit with a primary cardiac problem without

spiratory compromise.

Acceptance of Patients from Other Facilities Admissions from other hospitals, clinics, or agencies can be accepted if the patient meets the criteria of the service

physician on staff. If you receive a call from another facility regarding the transfer to CRMC, please refer the caller to the Bed

Emergency Medical Treatment and Labor Act (EMTALA) When an individual presents or is brought to the Emergency Department of CRMC and a request is made on the individual’s behalf for examination and treatment of a medical condition, a physician or advanced care practitioner will

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Patient Care-Specific

Hospitalists, CaroMont Inpatient Physicians, are available for the admission and consultation of your patients. Intensivists, CaroMont Critical Care Specialists, supervise the critical care units. They must be consulted for

They are also available to serve as the admitting physician to a critical care unit for your patients if you

All medical staff members are required to respond to consultation requests from their colleagues in a timely

urgent, or courtesy listing

Critical Care Units are ‘Open Units’ and appropriately credentialed and privileged practitioners are

Consultations on patients destined for admission to or admitted to one of the Critical Care Units are considered Emergency/Urgent Consultations and the request by the Attending/Admitting Physician must

All patients admitted to a Critical Care Unit bed must have a Critical Care Consult with the following

overflow patients admitted to Critical Care unit bed or PICS because of lack of availability of a

Uncomplicated patients admitted to a Critical Care Unit with a primary cardiac problem without

Admissions from other hospitals, clinics, or agencies can be accepted if the patient meets the criteria of the service

If you receive a call from another facility regarding the transfer to CRMC, please refer the caller to the Bed

rgency Department of CRMC and a request is made on the individual’s behalf for examination and treatment of a medical condition, a physician or advanced care practitioner will


provide a medical screening examination within the capabilities of the Hospital,available to the Emergency Department, for the purpose of determining the presence or absence of an Emergency Medical Condition. When an individual who is not a patient presents on Hospital property other than the Emergency Department and a request is made on the individual’s behalf for examination or treatment for what may be an Emergency Medical Condition, a physician or advanced care practitioner will provide a medical screening examination within the capabilities of the Hospital for the purpose of determining the presence or absence of an Emergency Medical Condition. In some circumstances, it may be appropriate to move the indivi An individual with an Emergency Medical Condition will receive either:

(1) Such further medical examination and treatment within the capabilities of the staff and facilities available as may be required to stabilize the Emergency Medical Condition, or

(2) An appropriate transfer to another facility. Individuals or their responsible decisionor request transfer to a facility of their choice.

Patient transfers will occur as specified in the Patient policies are on CHIP.)

Patient’s Bill of Rights ▪ Patient’s Bill of Rights: Care will be provided with an overriding concern for the values and dignity of the

by providing information, offering fair treatment, and granting autonomy over medical decisions.

Informed Consent ▪ It is hospital policy that all patients be asked to provide informed consent for all treatments and procedures.▪ It is the responsibility of the physician who is providing the treatment or procedure to provide adequate

information to enable the patient to make an informed decision. “Necessary Information” includes:o Information that a reasonable patient would need to know before making a decision. o Information should include, but may not be limited to:o Nature of the proposed and likelihood of achieving care, treatment, services, etc.o Potential benefits, risks, reasonao Any professional relationship to another health care provider or institution that might suggest a conflict

of interest o When indicated, an explanation of the Hospital’s policy related to DNR orders for surgical and

anesthetized patients

o Any limitations on the confidentiality of the information learned from or about the patient

Informed Consent: Blood Products▪ It is policy that all patients be asked to provide informed consent for administration of any type of blood product. ▪ It is the responsibility of the physician or LIP to provide adequate information to enable the patient to make an

informed decision.


provide a medical screening examination within the capabilities of the Hospital, including ancillary services routinely available to the Emergency Department, for the purpose of determining the presence or absence of an Emergency Medical

When an individual who is not a patient presents on Hospital property other than the Emergency Department and a request is made on the individual’s behalf for examination or treatment for what may be an Emergency Medical Condition, a

care practitioner will provide a medical screening examination within the capabilities of the Hospital for the purpose of determining the presence or absence of an Emergency Medical Condition. In some circumstances, it may be appropriate to move the individual to the Emergency Department for screening and treatment.

An individual with an Emergency Medical Condition will receive either:

Such further medical examination and treatment within the capabilities of the staff and facilities available as may required to stabilize the Emergency Medical Condition, or

An appropriate transfer to another facility. Individuals or their responsible decision-makers may refuse treatment or request transfer to a facility of their choice.

as specified in the Transfer of the Patient policy. (Complete EMTALA

Patient’s Bill of Rights: Care will be provided with an overriding concern for the values and dignity of theby providing information, offering fair treatment, and granting autonomy over medical decisions.

It is hospital policy that all patients be asked to provide informed consent for all treatments and procedures.responsibility of the physician who is providing the treatment or procedure to provide adequate

information to enable the patient to make an informed decision. “Necessary Information” includes:Information that a reasonable patient would need to know before making a decision. Information should include, but may not be limited to: Nature of the proposed and likelihood of achieving care, treatment, services, etc.Potential benefits, risks, reasonable alternatives

Any professional relationship to another health care provider or institution that might suggest a conflict

When indicated, an explanation of the Hospital’s policy related to DNR orders for surgical and

limitations on the confidentiality of the information learned from or about the patient

Informed Consent: Blood Products It is policy that all patients be asked to provide informed consent for administration of any type of blood product.

responsibility of the physician or LIP to provide adequate information to enable the patient to make an

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including ancillary services routinely available to the Emergency Department, for the purpose of determining the presence or absence of an Emergency Medical

When an individual who is not a patient presents on Hospital property other than the Emergency Department and a request is made on the individual’s behalf for examination or treatment for what may be an Emergency Medical Condition, a

care practitioner will provide a medical screening examination within the capabilities of the Hospital for the purpose of determining the presence or absence of an Emergency Medical Condition. In some

dual to the Emergency Department for screening and treatment.

Such further medical examination and treatment within the capabilities of the staff and facilities available as may

makers may refuse treatment

EMTALA and Transfer of the

Patient’s Bill of Rights: Care will be provided with an overriding concern for the values and dignity of the patient by providing information, offering fair treatment, and granting autonomy over medical decisions.

It is hospital policy that all patients be asked to provide informed consent for all treatments and procedures. responsibility of the physician who is providing the treatment or procedure to provide adequate

information to enable the patient to make an informed decision. “Necessary Information” includes: Information that a reasonable patient would need to know before making a decision.

Nature of the proposed and likelihood of achieving care, treatment, services, etc.

Any professional relationship to another health care provider or institution that might suggest a conflict

When indicated, an explanation of the Hospital’s policy related to DNR orders for surgical and

limitations on the confidentiality of the information learned from or about the patient

It is policy that all patients be asked to provide informed consent for administration of any type of blood product. responsibility of the physician or LIP to provide adequate information to enable the patient to make an


▪ The consent will remain in effect for the entire hospital stay.▪ All refusals of blood and/or blood products must be documented in the

Advance Directives ▪ Through the admission process, hospital inpatients are asked if they have an advance directive and the response

documented in the medical record. ▪ An Advance Directive Registry is maintained at CRMC which allows copies

hospitalizations. They are available through the Patient Representatives.

Ethical Issues ▪ The Ethics Committee deals with difficult treatment decisions, conflicts between caregivers and family, and lack

of consensus of care from caregivers. ▪ If needed, the Ethics Committee has a “Quick Response Team” to review an issue in a timely manner.

Patient’s Right to a Natural Death▪ It is the responsibility of the attending physician to review a living will and to enter appropriate

chart. ▪ Do Not Resuscitate Orders (DNR) must be written, signed, dated, and timed by the attending physician. ▪ Medical orders for a limited range of treatment options (MOST) must use the approved form and be signed, dated,

and timed. ▪ In addition to writing an order for DNR or MOST, the physician must write any entry in the progress notes and it

should be under continuous review to ensure that the orders remain current and appropriate. ▪ If a DNR or MOST patient requires surgery, the DNR or MOST

from anesthesia or is discharged from the PACU.

Organ, Tissue and Eye Procurement▪ All imminent and cardiac deaths will be evaluated for their potential as donors. ▪ No hospital staff or physician will discuss organ donation with families without consent of LifeShare.

Donation after Cardiac Death (DCD)▪ The approach to DCD may occur when a family has directed the healthcare team to withdraw life support of a

patient with a severe non-recoverable neurological devastation.▪ LifeShare will be notified to evaluate the patient for DCD.▪ Once the decision has been made to withdraw ventilator support, then the option of organ donation following

death by cardiopulmonary criteria can be offered to the family.▪ If DCD is an option and the family consents, LifeShare will conduct the authorization process and obtain written

consents for both organ and tissue donation. ▪ Pronouncement of death will be performed by the attending physician

NOT be involved in the organ/tissue or recovery team process. ▪ LifeShare will assemble a transplant team and contact the Main OR at CRMC. ▪ All expenses are covered by LifeShare.


The consent will remain in effect for the entire hospital stay. All refusals of blood and/or blood products must be documented in the medical record.

Through the admission process, hospital inpatients are asked if they have an advance directive and the response

An Advance Directive Registry is maintained at CRMC which allows copies to be available for future hospitalizations. They are available through the Patient Representatives.

The Ethics Committee deals with difficult treatment decisions, conflicts between caregivers and family, and lack caregivers.

If needed, the Ethics Committee has a “Quick Response Team” to review an issue in a timely manner.

Patient’s Right to a Natural Death It is the responsibility of the attending physician to review a living will and to enter appropriate

Do Not Resuscitate Orders (DNR) must be written, signed, dated, and timed by the attending physician. Medical orders for a limited range of treatment options (MOST) must use the approved form and be signed, dated,

on to writing an order for DNR or MOST, the physician must write any entry in the progress notes and it should be under continuous review to ensure that the orders remain current and appropriate. If a DNR or MOST patient requires surgery, the DNR or MOST will be suspended until the patient has recovered from anesthesia or is discharged from the PACU.

Organ, Tissue and Eye Procurement All imminent and cardiac deaths will be evaluated for their potential as donors. No hospital staff or physician will discuss organ donation with families without consent of LifeShare.

Donation after Cardiac Death (DCD) The approach to DCD may occur when a family has directed the healthcare team to withdraw life support of a

recoverable neurological devastation. LifeShare will be notified to evaluate the patient for DCD. Once the decision has been made to withdraw ventilator support, then the option of organ donation following

can be offered to the family. If DCD is an option and the family consents, LifeShare will conduct the authorization process and obtain written consents for both organ and tissue donation. Pronouncement of death will be performed by the attending physician or his/her designee. This physician will NOT be involved in the organ/tissue or recovery team process. LifeShare will assemble a transplant team and contact the Main OR at CRMC. All expenses are covered by LifeShare.

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Through the admission process, hospital inpatients are asked if they have an advance directive and the response

to be available for future

The Ethics Committee deals with difficult treatment decisions, conflicts between caregivers and family, and lack

If needed, the Ethics Committee has a “Quick Response Team” to review an issue in a timely manner.

It is the responsibility of the attending physician to review a living will and to enter appropriate orders in the

Do Not Resuscitate Orders (DNR) must be written, signed, dated, and timed by the attending physician. Medical orders for a limited range of treatment options (MOST) must use the approved form and be signed, dated,

on to writing an order for DNR or MOST, the physician must write any entry in the progress notes and it should be under continuous review to ensure that the orders remain current and appropriate.

will be suspended until the patient has recovered

No hospital staff or physician will discuss organ donation with families without consent of LifeShare.

The approach to DCD may occur when a family has directed the healthcare team to withdraw life support of a

Once the decision has been made to withdraw ventilator support, then the option of organ donation following

If DCD is an option and the family consents, LifeShare will conduct the authorization process and obtain written

or his/her designee. This physician will


Moderate Sedation ▪ Physicians must be credentialed to administer moderate sedation.▪ Administration is restricted to departments or patient care areas where specified monitoring, emergency

equipment, and required personnel can be provided.▪ Two personnel (Operator & Monitor) must be in attend▪ The Pre-Procedure and Pre-Sedation Assessment Form must be completed, timed, and dated by the physician

prior to administering any sedation.

Medication Reconciliation An accurate medication list is important for the patient’s health and safety. Pas follows: Upon admission

▪ Review home meds and determine if they will be continued/discontinued. ▪ Home meds must be reconciled before med orders can be processed and sent to pharmacy.

Upon transfer ▪ Review current meds and determine which ones should be continued/discontinued.

