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Guide to Preparing You for

Vol 2, September 2011


As you are all aware, the Joint Commission can visit UMMC at any time we expect that the next visit will be some time in the Fall 2011 BUT‌ With the new survey methodology, they visit UMMC any day to begin our week-long survey process We are providing this book to help you to be ready at any time!! Please review the contents on a regular basis to maintain your knowledge


Be PreparedGreet surveyors when they appear on your unit Be friendly and welcome them! The preferred way to conduct a survey is to observe practice, and trace any event that will help the surveyors gain information regarding normal processes. What do you need to do? • If possible, escort them to a clean area with seating • Perform a patient handoff! • Retrieve patient chart, flow sheets, and a workstation computer. Gather your information sources • 2 nurses to facilitate information gathering from paper & electronic records (surveyor may only allow one nurse) • Other disciplines (as available) to address questions related to their practice Are members of the team aware of their role? Surveyors can (and will) approach any member of the healthcare team and question them about their job functions, including: • Training & competency • Products & equipment they see you using • Hand Hygiene practices • Isolation standards • Patient Confidentiality Is your unit/ area ready? Do you know where your clean sweep checklists are? Have you looked them over? Are you performing clean sweeps?


Joint Commission HOT TOPICS Fall 2011 Patient Education All patients must be educated on the following elements: • Diagnosis and Treatment • Tests and Procedures • Safety/Prevention (e.g. DVT, falls, hygiene, smoking cessation, seat-belt use, diet and exercise, safe sex practices, etc.) • Adverse reactions of new meds (meds not on home list). Focus on High Alert medications (PINCH) P = Potassium I = Insulin N = Narcotics C = Chemotherapy H = Heparin and all other anticoagulants

Plan of Care Know that “plan of care” is documented in multiple locations in the medical record (electronic and paper) • H&P, resident sign out, progress notes, consults • RT, SW, Case Manager notes • Multidisciplinary plan of care – initial assessment, ongoing assessments. Other disciplines also contribute to electronic POC (PT/OT/Speech/ etc) The Plan of Care is an ongoing plan that is • multidisciplinary • individualized – based on patient needs • reflects changing priorities as appropriate • patient and/or family involved in setting goals YOU need to know the plan for your patient!


Adherence to Isolation and Proper use of Personal Protective Equipment (PPE) •

Perform Hand Hygiene- no excuses! STOP anyone who forgets hand hygiene or isolation standards

Encourage Proper use of PPE • No gowns, gloves, or masks outside of patient room. • Tie your gowns! • No masks dangling around neck or under nose. • No wearing gloves from one room to another! • Eye shieldso must be cleaned when leaving isolation room o front shield must be changed if visibly contaminated Intravascular Catheter Maintenance • Monitor all IV sites for signs of infiltration, phlebitis, or infection • Change dressings and perform catheter maintenance as required by policy • IV tubing and needleless cap changes are required every 96 hours! • IV fluids and infusions are changed according to whether they are manufacturer-prepared, or additives are instilled on-site • All medications and infusions must be labeled with date and time of expiration- contact pharmacy for labels


Equipment Cleaning Assume untagged equipment is dirty- clean prior to use! •

Remove CLEAN tag – when taking equipment into patient room CLEAN EQUIPMENT

After use, attach Soiled Tag and place in pick up area SOILED


Red = General Soil

Brown = Enhanced Contact Precautions SOILED EQUIPMENT Enhanced Contact

*Equipment in constant use does not require tagging – e.g. vital sign machines, but it needs to be wiped down between patients! OXIVIR Tb ® - new general cleaning wipe – contains Hydrogen Peroxide • General Organisms = 1 minute contact time (amount of time cleaner must remain wet on surface to be effective) • TB = 5 Minute contact time DISPATCH ® for C Diff cleaning of Enhanced Contact Rooms & Equipment •

C diff = 5 minute contact time


Pain Management Pain Screening must be performed for: • Inpatients -upon initial assessment & with vital signs • Outpatients - At each visit when patient has LIP contact • Behavioral Health – Min every 6 months with LIP visit REMEMBER: All patients must be screened pre-& post- a known painful procedure! Pain Assessment must be completed: • At initial assessment if patient reports pain • Upon first report of pain (if NOT identified on initial assessment) Remember to initiate pain assessment form- found in ad hoc charting. This will help us meet documentation requirements. Reassessment must take place: • At the time of Peak Analgesic Effect of meds – if patient is asleep (and unstimulated respiratory rate is within normal limits) you may delay pain reassessment until patient awakens. o Use a tool that is appropriate to your patient’s condition and developmental level. o Use the same tool for repeat assessment when possible to allow comparisons. Document the effectiveness of all PRN medications on EMAR