Upon surgery ▪ Review current meds and write orders for post

Upon discharge ▪ Review home med list AND current med list and then write order for discharge meds. ▪ “Resume meds from home” or “resume all pre

Code Purple Code Purple is used as a critical census alert when conditions in the ED are such that lack of inpatient capacity adversely impacts the ability of the ED staff to care for Code Purple Watch

▪ Paged when the ED has four admitted patients with no available beds.

Code Purple ▪ Paged when the ED has eight admitted patients with no available beds.▪ Physicians should evaluate patients to determine potential ▪ Accepting or refusing inbound transfers from other facilities will require direct communication between

physicians, shift manager, and/or administrator to review and discuss the circumstances.

Code Stroke ▪ The Rapid Response Team is called by the RN for all potential, new onset CVAs▪ Paged upon recognition of signs/symptoms of a stroke in a hospitalized patient. ▪ The RRT physician will request a code stroke be called


be credentialed to administer moderate sedation. Administration is restricted to departments or patient care areas where specified monitoring, emergency equipment, and required personnel can be provided. Two personnel (Operator & Monitor) must be in attendance.

Sedation Assessment Form must be completed, timed, and dated by the physician any sedation.

An accurate medication list is important for the patient’s health and safety. Please reconcile the patient’s medication list

Review home meds and determine if they will be continued/discontinued. Home meds must be reconciled before med orders can be processed and sent to pharmacy.

Review current meds and determine which ones should be continued/discontinued.

Review current meds and write orders for post-op meds.

Review home med list AND current med list and then write order for discharge meds. meds from home” or “resume all pre-op meds” are not acceptable orders.

Code Purple is used as a critical census alert when conditions in the ED are such that lack of inpatient capacity adversely impacts the ability of the ED staff to care for new patient arrivals.

Paged when the ED has four admitted patients with no available beds.

Paged when the ED has eight admitted patients with no available beds. Physicians should evaluate patients to determine potential discharges or transfers to a lower level of care.Accepting or refusing inbound transfers from other facilities will require direct communication between physicians, shift manager, and/or administrator to review and discuss the circumstances.

The Rapid Response Team is called by the RN for all potential, new onset CVAs

Paged upon recognition of signs/symptoms of a stroke in a hospitalized patient. The RRT physician will request a code stroke be called

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Administration is restricted to departments or patient care areas where specified monitoring, emergency

Sedation Assessment Form must be completed, timed, and dated by the physician

lease reconcile the patient’s medication list

Home meds must be reconciled before med orders can be processed and sent to pharmacy.

Code Purple is used as a critical census alert when conditions in the ED are such that lack of inpatient capacity adversely

discharges or transfers to a lower level of care. Accepting or refusing inbound transfers from other facilities will require direct communication between physicians, shift manager, and/or administrator to review and discuss the circumstances.


▪ In-Patient Stroke team includes: Rapid Respiratory Therapy and the Stroke Coordinator.

▪ This code is not overhead paged; members are notified by the Spectralink paging system. **If Last Known Well is Within the Last 6 Hours,

**If Last Known Well is Within the Last 24 Hours AND the Patient is Exhibiting Large Vessel Symptoms, Patient

is to be sent for STAT CTA Head/Neck. If Positive Transfer to Comprehensive Stroke Cent

Protection of Suicidal Patients (not on Psychiatry or in the Emergency Department)▪ Physician will assess and document a patient’s capacity to make healthcare decisions when there is a high risk of

suicidal or homicidal behavior. ▪ Patients who have been assessed as suicidal or homicidal will not be allowed to leave the Hospital until a

physician has determined that the patient is no longer a danger to self or others.▪ Attending physician should provide orders to deal with the situation.

Rapid Response Team

▪ There are three types of Rapid Response Teams (RRT’s) at CRMC:

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

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

o Obstetrical Rapid Response

▪ There are specific protocols available for each RRT. The protocol criteria are not exclusive, allowing healthcare staff to summon the RRT whenever a patient’s condition suddenly changes and deterioration in status is noted.

▪ Families may also activate RR if they have a concern about the patient they feel is not being addressed. ▪ RRT’s are activated by dialing “0” (Switchboard) and requesting RRT assistance at stated location and extension.

RRT’s 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 Record and placed in ▪ Reference the “Rapid Response Team Patient Care Protocol” (II

deteriorating conditions.

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 or non-invasive procedures in the outpatient setting w

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

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

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


Patient Stroke team includes: Rapid Response Team, Intensivist, Laboratory, Radiology CT, Shift Manager, Respiratory Therapy and the Stroke Coordinator. This code is not overhead paged; members are notified by the Spectralink paging system.

**If Last Known Well is Within the Last 6 Hours, call Intensivist to Determine if Pt is a TPA Candidate**


is to be sent for STAT CTA Head/Neck. If Positive Transfer to Comprehensive Stroke Cent

Protection of Suicidal Patients (not on Psychiatry or in the Emergency Department)Physician will assess and document a patient’s capacity to make healthcare decisions when there is a high risk of

assessed as suicidal or homicidal will not be allowed to leave the Hospital until a physician has determined that the patient is no longer a danger to self or others. Attending physician should provide orders to deal with the situation.

There are three types of Rapid Response Teams (RRT’s) at CRMC:

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

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

Obstetrical Rapid Response (Birthplace Team Leader, SWAT RN and SWAT PCT)

There are specific protocols available for each RRT. The protocol criteria are not exclusive, allowing healthcare staff to summon the RRT whenever a patient’s condition suddenly changes and deterioration in status is noted.

f they have a concern about the patient they feel is not being addressed. RRT’s are activated by dialing “0” (Switchboard) and requesting RRT assistance at stated location and extension. RRT’s are notified via the Spectralink paging system.

the RRT will assess the situation and utilize approved protocols as necessary. off information to the Hospitalist, the Attending Physician or responsible

consultant. Interventions are documented on the RRT Record and placed in the medical record. Reference the “Rapid Response Team Patient Care Protocol” (II-R-2 in Nursing Practice Guide) for triggers of

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.

invasive procedures in the outpatient setting will have 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.

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

9

Response Team, Intensivist, Laboratory, Radiology CT, Shift Manager,

This code is not overhead paged; members are notified by the Spectralink paging system. call Intensivist to Determine if Pt is a TPA Candidate**


is to be sent for STAT CTA Head/Neck. If Positive Transfer to Comprehensive Stroke Center

Protection of Suicidal Patients (not on Psychiatry or in the Emergency Department) Physician will assess and document a patient’s capacity to make healthcare decisions when there is a high risk of

assessed as suicidal or homicidal will not be allowed to leave the Hospital until a

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

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

(Birthplace Team Leader, SWAT RN and SWAT PCT)

There are specific protocols available for each RRT. The protocol criteria are not exclusive, allowing healthcare staff to summon the RRT whenever a patient’s condition suddenly changes and deterioration in status is noted.

f they have a concern about the patient they feel is not being addressed. RRT’s are activated by dialing “0” (Switchboard) and requesting RRT assistance at stated location and extension.

the RRT will assess the situation and utilize approved protocols as necessary. off information to the Hospitalist, the Attending Physician or responsible

the medical record. 2 in Nursing Practice Guide) for triggers of

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

ill have pain status addressed.


▪ There are multiple pain scales; the scale is selected based on the patient condition and/or understanding, but then all scales are converted to a 0-10 number, with 0pain.

Restraint Management ▪ Restraints are used only to reduce risk of self

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

▪ Restraints include the emergency or planned use of seof interventions.

▪ Medical/Surgical – Protects from unintentional self harm/injury.

▪ Behavioral – Violent, aggressive or destructive behavior posing a danger to self or others.

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.

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

Pt 18 and older must be seen every 8 hours after initiation of

restraint.

Pt 17 and younger must be seen every 4 hours after initiation of

restraint.

MD must document reason for restraint in progress notes

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 reason for restraint, patient condition both physical and

psychological, patient response to restraint, and justification to

continue use of restraint.


ain scales; the scale is selected based on the patient condition and/or understanding, but then 10 number, with 0-3 being mild pain, 4-6 moderate pain, and 7

Restraints are used only to reduce risk of self-injury or injury to others and only after noninterventions 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

Protects from unintentional self harm/injury.

Violent, aggressive or destructive behavior posing a danger to self or others.

type of restraint is NEVER determined by the equipment/medication being used. It is ALWAYS determined by the reason

Medical/Surgical Restraint

Patient must be seen within 1 hour after initiation Patient must be seen within 24 hours after initiation of restraint.

be seen every 8 hours after initiation of

and younger must be seen every 4 hours after initiation of

Orders: Need to be renewed every 24 hours

reason for restraint in progress notes every

in restraint. Restraint Progress Note can be


MD must document reason for restraint in progress notes

time you see patient in restraint. Restraint Progress Note can be


If Restraint Progress Note is not used, documentation must

include reason for restraint, patient condition both physical and


If Restraint Progress Note is not used, documentation must include

reason for restraint, patient condition both physical and


continue use of restraint.

10

ain scales; the scale is selected based on the patient condition and/or understanding, but then 6 moderate pain, and 7-10 being severe

injury or injury to others and only after non-physical, less restrictive

clusion, physical or chemical restraint and any combination

Violent, aggressive or destructive behavior posing a danger to self or others.

type of restraint is NEVER determined by the equipment/medication being used. It is ALWAYS determined by the reason

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

reason for restraint in progress notes every

in restraint. Restraint Progress Note can be

ted note meets all regulatory requirements.

If Restraint Progress Note is not used, documentation must include

reason for restraint, patient condition both physical and



Anticoagulation Therapy

When educating the patient/family on anticoagulation therapy, be sure to include the following:

▪ The importance of follow-up monitoring

▪ Compliance

▪ Drug-food interactions

▪ The potential for adverse drug reactions and interactions

Addressing Cultural Differences At CaroMont, we come in contact with patients from very diverse cultures and backgrounds. Patients’ behavior is

influenced by their culture, so it is important that to understand and respect their beliefs, values, and customs, even if th

are different from our own.

Common Areas Where Cultures Differ

▪ Views on Pain

o Some cultures value bearing pain silently, while others expect expressiveness.

▪ Dietary Preferences and Restrictions

o May eat or avoid certain food at certain times, or not eat some

▪ Conventional Medical Interventions

o Different views about when to seek professional medical help, treat oneself, or be treated by a family

member or traditional healer.

Ask questions:

▪ to avoid cultural stereotypes

▪ about views on health

▪ concerning privacy needs and accepted ways to show respect

▪ regarding patient's’ religious beliefs & family relationships.

Overcome Language Barriers

▪ Use CaroMont bilingual Spanish interpreters when appropriate, available Monday

Saturday-Sunday 7:00 a.m.-7:00 p.m.

▪ Use the Language Line when there is no immediate access to an interpreter. (You can ask a nurse of UCC for

assistance.

▪ Use one of the 150 forms available in Spanish that are available in the Form Directory on CHIP.

▪ Never use a patient’s family members or friends to interpret unless asking very basic information (name, address,

etc.)


When educating the patient/family on anticoagulation therapy, be sure to include the following:

up monitoring

The potential for adverse drug reactions and interactions

At CaroMont, we come in contact with patients from very diverse cultures and backgrounds. Patients’ behavior is

influenced by their culture, so it is important that to understand and respect their beliefs, values, and customs, even if th

Some cultures value bearing pain silently, while others expect expressiveness.

Dietary Preferences and Restrictions

May eat or avoid certain food at certain times, or not eat some foods at all.

Conventional Medical Interventions

Different views about when to seek professional medical help, treat oneself, or be treated by a family

member or traditional healer.

concerning privacy needs and accepted ways to show respect

’ religious beliefs & family relationships.

Use CaroMont bilingual Spanish interpreters when appropriate, available Monday-Friday 8:00 a.m.

7:00 p.m.

Use the Language Line when there is no immediate access to an interpreter. (You can ask a nurse of UCC for

Use one of the 150 forms available in Spanish that are available in the Form Directory on CHIP.

Never use a patient’s family members or friends to interpret unless asking very basic information (name, address,

11

At CaroMont, we come in contact with patients from very diverse cultures and backgrounds. Patients’ behavior is

influenced by their culture, so it is important that to understand and respect their beliefs, values, and customs, even if they

Different views about when to seek professional medical help, treat oneself, or be treated by a family

Friday 8:00 a.m.-6:30 p.m. and

Use the Language Line when there is no immediate access to an interpreter. (You can ask a nurse of UCC for

Use one of the 150 forms available in Spanish that are available in the Form Directory on CHIP.

Never use a patient’s family members or friends to interpret unless asking very basic information (name, address,


▪ Never use a child to interpret anything (prohibited by the Mental Health Developmental Disabilities and

Substance Abuse Act of 1985)

Quality can be defined as the degree to which health services for individuals and populations: Increase the likelihood of desired health outcomes; decrease the likelihood of undesirable health outcomes and are consistent with professional knowledge. CaroMont Health participates in several qualityorder to identify best practices while evaluating and implementing evidence based care.

These include (but may not be limited to): CMS and infections, (including hand washing and MRSA), reducing readmissions, etc. Specific diagnoses that include one or more of these initiatives include:

Diagnosis-Specific Infection

Sepsis Stroke AMI HF Pneumonia (PN) COPD Hip & Knee Surgery CABG Perinatal VTE

CAUTI CLABSI C Diff Surgical site infection*Sepsis within 7 days of admMRSA

*These items may be listed in multiple columns, showing the overlap or complexity of related items.

Maintaining high quality standards is not only best for our patients, but many are also tied to financial reimbursement. For those reasons, it is imperative that specific order sets are required to be used

▪ Document a contraindication in your H&▪ Reference the contraindication with the specific measure▪ Documentation must occur within acceptable timeframe

Required order sets (for core measures) are located in EHR and include:

▪ Sepsis ▪ Stroke

▪ AMI ▪ Heart Failure (Admit & Discharge Order Sets)▪ Surgery (SCIP)

▪ Pneumonia

▪ COPD

▪


Never use a child to interpret anything (prohibited by the Mental Health Developmental Disabilities and

Quality can be defined as the degree to which health services for individuals and populations: Increase the likelihood of desired health outcomes; decrease the likelihood of undesirable health outcomes and are consistent with professional

CaroMont Health participates in several quality-related initiatives that are recognized throughout the nation in order to identify best practices while evaluating and implementing evidence based care.

These include (but may not be limited to): CMS and TJC Core Measures, harm/never events, reducing hospitalinfections, (including hand washing and MRSA), reducing readmissions, etc. Specific diagnoses that include one or more

Infection-Related Surgery-Related

Other

Surgical site infection* Sepsis within 7 days of adm

Surgical site infection* Hip & knee surgery complications Outpatient surgery Wrong site surgery DVT/PE*

Falls/TraumaDVT/PE*Air EmbolismBlood incompatibility

*These items may be listed in multiple columns, showing the overlap or complexity of related items.

Maintaining high quality standards is not only best for our patients, but many are also tied to financial reimbursement. specific order sets are required to be used.

Document a contraindication in your H&P, progress notes, or discharge summary. Reference the contraindication with the specific measure

Documentation must occur within acceptable timeframe

Required order sets (for core measures) are located in EHR and include:

Heart Failure (Admit & Discharge Order Sets)

12

Never use a child to interpret anything (prohibited by the Mental Health Developmental Disabilities and

Quality

Quality can be defined as the degree to which health services for individuals and populations: Increase the likelihood of desired health outcomes; decrease the likelihood of undesirable health outcomes and are consistent with professional

related initiatives that are recognized throughout the nation in

TJC Core Measures, harm/never events, reducing hospital-acquired infections, (including hand washing and MRSA), reducing readmissions, etc. Specific diagnoses that include one or more

Other

Falls/Trauma DVT/PE* Air Embolism Blood incompatibility

*These items may be listed in multiple columns, showing the overlap or complexity of related items. Maintaining high quality standards is not only best for our patients, but many are also tied to financial reimbursement.


Core measure needs are communicated by: ▪ Inbasket messages within the EMR▪ Phone Calls to providers

▪ E-mails (if patient has been discharged and we have Specific core measure and quality metric requirements, along with more detailed explanations are located in the Appendix.

Peer Review Process Peer reviews are confidential and completedthe process. (Reference Medical Staff Bylaws/Rules and Regulations for more details.) Results of peer review will be maintained in respective software systems .

Appropriate Care - No follow

Questionable or

Inappropriate Care Should the PRC Chair deem necessary, cases are presented to Peer Review Committee. Findings and recommendations are reported to MEC.

Professional Practice EvaluationsFPPE – Focused Professional Practice Evaluations: a process which evaluates a practitionerto perform a specific privilege. These evaluations are done for new practitioners, new procedures or whenever a question arises regarding a practitioner’s ability to provider safe, high quality patient care (trend). FPPEs are geared to retaining practitioner while improving performance on aby the Quality Lead, Medical Director or Service Line Administrator. OPPE - Ongoing Professional Practice Evaluations: aassessing a practitioner’s clinical competence and professional behavior. The information gathered during this process factors into the decision to maintain, revise or revoke existing privileges. Such evaluations are completed for eachpractitioner bi-annually. Each Quality Lead, Medical Director or Service Line Administrator is required to review all department members bi-annually. Such information is maintained and available to software system.


within the EMR

if patient has been discharged and we have time to dictate an addendum for Core Measure Compliance)

Specific core measure and quality metric requirements, along with more detailed explanations are located in the

completed by the appropriate Service Line. The determination will specify next steps in the process. (Reference Medical Staff Bylaws/Rules and Regulations for more details.) Results of peer review will be maintained in respective software systems .

follow-up required

Should the PRC Chair deem necessary, cases are presented to Peer Review Committee. Findings and recommendations are reported to MEC.

To Medical Executive Committee for formal recommendations (proctorship, mentoring, FPPE process, etc.)

Professional Practice Evaluations (FPPE/OPPE) Professional Practice Evaluations: a process which evaluates a practitioner’s competence and/or ability

evaluations are done for new practitioners, new procedures or whenever a question arises regarding a practitioner’s ability to provider safe, high quality patient care (trend). FPPEs are geared to retaining practitioner while improving performance on a specific issue. They are initiated by the PR Coordinator and completed

by the Quality Lead, Medical Director or Service Line Administrator.

Ongoing Professional Practice Evaluations: a documented summary of ongoing data collected for the purpoassessing a practitioner’s clinical competence and professional behavior. The information gathered during this process

to maintain, revise or revoke existing privileges. Such evaluations are completed for eachannually. Each Quality Lead, Medical Director or Service Line Administrator is required to review all

annually. Such information is maintained and available to each practitioner

13

time to dictate an addendum for Core Measure Compliance)

Specific core measure and quality metric requirements, along with more detailed explanations are located in the

ropriate Service Line. The determination will specify next steps in the process. (Reference Medical Staff Bylaws/Rules and Regulations for more details.) Results of peer review will be

To Medical Executive Committee for formal (proctorship, mentoring, FPPE

’s competence and/or ability evaluations are done for new practitioners, new procedures or whenever a question

arises regarding a practitioner’s ability to provider safe, high quality patient care (trend). FPPEs are geared to retaining the They are initiated by the PR Coordinator and completed

documented summary of ongoing data collected for the purpose of assessing a practitioner’s clinical competence and professional behavior. The information gathered during this process

to maintain, revise or revoke existing privileges. Such evaluations are completed for each

annually. Each Quality Lead, Medical Director or Service Line Administrator is required to review all each practitioner via STATIT


Clinical Documentation ProgramA department of nurses within the Quality/CPI department have been trained in CaroMont’s clinical documentation program. This program helps facilitate accurate documentation for coding purposes and to capture severity of illness andrisk of mortailty., CDS staff may query the provider when additional documentation may be needed or is recommended. More detailed information and related education will be provided whenever a query is made to a new providerneeded. The phone number of teh CDS member placing the query will be at the bottom of the query. Other quality-related initiatives include: American Heart Associationcertifications for Stroke.

Hand Hygiene In 2017, hand hygiene compliance by providers increased to 87% from 81% in 201(HAIs) continue to be a serious problem for healthcare organizations and hand hygiene is the single moin 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:

o before and after each patient contact

o after contact with blood, body fluids, secretions, excretions, or non

o after contact with equipment, environmental surfaces, devices or removing gloves

▪ Hand hygiene should be performed between tasks and procedures on the same patient to prevencontamination 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).

▪ Handwashing with soap and running water is recommended if hands are visseconds. Turn the faucet off with a dry paper towel to avoid re

▪ ABHR is the most effective and preferred metcaring for patients with Clostridium difficile or Norovirus. ABHR does not kill spores; so decontamination with alcohol may not be as effective in these patients.

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


Documentation Program A department of nurses within the Quality/CPI department have been trained in CaroMont’s clinical documentation program. This program helps facilitate accurate documentation for coding purposes and to capture severity of illness andrisk of mortailty., CDS staff may query the provider when additional documentation may be needed or is recommended. More detailed information and related education will be provided whenever a query is made to a new provider

The phone number of teh CDS member placing the query will be at the bottom of the query.

related initiatives include: American Heart Association-Get with the Guidelines, TJC

Infection Prevention and Control

, hand hygiene compliance by providers increased to 87% from 81% in 2016. Healthcare(HAIs) continue to be a serious problem for healthcare organizations and hand hygiene is the single mo

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

Hand hygiene should be performed between tasks and procedures on the same patient to prevencontamination 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).

with soap and running water is recommended if hands are visibly soiled 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 Clostridium difficile or Norovirus. ABHR does not kill spores; so decontamination with alcohol may not be as effective in these patients.

ed in all patient care rooms, clinics and primary care sites.

14

A department of nurses within the Quality/CPI department have been trained in CaroMont’s clinical documentation program. This program helps facilitate accurate documentation for coding purposes and to capture severity of illness and risk of mortailty., CDS staff may query the provider when additional documentation may be needed or is recommended. More detailed information and related education will be provided whenever a query is made to a new provider and as

The phone number of teh CDS member placing the query will be at the bottom of the query.

Get with the Guidelines, TJC-Disease-specific

Prevention and Control

Healthcare-associated infections (HAIs) continue to be a serious problem for healthcare organizations and hand hygiene is the single most important action

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

after contact with equipment, environmental surfaces, devices or removing gloves

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

ibly soiled for a minimum of 15 contamination of hands.

hod of hand hygiene except when hands are visibly soiled and after caring for patients with Clostridium difficile or Norovirus. ABHR does not kill spores; so decontamination with

ed in all patient care rooms, clinics and primary care sites.


o 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’environment

CaroMont Health has a comprehensive Hand Hygiene Audit Program. If you are observed or coached about not adhering

to hand hygiene, please respond with “thank you for reminding me.” Audits are tabulated into monthly results and shared

with all staff. Hand hygiene observations are collected, reported and posted monthly on CHIP (the hospital intranet).

In 2018, Hand Hygiene audits will continue throughout the CaroMont Health system with data reported to providers and

personnel.

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 o

care and maintenance of Foley Catheters can prevent CAUTI. This includes:

▪ Cleaning patient’s perineum prior to Foley insertion.

▪ Using sterile technique when inserting Foley.

▪ Using securement device to secure Foley to upper leg.

▪ Maintaining closed drainage system.

▪ Keeping drainage bag below level of bladder.

▪ Emptying drainage bag when 2/3 full and whenever patient leaves unit.

▪ Using Foley removal protocol and promptly removing Foley catheters when patient no longer meets the keep a Foley catheter.

▪ Educate patients, and their families as needed, on CAUTI prevention and the symptoms of a UTI. Other methods for urinary management, such as female urinals, condom catheters, or in

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 chances to introduce bacteria to the urinary tract.

Central Line Associated Blood-Stream

● Promptly remove unnecessary central lines.

● Follow proper insertion practices: C.L.I.P.

● Perform hand hygiene before insertion.

● Adhere to aseptic technique.


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’



all staff. Hand hygiene observations are collected, reported and posted monthly on CHIP (the hospital intranet).


ssociated 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 o

care and maintenance of Foley Catheters can prevent CAUTI. This includes:

Cleaning patient’s perineum prior to Foley insertion.

Using sterile technique when inserting Foley.

Using securement device to secure Foley to upper leg.

Maintaining closed drainage system.

Keeping drainage bag below level of bladder.

Emptying drainage bag when 2/3 full and whenever patient leaves unit.

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

Educate patients, and their families as needed, on CAUTI prevention and the symptoms of a UTI.

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


ese devices may reduce the need for urinary catheterization to assess residual urine volume. Fewer

out catheterizations, mean fewer chances to introduce bacteria to the urinary tract.

Stream Infections (CLABSIs) Promptly remove unnecessary central lines.

Follow proper insertion practices: C.L.I.P. – Central Line Insertion Practices

Perform hand hygiene before insertion.

15

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



all staff. Hand hygiene observations are collected, reported and posted monthly on CHIP (the hospital intranet).


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,

Using Foley removal protocol and promptly removing Foley catheters when patient no longer meets the criteria to

Educate patients, and their families as needed, on CAUTI prevention and the symptoms of a UTI.

out catheterization, should be


ese devices may reduce the need for urinary catheterization to assess residual urine volume. Fewer

out catheterizations, mean fewer chances to introduce bacteria to the urinary tract.