Scope of Practice Questions are still coming in … Please see SCOPE OF PRACTICE intranet site REMEMBER: Any time patient care does not match the orders - a red flag is raised! Be sure to have orders for monitoring, devices, & medications. To enter verbal orders: 1. Receiver documents the order requested, including: • Patient’s name, date of birth or medical record number • Item requested (if medication – must include drug, dose, route, frequency of administration) • Date and time of order • Prescriber’s name and ID • Receiver’s name & credentials (RN, RT, RPh, PharmD) 2. Receiver shall write or input the order as received and then read the order back verbatim. 3. Provider must remain on the phone until the order entry is complete and read-back has occurred to address any clinical decision support alerts 4. The Provider issuing the order shall verbally confirm that the order is correct. 5. The receiver and provider must agree to discontinue any previous related orders, when applicable. 6. A Provider signature is required within 48 hours Review the process for emergency order entry _emr_med_ord_viewlet_swf.html


Scope of Practice Tips Make sure that RN can discuss decision making around drug choices: See Pain Management policy – PROE-013 “RN may exercise judgment based upon patient’s clinical condition at the time that a medication is needed and will consider their response to previous medications when determining the following: • Selection of prescribed drugs (e.g., acetaminophen and morphine) • Dosage within a prescribed range • Between routes of administration (e.g. IV or oral).” When patients arrive from other facilities, we will continue all existing support- including, but not limited to: • Oxygen • IV access • IV fluids • Infusions • Restraints, etc. RN will continue care as appropriate until a provider arrives at bedside to coordinate transition of care.


Patient Safety - Identify Patient Safety Risks •

Prevent wrong site surgery


Universal Protocol for every procedure – every time!! Especially when performing bedside procedures outside the protected environment of normal procedural areas Restraints and restraint alternatives… always use the least restrictive method possible. • Make sure you have an order every 24 hours • Ensure that restraint checks are documented Pressure Ulcer Prevention • Perform assessment, document Braden score, and compare to previous scores • Contact Wound Ostomy Continence Nurse (WOCN) team for pt with low Braden score (<16) or any indication of risk for breakdown • pressure ulcer, and of any patient who develops one Notify WOCN of any patient who is admitted with a while an inpatient. Implement DVT prophylaxis protocols • Encourage ambulation as appropriate • Consistent use of TEDS & venodynes Fall Prevention • Remind patients to ask for help with ambulation • Keep Call light with in pt’s reach • Keep bed in low position • Keep bed or stretcher wheels are locked • Assess for fall risk and implement precautions as indicated.


Do your part to reduce Hospital Acquired Infections! Hand hygiene remains the most important thing we can do to prevent infection. Prevent CLABSIs – (Central Line Associated BSIs) • Use cart and checklist to adhere to standard procedure • Use maximum sterile barriers • Perform appropriate site preparation • Maintain lines as per policy – including dressing changes, tubing and cap changes as required • Remove all lines as soon as possible when no longer necessary Prevent CAUTIs – (Catheter- Associated UTis) o Early catheter removal is key! o All in one foley kits help prevent UTIs Prevent SSIs (Surgical Site Infections) o Perform Preop scrubs and bathing as appropriate o Intra-op & post-op antibiotics Prevent & Treat MDROs-(multi-drug resistant organisms) o Isolate patients early to prevent transmission of infection o Use antibiotics carefully - change to less broad spectrum drugs when organisms are identified in cultures Nurses can initiate isolation precautions prior to provider entering order


Prepare Your Area - Perform Clean Sweep • Keep all areas clean & free from clutter! • Keep all medications secured – including IV fluids, syringes, and needles o Allow access to storage areas only to those whose job functions require area access. • Dispose of all expired medications and return those left from patients who are discharged • Keep all hallways clear and do not block exits, fire alarms, or medical gas shutoffs • Secure your O2 cylinders. Keep full tanks and empty ones in separate racks and clearly labeled o No more than 12 in one room • Clean and dirty supplies and equipment are stored separately and it is easy to tell which is which Prepare your charts • Ensure that all documents include patient name, birth date, and MR # (printed from Form Fast, label or handwritten on multiple page forms). • Remind team members that all entries must be dated and timed. • Ensure all medical records, clipboards, and computer screens are maintained in a confidential manner • Ensure that verbal orders signed within 48 hours


Patient Rights and Responsibilities • • •

Ensure that patients understand their rights and participate in planning their care whenever possible. Keep your name tag visible and worn above the waist Protect your patients’ privacy – both physical privacy (cover them & close doors if needed) and information privacy (HIPPA & patient confidentiality) o Do not call patients into exam rooms or triage areas by calling out their full name. Does your patent have an advanced directive? If so, is there a copy in the chart?