● Use maximal sterile barrier precautions (

● 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.

● Cover the site with sterile gauze or sterile, transparent, semi permeable dressings, BioPatch.

● Handle and maintain central lines appropriately:

● Comply with hand hygiene requirements.

● Scrub the access port or hub for 15 seconds immediately prior to 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 & mask

●

Importance of Preventing CLABSIs (Central

▪ National estimates indicate the cost of a Bloodstream infection around $45,CLABSIs with MRSA. CLABSIs with MRSA resulted in the highest attributed excess LOS of 23 days. CLABSIs lead to an increased length of stay as well an increase in risk of death.

▪ CLABSIs happen when pathogens are introduced into the bloofrom the hub or connector of the catheter. 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. If it’s determined that the patient continuincluding documentation (CHG bathing and Scrub the Hub).

▪ Use of chlorhexidine for bathing of patients with CL is a recommendation from the CDC for prevention of CLABSI (excluding NICU). This practice has been approved and placed into practice for all in(excluding NICU) at Caromont Health in July 2012.

▪ CUROS caps placed on all CL ports, TEGOS highTEGOS for dialysis catheters.

▪ CLABSI surveillance has been extended to include hemodialysis catheters.

▪ Prior to insertion, educate patients and, as needed, their families about central line infection prevention.


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.

nts.

Cover the site with sterile gauze or sterile, transparent, semi permeable dressings, 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 & mask

Importance of Preventing CLABSIs (Central-Line Associated Blood Stream Infections): National estimates indicate the cost of a Bloodstream infection around $45,814per episode

LABSIs with MRSA resulted in the highest attributed excess LOS of 23 days. CLABSIs lead to an increased length of stay as well an increase in risk of death.

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!

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. If 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 CL is a recommendation from the CDC for prevention of U). This practice has been approved and placed into practice for all in

at Caromont Health in July 2012.

CUROS caps placed on all CL ports, TEGOS high-flow needleless connector with White CUROS caps for

CLABSI surveillance has been extended to include hemodialysis catheters.

Prior to insertion, educate patients and, as needed, their families about central line

16

i.e., mask, cap, gown, sterile gloves, and sterile full body drape).

Cover the site with sterile gauze or sterile, transparent, semi permeable dressings, BioPatch.

each use with an appropriate antiseptic (e.g.,

per episode qne $58,614 for LABSIs with MRSA resulted in the highest attributed excess LOS of 23 days. 1

dstream from the skin around the insertion site or Following proper insertion, maintenance practices, and removal of

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. If it’s

es to have a need for CL, it is important to complete daily maintenance

Use of chlorhexidine for bathing of patients with CL is a recommendation from the CDC for prevention of U). This practice has been approved and placed into practice for all inpatients with CL

flow needleless connector with White CUROS caps for

Prior to insertion, educate patients and, as needed, their families about central line - associated bloodstream


Clostridium difficile (C.diff)

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

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 fiv

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

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

● C.diff prevention activities implemented at CRMC include antibiotic de

duration of stay), use of dedicated equipment

Multi-Drug Resistant Infections (MDRO)● Per the 2018 CRMC Antibiogram, about 60% of CaroMont Health Staphylococcus aureus isolates are MRSA,

resistant to nafcillin, cephalosporins and beta

piperacillin/tazobactam).

● Patient risk factors for MDRO include

catheters, antibiotic therapy, surgical procedures and immuno

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

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 authorized to discontinue Contact Precautions for MD

● 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.

● Educate patients, and their families as needed, about health care associated infection prevention strategies.


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


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 fiv


become colonized with it in their gut.

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

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.

Drug Resistant Infections (MDRO) 2018 CRMC Antibiogram, about 60% of CaroMont Health Staphylococcus aureus isolates are MRSA,

resistant to nafcillin, cephalosporins and beta-lactamase inhibitors (e.g., ampicillin/sulbactam,

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 infe



ion 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 authorized to discontinue Contact Precautions for MD

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

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

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

Educate patients, and their families as needed, about health care associated infection prevention strategies.

17

associated gastrointestinal illness. It


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


pump inhibitors, chemotherapy or gastrointestinal surgery are at a higher

escalation, enteric contact isolation (for

, and use of bleach to terminally clean rooms.

2018 CRMC Antibiogram, about 60% of CaroMont Health Staphylococcus aureus isolates are MRSA,

lactamase inhibitors (e.g., ampicillin/sulbactam,

stays in critical care, devices present including central lines and Foley

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



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

Only an Infection Preventionist is authorized to discontinue Contact Precautions for MDRO’s.

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

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

Educate patients, and their families as needed, about health care associated infection prevention strategies.


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 s

instance). VRE can be carried on our hands or contaminated equipment.

Carapenem-Resistant Enterobacteriaceae (CRE)● Enterobacteriaceae resides in our intestines as normal flora. It concerns us

antibiotics, including carbapenems.

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

contaminated equipment.

Extended Spectrum Beta Lactamase (ESBL)● The most common ESBL producing organisms include Klebsiella sp, Enterobacter sp, Acientobacter sp and

Escherichia coli.

● The bacteria develop resistance to beta

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) - Strategies to Reduce SSI Include:

▪ National estimated indicate the cost of a SSI around $20,785 and those with MRSA more than doubled the cost to $42,300 1 .

▪ Colon Order Set is to be used for COLO procedures.

▪ Whenever possible, identify and treat all infections remote to the surgical site before epostpone 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 location outside OR or proc

▪ 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

▪ Patients should shower with an antiseptic soap; 4% chlorhexidine gluconate (CHG) on the day prior to and 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


Vancomycin Resistant Enterococcus (VRE) 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.

Resistant Enterobacteriaceae (CRE) Enterobacteriaceae resides in our intestines as normal flora. It concerns us when it develops resistance to

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

Extended Spectrum Beta Lactamase (ESBL) ESBL producing organisms include Klebsiella sp, Enterobacter sp, Acientobacter sp and

The bacteria develop resistance to beta-lactam antibiotics, including penicillins and cephalosporins, and can also

such as aminoglycosides (e.g.. gentamycin and tobramycin) and quinolones (e.g.,

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

Strategies to Reduce SSI Include: estimated indicate the cost of a SSI around $20,785 and those with MRSA more than doubled the cost to

Colon Order Set is to be used for COLO procedures.

Whenever possible, identify and treat all infections remote to the surgical site before epostpone elective operations until the infection has resolved.

operatively; if it interferes with the procedure, remove immediately prior to Hair should be removed in location outside 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.

op application of CHG to the skin is recommended for high risk, high volume, problem

Patients should shower with an antiseptic soap; 4% chlorhexidine gluconate (CHG) on the day prior to and day of

an at and around the potential incision site to remove gross contamination before performing antiseptic skin preparation. Chloroprep is the recommended skin prep; a 30-

18

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

uch as cotton and polyester (scrubs and privacy curtains for

when it develops resistance to

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

ESBL producing organisms include Klebsiella sp, Enterobacter sp, Acientobacter sp and

lactam antibiotics, including penicillins and cephalosporins, and can also

such as aminoglycosides (e.g.. gentamycin and tobramycin) and quinolones (e.g.,

estimated indicate the cost of a SSI around $20,785 and those with MRSA more than doubled the cost to

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

operatively; if it interferes with the procedure, remove immediately prior to edure 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.

op application of CHG to the skin is recommended for high risk, high volume, problem-prone procedures.

Patients should shower with an antiseptic soap; 4% chlorhexidine gluconate (CHG) on the day prior to and day of

an at and around the potential incision site to remove gross contamination before -second friction scrub with


a back and forth motion is necessary; a 120pooling.

▪ Post-operative incision care should have the sterile dressing left intact until postsurgery = day zero). If dressing is manipulated prior to day two use sterile technique.

▪ Staph aureus nasal screening for high risk surgical procedures (placement of implanted materials)

▪ Preoperative antibiotics should be adminispathogens, dose 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▪ Educate patients, and their families as needed, about surgical site infection prevention.

Ventilator-Associated Events (VAEs)● National estimates indicate the cost of a ventilator

length of stay of 13.1 days. 1

● Physicians coordinating care and standardizing patient care protocols.

● Physical Therapy protocol for progressive m

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

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

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 Ce

and Medicaid. ASP 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. ASP reduce hospital rates of Clostridium difficile infections and reduces antibiotic resistance, as well as saes

the hospital money.

At CRMC, we utilize an electronic program, TheraDoc

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 c


a back and forth motion is necessary; a 120-second scrub is required for the groin. Allow to dry 3 minutes; avoid

operative incision care should have the sterile dressing left intact until post-operative day two (day of surgery = day zero). If dressing is manipulated prior to day two use sterile technique.

Staph aureus nasal screening for high risk surgical procedures (placement of implanted materials)

Preoperative antibiotics should be administered within 60 minutes of surgery, agent appropriate for the anticipated dosed per the Caromont Health Antibiotic grid. Surgical prophylaxis should be stopped at

Urinary catheters are removed on POD 1 or POD 2 with day of surgery begin day zero. Educate patients, and their families as needed, about surgical site infection prevention.

Associated Events (VAEs) National estimates indicate the cost of a ventilator-associated pneumonia to be around $40,144 and increased

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


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



axis. ASP reduce hospital rates of Clostridium difficile infections and reduces antibiotic resistance, as well as saes

At CRMC, we utilize an electronic program, TheraDoc�, to pull in real-time culture information in order to follow sepsis

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.

19

equired for the groin. Allow to dry 3 minutes; avoid

operative day two (day of

Staph aureus nasal screening for high risk surgical procedures (placement of implanted materials)

tered within 60 minutes of surgery, agent appropriate for the anticipated dosed per the Caromont Health Antibiotic grid. Surgical prophylaxis should be stopped at

associated pneumonia to be around $40,144 and increased

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

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


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



axis. ASP reduce hospital rates of Clostridium difficile infections and reduces antibiotic resistance, as well as saes

time culture information in order to follow sepsis

bug mismatches. Recommendations are made by the Antimicrobial Stewardship

ontacting the provider.


Vaccine Preventable Diseases Studies published in the Journal of the American Medical Association (JAMA)

measles and pertussis. Measles and pertussis (whooping cough), both

States. Measles was declared eradicated from the United States in 2000 but has recently resurged, with 667 cases in 2014

and 189 in 2015, according the the Centers for Disease Control and Prevention (CDC).

2,000 U.S. cases for several years in the 1970’s and ‘80s before resurging to more than 48,000 cases in 2012, a 6

high, according to the CDC. CDC urges healthcare professionals to consider measles when evaluating pati

febrile rash and ask about a patient’s vaccine status, recent travel history, and contact with individuals who have febrile

rash illness.

Measles is an acute viral respiratory illness. It is characterized by a prodrome of fever (as high as 105°F

cough, coryza, and conjunctivitis – the three “C”s

maculopapular rash. The rash usually appears about 14 days after a person is exposed; however, the incubation period

ranges from 7 to 21 days. The rash spreads from the head to the trunk to the lower extremities. Patients are considered to

be contagious from 4 days before to 4 days after the rash appears. Of note, sometimes immunocompromised patients do

not develop the rash.

Influenza Vaccine: For the safety of our patients and community, and to comply with national recommendations, the

influenza vaccination is mandatory for all CaroMont Health employees, volunteers, students, vendors, active and courtesy

medical staff members, and advanced care practitioners unless they have an approved declination. Active and Courtesy

Medical Staff and Advanced Care Practitioners who are not vaccinated or fail to submit proof will be asked to take a

Leave of Absence for the entire influenza season or b

The Bloodborne Pathogens Plan and TB Plan

The Bloodborne Pathogens (BBP) Plan and the TB Plan are both located on CHIP in Compliance 360.

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 pro

against HIV.

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

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

CaroMont Health to personnel workin

as a series of three injections over a six

checked following the 3rd injection to ensure protection.


Journal of the American Medical Association (JAMA) in 2016 relates vaccine refusal to a rise in

measles and pertussis. Measles and pertussis (whooping cough), both highly contagious, are on the rise in the United


and 189 in 2015, according the the Centers for Disease Control and Prevention (CDC). Pertussis dropped to fewer than

2,000 U.S. cases for several years in the 1970’s and ‘80s before resurging to more than 48,000 cases in 2012, a 6

CDC urges healthcare professionals to consider measles when evaluating pati


Measles is an acute viral respiratory illness. It is characterized by a prodrome of fever (as high as 105°F

the three “C”s – a pathognomonic enanthema (Koplik spots) followed by a


21 days. The rash spreads from the head to the trunk to the lower extremities. Patients are considered to


accine: For the safety of our patients and community, and to comply with national recommendations, the


ced care practitioners unless they have an approved declination. Active and Courtesy


Leave of Absence for the entire influenza season or be placed on Administrative Leave.

The Bloodborne Pathogens Plan and TB Plan


The BBP Plan includes the following information:

hospital (biohazard signs).

BBP are microorganisms that are carried in the blood and body fluids of infected people and include HIV, HBV

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

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

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

CaroMont Health 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 3rd injection to ensure protection.

20

in 2016 relates vaccine refusal to a rise in

highly contagious, are on the rise in the United


Pertussis dropped to fewer than

2,000 U.S. cases for several years in the 1970’s and ‘80s before resurging to more than 48,000 cases in 2012, a 6-year

CDC urges healthcare professionals to consider measles when evaluating patients with


Measles is an acute viral respiratory illness. It is characterized by a prodrome of fever (as high as 105°F) and malaise,

a pathognomonic enanthema (Koplik spots) followed by a


21 days. The rash spreads from the head to the trunk to the lower extremities. Patients are considered to


accine: For the safety of our patients and community, and to comply with national recommendations, the


ced care practitioners unless they have an approved declination. Active and Courtesy



BBP are microorganisms that are carried in the blood and body fluids of infected people and include HIV, HBV

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

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

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

g in a job that puts them at risk for exposure to HBV. This vaccine is given

month period and is safe and effective. Hepatitis B titer should be


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

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

membranes via sharps injuries, puncture wounds and/or non

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

protective equipment (mask, gloves, gowns, face shields).

● Use standard precautions with all patients every time that you anticipate contact with blood, body fluids, no

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 or mouth with water immediately following a splash. Report the exposure incident to 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

people with active TB cough, sing, speak or sneeze.

● TB may be active or inactive (also called 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.

● TB skin test (TST) is the test provided at CaroMont Health and is placed intradermally and read after 48

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

EHS and/or Department of Health. Personnel are screened prior to employment and annually thereafter.

● Early detection, isolation and treatment is key to controlli

● At CaroMont Regional Medical Center, patients 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

day); the door is kept closed and personnel are required to wear a fit tested respirator mask to enter.

Please notify Infection Prevention and Control (ext. 2913) or Employee Health Services (ext. 2179) for additional

information or questions about either of these plans.

1. Health-Care Associated Infections: A Meta

System. JAMA Intern Med. 2013:173(22):2039

September 2, 2013.

Emergency management is the discipline of dealing with and avoiding risks. It is the continuous process by which all individuals, groups, and communities manage hazards in an effort to avoid or ameliorate the impact of from hazards.


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

BBP are transmitted through direct contact with infected blood and body fluids which enter through mucous

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

ion is always practicing standard precautions, which includes using appropriate personal

protective equipment (mask, gloves, gowns, face shields).

Use standard precautions with all patients every time that you anticipate contact with blood, body fluids, no

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


anager 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 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

TB skin test (TST) is the test provided at CaroMont Health and is placed intradermally and read after 48

action means you’ve probably been exposed to the TB germ and will need further follow


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

At CaroMont Regional Medical Center, patients suspected or known to be infected with TB are placed on

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



s about either of these plans.

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

Emergency Management

Emergency management is the discipline of dealing with and avoiding risks. It is the continuous process by which all individuals, groups, and communities manage hazards in an effort to avoid or ameliorate the impact of

21

BBP are transmitted through direct contact with infected blood and body fluids which enter through mucous

ion is always practicing standard precautions, which includes using appropriate personal

Use standard precautions with all patients every time that you anticipate contact with blood, body fluids, non-

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


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

It is spread through the air when

TB may be active or inactive (also called 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

TB skin test (TST) is the test provided at CaroMont Health and is placed intradermally and read after 48-72 hours.

action means you’ve probably been exposed to the TB germ and will need further follow-up with


At CaroMont Regional Medical Center, patients suspected or known to be infected with TB are placed on

Airborne Isolation Precautions means the patient is placed in a negative pressure room (checked by Nursing each



analysis of Costs and Financial Impact on the U.S. Health Care

2046.loi:10.1001/jamainternmed.2013.9763 Published online

Emergency Management

Emergency management is the discipline of dealing with and avoiding risks. It is the continuous process by which all individuals, groups, and communities manage hazards in an effort to avoid or ameliorate the impact of disasters resulting


Physicians perform a vital role during an emergency response event (e.g., mass casualty event, hazardous material incident, infrastructure failure, etc.). Whenever advised of an emergency response situation, all availablereport to CRMC or other designated site. Four (4) keys for Medical Staff emergency management response:

▪ Understand the overall Incident Command structure

▪ 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. Chief of Staff is notified whenactivated. Chief of Staff will receive situation briefing from Incident Command. Chief of Staff will communicate with Medical Staff and co-direct medical staff response with the Medical Staff Branch Director. Medical Staff Branch Direccoordinates medical staff response and reports to the Operations Section Chief in the Incident Command structure.

Four roles in Medical Staff Branch:

▪ Medical Staff Branch Director - coordinates medical staff response and assignments.

▪ Inpatient Medical Unit Leader - coordinates inpatient processing.

▪ Medical Support Services Unit Leader

support functions (Laboratory, Radiology, Respiratory, Infection Prevention, et

▪ Mass Casualty Medical Care Unit Leader

Section to coordinate the triage, treatment, and management of casualties, including oncommunication, surgical case coordinationphysician, and other medical staff resources deployed to respond to mass casualty incident.


Physicians perform a vital role during an emergency response event (e.g., mass casualty event, hazardous material incident, infrastructure failure, etc.). Whenever advised of an emergency response situation, all available

Four (4) keys for Medical Staff emergency management response: Understand the overall Incident Command structure

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. Chief of Staff is notified whenactivated. Chief of Staff will receive situation briefing from Incident Command. Chief of Staff will communicate with

direct medical staff response with the Medical Staff Branch Director. Medical Staff Branch Direccoordinates medical staff response and reports to the Operations Section Chief in the Incident Command structure.

coordinates medical staff response and assignments.

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 oncommunication, surgical case coordination physician, immediate care area physician, alternate care area physician, and other medical staff resources deployed to respond to mass casualty incident.

22

Physicians perform a vital role during an emergency response event (e.g., mass casualty event, hazardous material incident, infrastructure failure, etc.). Whenever advised of an emergency response situation, all available medical staff

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

Incident Command structure facilitates the optimal response. Chief of Staff is notified when Incident Command is activated. Chief of Staff will receive situation briefing from Incident Command. Chief of Staff will communicate with

direct medical staff response with the Medical Staff Branch Director. Medical Staff Branch Director coordinates medical staff response and reports to the Operations Section Chief in the Incident Command structure.

prioritizes and expedites testing/treatment procedures and coordinates

works directly with Casualty Care Unit Leader in Operations Section to coordinate the triage, treatment, and management of casualties, including on-the-scene physician

physician, immediate care area physician, alternate care area physician, and other medical staff resources deployed to respond to mass casualty incident.


Code RED Code Red is paged to indicate the presence of fire, smoke and/or burning odor. Physicians and other LIPs should remain in the area they are located at the time an alarm sounds and to render assistance under the direction of the manager or employees in the area as needs arise. (Reference Environment of Care policy EC.5.10)

If you are directly involved with a fire, implement RACE:

▪ Rescue patients

▪ Activate by pulling alarm & dial 911

▪ Contain by closing doors & clearing halls

▪ Extinguish if possible or evacuate

Our building is constructed to withstand the spread off. Fire and smoke doors are a major component of the compartmentalization concept. They cannot be blocked or impaired from closing. If the need for evacuation arises, there are two types Partial - The movement of patients or a department to another location within the hospital. There are two types of partial evacuation:

▪ Horizontal - Movement on the same hospital level beyond the smoke barrier and normallthe facility.

▪ Vertical - Movement up or down one or more hospital levels using the nearest unencumbered exit stairwell. Elevators cannot be used.

Full - The movement of all patients and staff to safety outside the hospital, to


Environment of Care

Code Red is paged to indicate the presence of fire, smoke and/or burning odor. Physicians and other LIPs should remain in the area they are located at the time an alarm sounds and to render assistance under the direction of the manager or

area as needs arise. (Reference Environment of Care policy EC.5.10)

If you are directly involved with a fire, implement To use a fire extinguisher, implement

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. If the need for evacuation arises, there are two types if evacuation: partial or full.

The movement of patients or a department to another location within the hospital. There are two types of partial

Movement on the same hospital level beyond the smoke barrier and normall

Movement up or down one or more hospital levels using the nearest unencumbered exit stairwell.

The movement of all patients and staff to safety outside the hospital, to another hospital or to alternative sites.

23

Environment of Care

Code Red is paged to indicate the presence of fire, smoke and/or burning odor. Physicians and other LIPs should remain in the area they are located at the time an alarm sounds and to render assistance under the direction of the manager or

To use a fire extinguisher, implement PASS: ▪ Pull pin

▪ Aim nozzle at base of the fire

▪ Squeeze handles together

▪ Sweep from side to side

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

if evacuation: partial or full.

The movement of patients or a department to another location within the hospital. There are two types of partial

Movement on the same hospital level beyond the smoke barrier and normally toward the exterior of

Movement up or down one or more hospital levels using the nearest unencumbered exit stairwell.

another hospital or to alternative sites.


Environment of Care Basics

What are some general safety risks in your work area?

▪ Remove/confine the safety hazard and call Housekeeping to assist in the clean

▪ Work orders can be filed from CHIP page under the

Services can be called to assist.

▪ For medical equipment that is broken or damaged, you can fill out a CRT tag request on CHIP under Service

Requests tab on the left side of the page.

▪ For acutely hazardous spills:

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

o Insure affected persons are evacuated and receive medical treatment.

o Use adequate personal protective equipment.

o Evaluate need to evacuate or restrict access to area.

o Notify your supervisor.

o Contact the Nursing Shift Manager (ext. 2131)

What is an incident?

▪ Any occurrence that is not in line with the routine operation of CaroMont Health.

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

▪ Notify the Nursing Shift Manager (ext 2131) and complete a Quantros Report as soon as feasible, or within 24

hours of the incident

What should you do if there is a serious incident emergency or a sentinel event?

▪ Call 911 (emergency operator) to report the serious incident emergency.

▪ Notify Patient Safety and Risk Management as soon as possible in the case of a sentinel event.

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

▪ Notify Security immediately of all visit

▪ If the staff member discovering the incident believes that the visitor should go to the Emergency Department, this

fact and reason must be noted on the Quantros Report.


What are some general safety risks in your work area?

Remove/confine the safety hazard and call Housekeeping to assist in the clean-up.

Work orders can be filed from CHIP page under the Service Request link. If there is an immediate need, Facility

For medical equipment that is broken or damaged, you can fill out a CRT tag request on CHIP under Service

Requests tab on the left side of the page.

Isolate the area to prevent tracking and disturbing the spill.

Insure affected persons are evacuated and receive medical treatment.

Use adequate personal protective equipment.

Evaluate need to evacuate or restrict access to area.

Contact the Nursing Shift Manager (ext. 2131)

Any occurrence that is not in line with the routine operation of CaroMont Health.

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


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

What should you do if there is a serious incident emergency or a sentinel event?

(emergency operator) to report the serious incident emergency.

Notify Patient Safety and Risk Management as soon as possible in the case of a sentinel event.

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

Notify Security immediately of all visitor incidents involving theft.

If the staff member discovering the incident believes that the visitor should go to the Emergency Department, this

fact and reason must be noted on the Quantros Report.

24

Service Request link. If there is an immediate need, Facility

For medical equipment that is broken or damaged, you can fill out a CRT tag request on CHIP under Service

Report the injury to your supervisor; seek medical attention (if needed) through Employee Health and complete a


Notify the Nursing Shift Manager (ext 2131) and complete a Quantros Report as soon as feasible, or within 24

Notify Patient Safety and Risk Management as soon as possible in the case of a sentinel event.

If the staff member discovering the incident believes that the visitor should go to the Emergency Department, this


Where can you smoke at CaroMont Health?

▪ Smoking is not permitted inside any CaroMont Health building, and there are no exceptions.

Healthcare Reform and Impact to CaroMont Health

Following is some general information regarding how healthcare reform impacts CaroMont Health.