Patient Identification – use at least 2 ways to identify your patient – especially prior to all lab draws, medications, procedures, and treatments • Use 1st and last name and date of birth or medical record number (Ask pt to state their name & DOB whenever possible) • Label all specimens at the patient’s bedside • All patients should have an ID band at all times Improve Staff Communication - be able to discuss handoff communication from shift to shift, transfers among units, and to and from procedure & testing areas.

Critical Lab Results- all critical lab results are called directly to a provider. Nurse can check result status in Powerchart and check comment section to determine who was notified.


Emergency Preparedness • Keep corridors clear for egress and clutter-free • Do not block fire pulls, extinguishers, or emergency exits • Clinical equipment maintenance must be within 1 year of date on tag • Emergency equipment is accessible and checked every shift – Maintain current month only • Know UMMC’s Emergency Management codes Code Blue = Resuscitation Code Orange = Hazmat Event Code Pink = Infant/child abduction Code Red = Fire C C d Y w = m g n P n A n Coood deee Y Yeeellllllooow w= = EEEm meeerrrg geeen ncccyyy P Plllaaan nA Accctttiiivvvaaatttiiiooon n Code Black – Important Information

Know your emergency numbers o Code Blue & Fire – 8-2911 o Security – call 8-8711 o SOSC - 8-5174 o Rapid Response Team (RRT) - 8- STAT (8-7828) Chain of Command • The nurse is responsible for early detection of patient condition changes and communication to provider • If you are concerned about your patient’s condition and provider is not available or responding in timely manner, use the nursing and physician chain of command. Adult Rapid Response Team (RRT) • Provides early detection and rapid intervention • Roll Out beginning 10/1/11 - weekend day shift will eventually cover 24 / 7 • Call 8-STAT to activate the Rapid Response Team • Patients & family members must know that they can ask the nurse to initiate rapid response


Know what to do in the event of a fire: Rescue patients, staff, and visitors in danger Alert Activate Fire alarm â&#x20AC;&#x201C; call 8-2911 Confine Close all doors & Windows Extinguish fire if possible Know how to use a fire extinguisher if needed: Pull pin Aim nozzle at the base of fire Squeeze handle Sweep from side to side Environment of Care Is your unit safe for patients and staff? o Keep floors clean and dry o Ensure that all wiring is safely covered and off the floor o Keep O2 cylinders in appropriate tank holders, separate empty from full, and no more than 12 in one room o No items closer than 18 inches from the ceiling â&#x20AC;&#x201C; they could block sprinkler heads during a fire o Remove excess and/or unnecessary equipment from unit

Know where to locate Material Safety Data Sheets for any product you are using (MSDS)


Are medications safely secured on your unit? • Med carts should be locked • Med rooms should remain locked- do not allow access to anyone whose job does not require them to enter • Remove expired drugs • Multi-dose vials are good for 28 days if dated and timed • Return any drugs not for current patient to pharmacy Medication Reconciliation • Required upon admission, at discharge, and any time a patient is moved from one level of care to another • RNs have a responsibility to collect or validate information regarding home medications and contribute to the home medication list • Providers are responsible for performing the medication reconciliation Sedation and Anesthesia • Pre-sedation and pre-anesthesia assessment completed • Immediate pre-procedure Vital Signs completed • Discharge order present and/or criteria are met prior to patient leaving procedure area For Invasive or Operative Procedure • Consent present • Time out performed and documented prior to procedure and includes verification of: ƒ ƒ ƒ ƒ

Correct patient Correct procedure Correct site Site Marking done

Immediate post-procedure note is documented before patient is transferred to another level of care


And last, but not least…… Make surveyors feel welcome and recognize them as respected professionals. Because of the tracer methodology, be aware that your unit may be surveyed more than once. Have a Positive Attitude Smile Make eye contact Welcome surveyors to your unit Be Concise Answer the question to the best of your ability, but do not offer more information than necessary. Ask for clarification if you do not understand the terminology used, or what specific information surveyor is trying to obtain Do not be afraid to tell surveyors that you do not know all answers, but that you know your resources for information…. • Intranet resources • Charge nurse • Nurse manager • Other departmental or hospital resources


September, 2011


Guide to Preparing You for The Joint Commission