▪ Value-Based Purchasing - annual reduction in Medicare reimbursement with potential to gain all or more back, based on our clinical outcomes (mortality), Patient Satisfaction, Cost

▪ Never Events – healthcare acquired conditions or infections that were not present on admission.▪ Readmission Reduction – 30 day risk adjusted readmissions for specific primary diagnoses▪ Hospital Acquired Condition Penalty

category in the nation for having more hospital acquired conditions and ▪ The Joint Commission Disease-Specific Certifications

Case Management Services We Provide:

▪ Discharge Planning

o Home Health Care

o DME

o ALF, SNF

o Acute Rehab, Short Term Rehab

o LTAC (Long Term Acute Care)

o Indigent Services

o Readmission Assessments

o Follow-up Phone Calls

▪ Social Work

o Adoptions

o DSS Referrals / Case, Neglect and Abuse

o Homeless

o Undocumented Patients

▪ Utilization Review

o Medicare / Medicaid Compliance

o Outpatient, Observation, Inpatient Status


Where can you smoke at CaroMont Health?

permitted inside any CaroMont Health building, and there are no exceptions.



reduction in Medicare reimbursement with potential to gain all or more back, clinical outcomes (mortality), Patient Satisfaction, Cost

healthcare acquired conditions or infections that were not present on admission.30 day risk adjusted readmissions for specific primary diagnoses

Hospital Acquired Condition Penalty - reduction in Medicare payment to hospitals who are in the 25% worst category in the nation for having more hospital acquired conditions and infections

Specific Certifications for Stroke

Department-Specific References

Acute Rehab, Short Term Rehab

LTAC (Long Term Acute Care)

DSS Referrals / Case, Neglect and Abuse

Medicare / Medicaid Compliance

Outpatient, Observation, Inpatient Status

25

permitted inside any CaroMont Health building, and there are no exceptions.



reduction in Medicare reimbursement with potential to gain all or more back,

healthcare acquired conditions or infections that were not present on admission. 30 day risk adjusted readmissions for specific primary diagnoses

reduction in Medicare payment to hospitals who are in the 25% worst

Specific References


o Medical Necessity Review –

o Hospital Issued Notices of Non

o Private insurance certification

o Denials and Appeals (RAC, etc.)

o Physician Advisor services or secondary review is provided by EHR (Executive Health Resources)

Departmental Coverage:

▪ Unit Based Coverage – Medical / Surgical Units (excludes Psychiatry) 8:30am

– 8:30pm Saturday & Sunday.

▪ Emergency Department – 11:00am-

Saturday & Sunday. Social Worker on call 5pm

Important Information to Help You with Our Patients:

▪ Always document patient status – outpatient

expectation at the time your decision is being made.

▪ Document medical necessity for admission and reason for continued stay each day.

▪ Discuss and document discharge plan with patient fam

discharge.

▪ Discharge / transfer patients as early in the day as possible. Some facilities will not accept patients back after

4:00pm.

▪ A hard prescription must be sent with the patient to an ALF or S

▪ Physicians must sign an FL2 on patient(s) going to ALFs and SNFs.

▪ Please respond to all request from the Utilization Review Specialist(s) to follow up with EHR Physician Advisor

regarding patient status, and the Medical Director of

review on a case being denied.

Department Director: Peggy Blackburn, 704

Manager, Case Management: Renee Lawing, BSN, RN, 704

Department of Laboratory MedicineServices We Provide

▪ Laboratory Customer Call Center: 2881 (704encourage you to use this one number to access all areas of the laboratory (24/7).

▪ In-house Laboratory - 24 hours a day, 7 days a week, 99% of testing performed on▪ Outpatient Service Centers:


– Interqual Criteria

Hospital Issued Notices of Non-Coverage (HINNs)

Private insurance certification

Denials and Appeals (RAC, etc.)

Physician Advisor services or secondary review is provided by EHR (Executive Health Resources)

Medical / Surgical Units (excludes Psychiatry) 8:30am-5:00pm Monday

-9:30am Monday – Thursday, 1:00pm-9:30pm Friday, 10:00am

Saturday & Sunday. Social Worker on call 5pm-8:00am everyday.

Important Information to Help You with Our Patients:

outpatient, observation, or inpatient based on the patient’s condition and your

expectation at the time your decision is being made.

Document medical necessity for admission and reason for continued stay each day.

Discuss and document discharge plan with patient family and Discharge Planning Specialist

Discharge / transfer patients as early in the day as possible. Some facilities will not accept patients back after

A hard prescription must be sent with the patient to an ALF or SNF for narcotics.

Physicians must sign an FL2 on patient(s) going to ALFs and SNFs.

Please respond to all request from the Utilization Review Specialist(s) to follow up with EHR Physician Advisor

regarding patient status, and the Medical Director of private insurance companies requesting a “peer to peer”

Peggy Blackburn, 704-834-2774, peggy.blackburn @caromonthealth.org

Renee Lawing, BSN, RN, 704-834-3906, [email protected]

Department of Laboratory Medicine

Laboratory Customer Call Center: 2881 (704-834-2881) Only 1 number to remember for laboratory ! We encourage you to use this one number to access all areas of the laboratory (24/7).

24 hours a day, 7 days a week, 99% of testing performed on-site

26

Physician Advisor services or secondary review is provided by EHR (Executive Health Resources)

5:00pm Monday – Friday, 8:30am

9:30pm Friday, 10:00am-10:00pm

, observation, or inpatient based on the patient’s condition and your

ily and Discharge Planning Specialist prior to the day of

Discharge / transfer patients as early in the day as possible. Some facilities will not accept patients back after

Please respond to all request from the Utilization Review Specialist(s) to follow up with EHR Physician Advisor

private insurance companies requesting a “peer to peer”

[email protected]

number to remember for laboratory ! We


o Outpatient/Presurgery Center, Mondayo Selected CMG practices also provide CaroMont Lab collections. Call Lab for specifics

▪ Consultation and Support o Professional Consultation: Pathologist

▪ Professional Pathology and clinical consultations or assistappropriate testing or test utilization.

▪ On site Monday – Friday during office hours, or ono Technical Consultation/Support: Technical Specialists / Managers

▪ Questions concerning ▪ On site 24 hours a day, 7 days a week.

▪ Lab Phlebotomy Services are provided to nono Patient Care Staff collect all blood specimens in the Emergency Department, Birthplace

Critical Care units (ICU, CCU, CVRU, SICU).

Priorities/Timeframes you Need to Know (Inpatient Order Priorities)▪ CHART 7AM – Routine testing with results available “On Chart by 7 am”. ▪ TODAY - If ordered before 1 pm, results available by 4

flexibility to combine the testing with other lab tests to reduce venipunctures and blood volume.▪ NEXT LIST – Phlebotomist makes rounds throughout CRMC every 2 hours.▪ TIMED - Collected as close as possib▪ STAT - Results available within one hour of laboratory order. Stat tests requests should not be requested “In

advance” and should be for medical reasons to limit overuse.

Getting You the Results You Need ▪ Inpatient - Transmitted electronically. Available in Sorian Clinical & Document Management systems. ▪ Outpatient - Distributed based on patient type, location, practice EHR and physician preference. ▪ Critical Test results are called to the

Lab Resources to Make Your Work Easier

▪ www.caromontlab.org (Also available from “Links” within Sorian)o Test menu, specimen requirements, patient collection instructions, laboratory policies.o Laboratory compliance information including Medicare limited coverage test policies.o Direct access to ARUP Consult

selection and interpretation.

We Provide the Qualifications and Quality Services You Should Expect▪ Testing performed by credentialed Clinical Laboratory Scientists and Medical Laboratory Technicians.▪ State-of the-art technology under the direction of Board Certified Pathologists. ▪ Accredited by the College of American Pathologists (CAP), American Association of Blood Banks (AABB), and

is Clinical Laboratory Improvement Amendments (CLIA) certified. ▪ For testing not available in-house, referral to a fully▪ Contracted with ARUP® Laboratories who serve as our primary reference laboratory


ery Center, Monday-Friday 06:30 until 5:00 pm. Selected CMG practices also provide CaroMont Lab collections. Call Lab for specifics

Professional Consultation: Pathologist Professional Pathology and clinical consultations or assistance with questions regarding appropriate testing or test utilization.

Friday during office hours, or on-call weekends, holidays, and after hours. Technical Consultation/Support: Technical Specialists / Managers

Questions concerning methodologies/procedures. On site 24 hours a day, 7 days a week.

Lab Phlebotomy Services are provided to non-Critical Care Areas and Critical Care StepPatient Care Staff collect all blood specimens in the Emergency Department, BirthplaceCritical Care units (ICU, CCU, CVRU, SICU).

Priorities/Timeframes you Need to Know (Inpatient Order Priorities) Routine testing with results available “On Chart by 7 am”.

If ordered before 1 pm, results available by 4 pm. “Today” requests allow laboratory the greatest flexibility to combine the testing with other lab tests to reduce venipunctures and blood volume.

Phlebotomist makes rounds throughout CRMC every 2 hours. Collected as close as possible to the request time, usually during the next phlebotomy round.

Results available within one hour of laboratory order. Stat tests requests should not be requested “In advance” and should be for medical reasons to limit overuse.

Transmitted electronically. Available in Sorian Clinical & Document Management systems. Distributed based on patient type, location, practice EHR and physician preference.

Critical Test results are called to the ordering physician or inpatient unit (if applicable)

(Also available from “Links” within Sorian) Test menu, specimen requirements, patient collection instructions, laboratory policies.Laboratory compliance information including Medicare limited coverage test policies.

Consult ® - A laboratory support tool and physician’s guide t

selection and interpretation.

We Provide the Qualifications and Quality Services You Should Expect Testing performed by credentialed Clinical Laboratory Scientists and Medical Laboratory Technicians.

art technology under the direction of Board Certified Pathologists. Accredited by the College of American Pathologists (CAP), American Association of Blood Banks (AABB), and is Clinical Laboratory Improvement Amendments (CLIA) certified.

house, referral to a fully-accredited reference laboratory (<1% of total test volume). Contracted with ARUP® Laboratories who serve as our primary reference laboratory

27

Selected CMG practices also provide CaroMont Lab collections. Call Lab for specifics

ance with questions regarding

call weekends, holidays, and after hours.

Critical Care Areas and Critical Care Step-down units only. Patient Care Staff collect all blood specimens in the Emergency Department, Birthplace and primary

pm. “Today” requests allow laboratory the greatest flexibility to combine the testing with other lab tests to reduce venipunctures and blood volume.

le to the request time, usually during the next phlebotomy round. Results available within one hour of laboratory order. Stat tests requests should not be requested “In

Transmitted electronically. Available in Sorian Clinical & Document Management systems. Distributed based on patient type, location, practice EHR and physician preference.

Test menu, specimen requirements, patient collection instructions, laboratory policies. Laboratory compliance information including Medicare limited coverage test policies.

A laboratory support tool and physician’s guide to laboratory test

Testing performed by credentialed Clinical Laboratory Scientists and Medical Laboratory Technicians.

Accredited by the College of American Pathologists (CAP), American Association of Blood Banks (AABB), and

accredited reference laboratory (<1% of total test volume).


Department Director: David Mills, 704-834Medical Director: Steven Tracy, MD, 704-

Pharmacy Services Services We Provide

▪ Main Pharmacy Contact: 2234 (704o Press “9” for fast access to a pharmacisto Clinical Pharmacist contact o Emergency Department Clinical Pharmacist

▪ Pharmacy Managed Protocols:

o TPN

▪ Pharmacist manages electrolytes while Registered Dietician manages macronutrients▪ Reviewed and adjusted daily

o Heparin

▪ Pharmacist managed▪ Anti-Xa used (rather than ▪ Three protocols available

– Low Intensity Protocolo ACS or with Integrilin / tPAo No Boluses for vascular surgery patients or stroke patients with neurology

consult– High Intensity Protocol

o DVT, PE, Bridge Therapy, Atrial Fibrillationo Warfarin

▪ Pharmacists manage warfarin housewide▪ Patient reviewed and new dose ordered each day

o Other oral anticoagulants (Xarelto, Eliquis, Pradaxa)o Enoxaparin Treatment Dosingo Argatroban

o Integrilin for ACS or PCIo Vancomycin

o Aminoglycosides

o Zosyn – Extended Infusion▪ 4.5g Q8 hours unless CrCl <20ml/min, then 4.5g IV Q12 hours▪ Pharmacist will change to traditional dosing if IV incompatibilities or exclusion criteria met.

o Automatic Renal Dosing Protocol▪ Consists of antimicrob

Available References:

▪ CHIP: Micromedex ▪ www.uptodate.com (requires a sign-

tracking of CME.


834-2885, [email protected] -834-2881

Main Pharmacy Contact: 2234 (704-834-2234) Press “9” for fast access to a pharmacist

posted on each unit artment Clinical Pharmacist: 4327

Pharmacist manages electrolytes while Registered Dietician manages macronutrientsReviewed and adjusted daily

Pharmacist managed

Xa used (rather than aPTT) to monitor Three protocols available

Low Intensity Protocol ACS or with Integrilin / tPA

No Boluses for vascular surgery patients or stroke patients with neurology consult

High Intensity Protocol DVT, PE, Bridge Therapy, Atrial Fibrillation

Pharmacists manage warfarin housewide

Patient reviewed and new dose ordered each day

Other oral anticoagulants (Xarelto, Eliquis, Pradaxa) Enoxaparin Treatment Dosing

Integrilin for ACS or PCI

Extended Infusion (restricted to infectious disease providers) 4.5g Q8 hours unless CrCl <20ml/min, then 4.5g IV Q12 hours

Pharmacist will change to traditional dosing if IV incompatibilities or exclusion criteria met.Automatic Renal Dosing Protocol

Consists of antimicrobials, enoxaparin, famotidine, metoclopramide

-in/registration, but available with no charge. Sign-in/registration allows for

28

Pharmacist manages electrolytes while Registered Dietician manages macronutrients

No Boluses for vascular surgery patients or stroke patients with neurology

Pharmacist will change to traditional dosing if IV incompatibilities or exclusion criteria met.

in/registration allows for


▪ Formulary available in CPOE

Pertinent Therapeutic Interchanges:

▪ Quinolones available: levofloxacin/ciprofloxacin▪ Levalbuterol to Albuterol with exception of pediatric patients▪ Many of the non-insulin diabetic agents (januvia, metformin, byetta, etc) are changed to sliding scale insulin on

admission

Pertinent Restrictions:

▪ U-500 insulin and insulin pump orders restricted to Endocrinologist▪ IV Administration Grid available on

Insulin Tips:

▪ Sliding scale insulin for patient on a diet: ▪ Sliding scale insulin for patients on ▪ Endotool used for insulin drips in the critical care areas. Transitional orders are provided

and used to determine new, transitional dose. If patient is not stable on Endotool, transitional inaccurate.

▪ Lantus standard administration times are 9am or 9pm. Doses written between 10am and 4pm will be scheduled at 9pm and a one-time NPH order will be provided by the pharmacist to provide adequate coverage. Doses written after 11 pm will be scheduled for 9 am.

Restricted Antimicrobials: ▪ CRMC restricts certain antimicrobial agents as outlined in the Antimicrobial Stewardship policy.▪ Restricted antimicrobials:

o Ertapenem (Invanz®): unless used to treat an ESBL with known susceptibilities o Meropenem (Merrem ®) o Daptomycin (Cubicin ®) o Tigecycline (Tygacil ®) o Ceftaroline (Teflaro®) o Ceftolozane/tazobactam (Zerbaxa®)o Ceftazidime/avibactam (Avycaz®)o Amphotericin (AmBisome®, Amphocin®, Fungizone®)o Micafungin (Mycamine®) o Colistemethate (Colistin®) o Piperacillin / Tazobactam (Zosyn®)

▪ Controlled antimicrobials (reviewed by infectious disease providers for ongoing use):

o Linezolid (Zyvox®) o Imipenem / cilastatin (Primaxin®)

Automatic Medication Discontinuation:


Quinolones available: levofloxacin/ciprofloxacin

with exception of pediatric patients

insulin diabetic agents (januvia, metformin, byetta, etc) are changed to sliding scale insulin on

500 insulin and insulin pump orders restricted to Endocrinologist IV Administration Grid available on Compliance360– Identifies medications restricted to specific units

Sliding scale insulin for patient on a diet: Novolog before meals and at bedtime

Sliding scale insulin for patients on continuous feeding or NPO: Novolog every 4 hoursin the critical care areas. Transitional orders are provided

and used to determine new, transitional dose. If patient is not stable on Endotool, transitional

Lantus standard administration times are 9am or 9pm. Doses written between 10am and 4pm will be scheduled at time NPH order will be provided by the pharmacist to provide adequate coverage. Doses written

ll be scheduled for 9 am.

CRMC restricts certain antimicrobial agents as outlined in the Antimicrobial Stewardship policy.

Ertapenem (Invanz®): unless used to treat an ESBL with known susceptibilities

Ceftolozane/tazobactam (Zerbaxa®) Ceftazidime/avibactam (Avycaz®) Amphotericin (AmBisome®, Amphocin®, Fungizone®)

Piperacillin / Tazobactam (Zosyn®)

Controlled antimicrobials (reviewed by infectious disease providers for ongoing use):

Imipenem / cilastatin (Primaxin®)

29

insulin diabetic agents (januvia, metformin, byetta, etc) are changed to sliding scale insulin on

Identifies medications restricted to specific units

Novolog every 4 hours

in the critical care areas. Transitional orders are provided once stable on Endotool and used to determine new, transitional dose. If patient is not stable on Endotool, transitional dose may be

Lantus standard administration times are 9am or 9pm. Doses written between 10am and 4pm will be scheduled at time NPH order will be provided by the pharmacist to provide adequate coverage. Doses written

CRMC restricts certain antimicrobial agents as outlined in the Antimicrobial Stewardship policy.

Ertapenem (Invanz®): unless used to treat an ESBL with known susceptibilities to ertapenem


▪ For any order with an unspecified length of therapy, a sixty (60) day automatic stop order will be in effect for all medications with the following exceptions:

Medication

Ketorolac (Toradol)

Nesiritide (Natrecor)

Ziprasidone Injection (Geodon)

Meperidine (Demerol)

Mannitol Continuous Infusion

Mannitol Bolus Intermittent Dosing

Mannitol Bolus Iron Sucrose (Venofer)

Hypertonic Saline (> 0.9% NaCl) Continuous Infusion

Hypertonic Saline (> 0.9% NaCl) Bolus Intermittent Dosing

Oseltamivir (Tamiflu)

Parenteral Opiate Therapy

Antimicrobial Antimicrobial Therapy (excluding antiretroviral therapy)

All other medications unless otherwise specified

*Active order duration = 24 hours based on the requirement for use of the Hypertonic Saline Protocol Form.

Medications that are about to expire will print at the top of the Medication Medication List at 48 hours prior to the stop date and again at 24 hours prior to the stop date. This is located in the order section of the physician chart. Medications approaching expiration will also be identified in Soari72 hours prior to the time of expiration. These orders may also be renewed within Soarian.

Department Director: Mark Chaparro, [email protected] Manager: Michael Oliver, michael.oliverClinical Pharmacy Manager: Connie Street,

Clinical Research Department ▪ CaroMont Health Institutional Review Board

o Reviews all Human Subject Research Activitieso Serves as the Privacy Board for

▪ Office of Human Research Ethics

o Establishes IRB policies and procedureso Provides education and guidance to the IRB and Investigators at CaroMont Healtho Monitors compliance of research projects

▪ Contact Michelle Cook at x3891


For any order with an unspecified length of therapy, a sixty (60) day automatic stop order will be in effect for all medications with the following exceptions:

Medication Active Order Duration

5 days

3 days

Ziprasidone Injection (Geodon) 2 days

2 days

12 hours

Mannitol Bolus Intermittent Dosing 24 hours

5 days

Hypertonic Saline (> 0.9% NaCl) Continuous Infusion 24 hours

Hypertonic Saline (> 0.9% NaCl) Bolus Intermittent Dosing 24 hours

Treatment = 5 daysProphylaxis = 10 days

14 days

Antimicrobial Antimicrobial Therapy (excluding antiretroviral therapy) 14 days

All other medications unless otherwise specified 60 days


Medications that are about to expire will print at the top of the Medication Reconciliation/Chronological Medication List at 48 hours prior to the stop date and again at 24 hours prior to the stop date. This is located in the order section of the physician chart.

Medications approaching expiration will also be identified in Soarian with a notification icon to the physician 72 hours prior to the time of expiration. These orders may also be renewed within Soarian.

[email protected] 70-834-2239 (2239)Michael Oliver, [email protected] 704-834-3644 (3644)

, [email protected] 704-834-3641 (3641)

CaroMont Health Institutional Review Board

Reviews all Human Subject Research Activities

Serves as the Privacy Board for research-related HIPAA issues

Establishes IRB policies and procedures

Provides education and guidance to the IRB and Investigators at CaroMont HealthMonitors compliance of research projects

30

For any order with an unspecified length of therapy, a sixty (60) day automatic stop order will be in effect for all

Active Order Duration

5 days

3 days

2 days

2 days

12 hours

24 hours

5 days

hours

24 hours

Treatment = 5 days Prophylaxis = 10 days

14 days

14 days

60 days


Reconciliation/Chronological Medication List at 48 hours prior to the stop date and again at 24 hours prior to the stop date. This is located in

an with a notification icon to the physician 72 hours prior to the time of expiration. These orders may also be renewed within Soarian.

2239 (2239) 3644 (3644)

3641 (3641)

Provides education and guidance to the IRB and Investigators at CaroMont Health


Research Administration Department▪ Responsible for administration and support of all research at CaroMont Health (hospital and practices)

o Contract and budget reviewo Education and training

o Compliance

▪ Can provide trained study coordinators for your clinical ▪ Can locate trials in your area of expertise▪ Can help you start a research program in your specialty group▪ The latest clinical trial technology for sites is available at CaroMont Health:

o Clinical Conductor (web-based clinical trial management system)o Greenphire (patient stipends using ClinCard MasterCard/debit cards)o CITI Program (web-based clinical trials training program)

▪ Contact Tammy Cozad at x4843


Research Administration Department Responsible for administration and support of all research at CaroMont Health (hospital and practices)

Contract and budget review

Can provide trained study coordinators for your clinical trials

Can locate trials in your area of expertise

Can help you start a research program in your specialty group

The latest clinical trial technology for sites is available at CaroMont Health: based clinical trial management system)

Greenphire (patient stipends using ClinCard MasterCard/debit cards) based clinical trials training program)

31

Responsible for administration and support of all research at CaroMont Health (hospital and practices)


Core Measures and Other Quality MeasuresAMI

Core Measure Explanation

Aspirin at Arrival Patient must have an Aspirin 24 hr before or after arrival time.

Reason for no ASA at Arrival ASA or no Antiplatelets. If the patient has an ASA allergy automatic contraindication.

No anticoagulation

Aspirin Prescribed at Discharge All MI patients should receive ASA at Discharge unless there is a

documented reason for not administering.

ACE/ARB for LVSD All MI patients should receive an ACE/ARB at Discharge if EF <40.

Documentation of a contraindication must be specific. Example ACE/ARB due to hypotension.

Documentation of an allergy to ACE or ARB does not count as an automatic contraindication. Example cover a reason for no ARB.

Beta Blocker Prescribed at Discharge All MI patients must have a Beta Blocker prescribed at Discharge

unless there is clear documentation of a contraindication.

Example –

Not Acceptable be specific to beta blockers.

Fibrinolytic Therapy Within 30 Minutes of Hospital Arrival Lytics must start infusing within 30 minutes of hospital arrival. Reason

for a delay must be clearly documented due to GI Bleed.

The delay can not be system related.

Primary PCI Received Within 90 Minutes of Hospital Arrival This measure applies to STEMI or new LBBB patients going

emergently to the Cath Lab. PCI time is the time the balloon was inflated,

This time is measured from the arrival time at the hospital

Reason for Delay in PCI Can not be a system delay


Core Measures and Other Quality Measures

Explanation

Patient must have an Aspirin 24 hr before or after arrival time.

Reason for no ASA at Arrival – Physician must document stating no ASA or no Antiplatelets. If the patient has an ASA allergy - this is an automatic contraindication.

No anticoagulation does not cover ASA.

All MI patients should receive ASA at Discharge unless there is a documented reason for not administering.

All MI patients should receive an ACE/ARB at Discharge if the have an

Documentation of a contraindication must be specific. Example ACE/ARB due to hypotension.

Documentation of an allergy to ACE or ARB does not count as an automatic contraindication. Example – Pt allergic to Zestril does not

reason for no ARB.

All MI patients must have a Beta Blocker prescribed at Discharge unless there is clear documentation of a contraindication.

– No BB due to hypotension.

Not Acceptable – DC all hypertensive meds. The documentation must be specific to beta blockers.

Lytics must start infusing within 30 minutes of hospital arrival. Reason for a delay must be clearly documented – Delay in Fibrinolyticdue to GI Bleed.

The delay can not be system related.

This measure applies to STEMI or new LBBB patients going emergently to the Cath Lab. PCI time is the time the balloon was inflated, stent was expanded or 1st pass of a thrombectomy device.

This time is measured from the arrival time at the hospital

Can not be a system delay – example – Cath lab busy- not available

32

Addendum

Patient must have an Aspirin 24 hr before or after arrival time.

Physician must document stating no this is an

All MI patients should receive ASA at Discharge unless there is a

the have an

Documentation of a contraindication must be specific. Example – No

Documentation of an allergy to ACE or ARB does not count as an Pt allergic to Zestril does not

All MI patients must have a Beta Blocker prescribed at Discharge

meds. The documentation must

Lytics must start infusing within 30 minutes of hospital arrival. Reason Delay in Fibrinolytic Therapy

This measure applies to STEMI or new LBBB patients going emergently to the Cath Lab. PCI time is the time the balloon was

pass of a thrombectomy device.

not available


Must be patient related difficulty crossing the lesion, patient did not present with any signs and symptoms of ACS, patient needed to rule out for dissection etc…

CPR, Defibrillation, V Fib, IABP, or intubation within the first 90 minutes are automatic r

Must state Cath Lab delayed d/t or PCI delayed d/t…

Statin Prescribed at Discharge All MI patients should receive a Statin at Discharge unless there is a documented contraindication.

Example –

Heart Failure: Admit AND Discharge Order Sets are Required

Requirement Explanation

Evaluation of LVS Function echo ordered and completed or EF stated in the record (there is no time limit for last echo)

ACEI or ARB for LVSD (EF < 40%) or

Discharge Instructions To address at discharge:

● Activity

● Diet

● Follow up

● Medications

● Symptoms worsening

● Weight monitoring

Follow up Appointments:

• Heart Failure Nurse or NP 5

• PCP within 10

• Cardiologist 3

• BMP within 1 week of discharge

Discharge Medications:

Home medications should be addressed on admission and at discharge.

“Get with the Guidelines” Medication Recommendations

Preferred Beta Blocker (carvedilol, metoprolol EF <40%; or contraindication documented


Must be patient related – patient refusal, patient delay in consent, difficulty crossing the lesion, patient did not present with any signs and symptoms of ACS, patient needed to rule out for dissection etc…

CPR, Defibrillation, V Fib, IABP, or intubation within the first 90 minutes are automatic reasons for delay.

Must state Cath Lab delayed d/t or PCI delayed d/t…

All MI patients should receive a Statin at Discharge unless there is a documented contraindication.

– No statin due to elevated LFT’s.

Admit AND Discharge Order Sets are Required

Explanation echo ordered and completed or EF stated in the record (there is no time limit for last echo)

(EF < 40%) or contraindication for both classifications documented

To address at discharge:

Activity

Diet

Follow up

Medications

Symptoms worsening

Weight monitoring

Follow up Appointments:

Heart Failure Nurse or NP 5-7 days

PCP within 10 days

Cardiologist 3-4 weeks

BMP within 1 week of discharge

Discharge Medications:


Preferred Beta Blocker (carvedilol, metoprolol succinate, bisoprolol) if EF <40%; or contraindication documented

33

patient delay in consent, difficulty crossing the lesion, patient did not present with any signs and symptoms of ACS, patient needed to rule out for dissection etc…

CPR, Defibrillation, V Fib, IABP, or intubation within the first 90

All MI patients should receive a Statin at Discharge unless there is a

echo ordered and completed or EF stated in the record (there is no time

contraindication for both classifications documented


succinate, bisoprolol) if


Aldosterone Antagonist (on ACEI/ARB & BB >3 months & EF<40%) or contraindication documented. If not on ACEI/ARB therapy due to CKD/ARF, etc must be clearly stated in the record

Hydralazine + Nitrate Therapy (African American on ACEI/ARB & BB >3 months with EF<40%); or contraindication documentedclearly stated in the record

Anticoagulation for atrial fibrillation/history of/PAF,contraindication documented

Other “Get with the Guidelines” Recommendations

�� contraindications must be clearly stated in the record �� stated in the record

Advance Care Planning addressed

Smoking cessation counseling

HF Recommendations Nephrology Consult for GFR <30

Cardiology Consult for New HF Diagnosis

QLC Consult for advanced heart failure/Stage IV/end stage assessment for hospice or palliative care

NYHA Classification Documentation

Admission and Re

Admission: can be documented via the use of the Heart Failure Order Sets on admission (short or long form)

Discharge: can be documented via use of the HF Discharge Order Set, HHC HF Discharge Order Set, or SNF HF Discharge Order Set

Can be documented in progress notes on Heart Failure


Aldosterone Antagonist (on ACEI/ARB & BB >3 months & EF<40%) or contraindication documented. If not on ACEI/ARB therapy due to CKD/ARF, etc – cannot infer reason for not being on spironolactmust be clearly stated in the record

Hydralazine + Nitrate Therapy (African American on ACEI/ARB & BB >3 months with EF<40%); or contraindication documented-must be clearly stated in the record

Anticoagulation for atrial fibrillation/history of/PAF, etc. or contraindication documented �� contraindications must be clearly stated in the record �� !" � #$ must be cle

stated in the record

Advance Care Planning addressed

Smoking cessation counseling

Nephrology Consult for GFR <30

Cardiology Consult for New HF Diagnosis

QLC Consult for advanced heart failure/Stage IV/end stage – assessment for hospice or palliative care

Admission and Re-evaluation at Discharge

Admission: can be documented via the use of the Heart Failure Order on admission (short or long form)


Can be documented in progress notes on NYHA Classification for Acute

Heart Failure document on admission and/or discharge

34

Aldosterone Antagonist (on ACEI/ARB & BB >3 months & EF<40%) or contraindication documented. If not on ACEI/ARB therapy due to

cannot infer reason for not being on spironolactone –

Hydralazine + Nitrate Therapy (African American on ACEI/ARB & BB must be �� #$

must be clearly

Admission: can be documented via the use of the Heart Failure Order


NYHA Classification for Acute


Sepsis : ● Order set is available in the EHR. ● Pts with Severe Sepsis / Septic Shock should be in PICU or an acute care bed with an Intensivist consult.


3 Hour Bundle for

Severe Sepsis

1.) Lactic Acid

2.) Blood Culture (Prior to Antibiotics)

3.) Antibiotic

*To be Completed within 3 Hours

6 Hour Bundle for Septic Shock

1.) 30 ML/KG Crystalloids

2.) Vasopressors (Persistent Hypotension)

3.) Repeat Lactic acid

*To be Completed with 6 Hours

MD Documentation Required with 6 hours of Septic Shock

1.) Temp, Pulse, Heart Rate, & BP

2.)Cardiopulmonary Assessment

3.) Capillary Refill: Completed and the results

4.) Peripheral Pulse Eval: Radial, Dorsalis, Pedis, or Post Tib

(Must Document

5.) Skin Exam: Superficial Circulatory Status

Examples: Pink with Good Cap Refill; or, Skin over Knees Purple & Mottled

Epic Smart Form and Alerts

Epic will Fire a Sepsis alert to the RN, Attending MD, Sepsis Specialist, and the Shift Supervisor. The RN will call the provider and provide update on the pt’s assessment and lab findings, MD will need to determine if the pt has a source, and access the Smart form to complete documentation. Sepsis order set should be used, and the 3 anrespective 3 and 6 hour windows.

Bed Placement

Severe Sepsis / Septic Shock patients should be admitted to PICU / ICU only * monitored bed does not always mean PICU

Transfer or admission of a patient to ICU

Requires a Critical Care Medicine consult.


Pts with Severe Sepsis / Septic Shock should be in PICU or an acute care bed with an Intensivist consult.

Acid

2.) Blood Culture (Prior to Antibiotics)

*To be Completed within 3 Hours

1.) 30 ML/KG Crystalloids

2.) Vasopressors (Persistent Hypotension)

3.) Repeat Lactic acid

*To be Completed with 6 Hours

1.) Temp, Pulse, Heart Rate, & BP

2.)Cardiopulmonary Assessment

3.) Capillary Refill: Completed and the results

4.) Peripheral Pulse Eval: Radial, Dorsalis, Pedis, or Post Tib

(Must Document at least One of These)

5.) Skin Exam: Superficial Circulatory Status


Epic will Fire a Sepsis alert to the RN, Attending MD, Sepsis Specialist, and Shift Supervisor. The RN will call the provider and provide update on the

pt’s assessment and lab findings, MD will need to determine if the pt has a source, and access the Smart form to complete documentation. Sepsis order set should be used, and the 3 and 6 hour bundles should be met within the respective 3 and 6 hour windows.

Severe Sepsis / Septic Shock patients should be admitted to PICU / ICU only * monitored bed does not always mean PICU.

Requires a Critical Care Medicine consult.

35

Pts with Severe Sepsis / Septic Shock should be in PICU or an acute care bed with an Intensivist consult.


Epic will Fire a Sepsis alert to the RN, Attending MD, Sepsis Specialist, and Shift Supervisor. The RN will call the provider and provide update on the

pt’s assessment and lab findings, MD will need to determine if the pt has a source, and access the Smart form to complete documentation. Sepsis order

d 6 hour bundles should be met within the

Severe Sepsis / Septic Shock patients should be admitted to PICU / ICU only


Stroke (Includes: Ischemic Strokes, Hemorrhagic Strokes, and TIAs,) Order sets are Required for the Following:

● Ischemic Stroke (Please use for TIAs)

●

● Hemorrhagic Stroke

● TPA


t-PA < 60 minutes from arrival to ED; Indicated for 3-4.5 hours of last known well

ED measure: Document contraindication or reason for delay > 60 minutes window

Antithrombotic Therapy by end of day 2 of admission

Document contraindication

Antithrombotic prescribed at Discharge


VTE Prophylaxis; by day 2 of admission

Note: Ambulation

Lipid Panel within 48 Hours After Arrival

LDL >70 Initiate a Statin Consider Intensive statin;

Continue Statin @ Discharge Note: If LDL not available at time of discharge, Patient Statin; Consider Inte

Anticoagulation for Atrial Fibrillation/ Flutter

Document Contraindication link

PT/OT Document ContraindicationNote: PT/OT Must be Referenced with Reason


(Includes: Ischemic Strokes, Hemorrhagic Strokes, and TIAs,)

Ischemic Stroke (Please use for TIAs)

Explanation

ED measure: Document contraindication or reason for delay > 60 minutes



Ambulation and TED hose are not acceptable

within 48 Hours After Arrival

Consider Intensive statin; Document Contraindication

If LDL not available at time of discharge, Patient MUST be D/C on Statin; Consider Intensive statin

Document Contraindication linked with no OAC

Document Contraindication : PT/OT Must be Referenced with Reason

36

ED measure: Document contraindication or reason for delay > 60 minutes

be D/C on


Spiritual Care Department (Chaplaincy)

Spiritual Care Services Provided:

· 24/7 coverage…A chaplain is available at all times.

· Spiritual Support and Counseling

· Build on the resources of one’s faith

· Help in examination of questions regarding faith, belief and doubt

· Crisis Intervention

· Participating in Family Conferences

· Assist with Life Support and other

· Rounding on all hospital units

· Responding to referrals

· Pre-op visits

· Response to all Code Blues and Trauma Calls

· Sacraments of Communion and Baptism

· Blessings

· End of Life Rituals

· Memorial Services

· Marriages

· Consultations

· Facilitation of Spirituality and Grief Groups

· Seminars/In-service presentations on such subjects as Grief, Spiritual Resources for Healing,

Spiritual Assessment, Death and Dying, Theological Reflection, Caring for the Caregiver, Bereavement

Ministry.

· Accredited Clinical Pastoral Education (ACPE) to Clergy, Seminarians and qualified Laity.


Spiritual Care Department (Chaplaincy)

24/7 coverage…A chaplain is available at all times.

Counseling

Build on the resources of one’s faith

Help in examination of questions regarding faith, belief and doubt

Participating in Family Conferences

Assist with Life Support and other Ethical Issues.

Rounding on all hospital units

Response to all Code Blues and Trauma Calls

Sacraments of Communion and Baptism

Facilitation of Spirituality and Grief Groups

service presentations on such subjects as Grief, Spiritual Resources for Healing,

ssessment, Death and Dying, Theological Reflection, Caring for the Caregiver, Bereavement

Accredited Clinical Pastoral Education (ACPE) to Clergy, Seminarians and qualified Laity.

37

service presentations on such subjects as Grief, Spiritual Resources for Healing,

ssessment, Death and Dying, Theological Reflection, Caring for the Caregiver, Bereavement

Accredited Clinical Pastoral Education (ACPE) to Clergy, Seminarians and qualified Laity.

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