Patient Care Orientation

1. Patient Care Orientation Part Two

2. Restraint Use

3. Your Role In Restraint Use The restraint event begins with the RN assessment. Other disciplines contribute data to this assessment. • Alternatives to Restraints • Each department has its own set of restraint alternatives that they have chosen for use with their patient populations. Alternatives must be trailed and documented before restraints can be considered. Each policy has a list of restraint alternatives. • M/U has 3 types of restraints – • Waist Restraint – disposable • Velcro Tying Restraints – disposable • Velcro Locking Restraints – cleaned and reused • There are 7 points of restraint taught to the staff as well as positioning the patient on the bed. • 1 point – waist restraint • 2 points – most frequently are the two wrists • 3 points – waist and wrists • 4 points – ankles and wrists • 5 points – ankles, wrists and waist • 7 points – ankles, wrists, waist and biceps The patient can be positioned face up or face down based on status. When ankles are in restraints they should be anchored straight to the bottom of the bed and not “spread eagle” to the sides of the bed.

4. Restraints Continued… Safe discontinuation – Restraints will be removed one at a time as the RN assesses the patient’s readiness for restraints to be removed. The patient must never be in one point of restraint unless that is a waist restraint. When a patient is in four point restraints the RN should remove an ankle or wrist first. The next restraint removed must be the opposite limb – for example if the right wrist is removed the next restraint removed is the left ankle. The time of discontinuation must be charted. There are two restraint policies (AKN) • Restraints for Non-Behavioral or Acute Medical & Surgical Care • Restraint/Seclusion for Behavioral Management of Patients There are basically 3 exclusions to the policies: • Devices used to aid with positioning and/or keep immobilized during medical, dental, diagnostic or surgical procedures. • Adaptive/supportive devices, such as braces, orthopedic appliances which are used for voluntary support to achieve proper body position or alignment. • Use of forensic restraints (such as handcuffs or shackles) applied by law enforcement officials.

5. Restraints Continued… Restraints for Non-Behavioral or Acute Medical Surgical Care – (AKN) This policy is used for anticipated situations when there is a need to restrict the patient’s free movement and access to the tubes, drains, etc. (Restraint during detoxification is to follow the medical/surgical restraint policy.) • The order is for 24 hours and the preprinted order set must be used. The MD will authenticate the order within 24 hours along with their face to face assessment of the patient and the need for continued restraint on this preprinted order set. • The patient will receive the following cares at a minimum: • Q hour – CMS • Q 2 hours – Fluid, elimination and repositioning • TID and PRN – Food • Q12 hours – ADLs and hygiene • Cares are documented on the flow sheet. • The MD will complete a face to face assessment for continued need every 24 hours. • RN re-assessments are done q 8 hours. • If after a period of time without restraints the patient needs to have them re-applied, a new order must be obtained.

6. Restraints Continued… Restraint/Seclusion for Behavioral Management of Patients – (AKN) This policy is for unanticipated situations of sudden aggressive behavior that could result in harm to self or others. • The order is age dependent – there are order sets for each age group. The MD will authenticate the order within 24 hours. • A MD Face to Face Assessment is completed within 1 hour after the restraints have been applied. • Care for the patient includes 1:1 staffing the entire time they are in restraints and cares given the same as the acute med/surgical policy. The patient will be checked every 15 minutes and those checks documented. • The order renewal and face to face MD reassessment are guided by the age of the patient as follows: • Order Renewal: • Adult (18 yr.-older) • Adolescent (9-17 yrs) • Child (under 9 yrs.) • Face to Face Assessment: • Adult Q 8 hours • Adolescent and child Q 4 hours • Once restraints are released the patient will have a debriefing with the staff and it will be documented in the chart. The family, patient and staff will also have a debriefing and it will be documented as well. The only exception is if the patient does not want the family involved.

7. Final Restraints Comments • Notify hospital leadership if the patient remains in restraints for more than 12 hours. They will be involved in reassessment of the need for restraints. During the day it is the Nurse Manager, on other shifts it is the Administrative Supervisor. • If the order for restraint was obtained from an MD that is not the attending physician, then the attending must be notified. The attending will have more information about the patient that may impact the continued use of restraints. • Remember to document and get credit for all the alternatives that you attempt before during and after restraint are utilized.

8. Patient Care Information

9. Patient Safety Initiatives To provide our patients with a safe healing environment we have initiated safety goals around the care of the patient. Some of the goals you should become familiar with include: • 2 Patient Identifiers • Unacceptable abbreviations • Clinical Alarms • Pause for the Cause & Surgical Site Marking • Reduce hospital acquired infections: hand hygiene All five will be discussed in the following slides. VORB/TORB Look Alike / Sound Alike Meds – Tallman letters Communication Handoffs Medication Reconciliation

10. It Takes 2 • Matching the right patient to the right treatment or service: • When obtaining blood samples or administering medication or applying the patients armband, two patient identifiers will be used to compare to the same two printed identifiers on the lab request, medication record, or patient’s medical record. • Patient Identifiers Include: • Patient’s stated name and date of birth are compared against the printed name and DOB on the medication record, specimen label, or medical record. • Patient’s unable to state their name and DOB: • Verification by a family member • Verification by carefully matching the name and DOB on the wristband with the same info on the medical record, specimen label. • A patient room number will never be used as a method of patient identification or verification. • Exception to above is the administration of blood products. In this instance, use patient name, birth date and social security number.

11. Unacceptable Abbreviations • We have developed a list of abbreviations that are not approved for use within the medical record (documentation, notes or orders). • Orders written with an unacceptable abbreviation will not be accepted or executed. • Unacceptable orders will be clarified by the nurse and documented as a verbal order before executing. • Ask the unit charge nurse for more information regarding unacceptable abbreviations Clinical Alarms Goal: Improve the effectiveness of clinical alarms. • Examples of clinical alarms are : cardiac monitor alarms, fetal monitor alarms, apnea alarms, door alarms, elopement / abduction alarms, infusion pump alarms, bed alarms, bathroom alarms or respirator alarms Clinical Alarm Considerations: • Clinical alarms are basically all patient care equipment containing alarm functions • Alarm functions should be managed/adjusted by the assigned staff RN or other hospital designee. Collaborate with the charge nurse if you are having difficulty setting/adjusting alarm parameters with your patients. • Alarm policies are practiced • If an alarms fails, a Patient/Visitor Safety Report is completed, Risk Management is notified, and the equipment is immediately sent to Clinical Equipment Services (CES) for evaluation

12. Pause for the Cause Goal: Eliminate wrong site, wrong patient, wrong procedure/surgery. Done prior to local injection/incision/start of procedure – • Surgical Site Marking: The surgical site is marked for correct site and laterality, per policy. • Pause for the Cause: The circulating RN reads the patient’s full name and procedure including site / side, from the consent form. All members of the surgical team listen and confirm the correct procedure, patient, surgical site and side (laterality).

13. Safety & Ethical Situations • If you encounter a potential hazard or unsafe situation in our hospital or if you have an ethical concern regarding our practices or a patient care situation, you should discuss this with the charge nurse. • We encourage reporting of safety concerns, incidents, hazards and ethical concerns. • We have committees and processes in place to address these issues and make changes when appropriate. • Concerns reported to the charge nurse may be escalated to the unit leadership. • You may be asked to complete a “Patient/Safety Visitor Report” or “Area of Concern Form” to document the events. • When in doubt – fill it out!

14. Vital Patient Care Issues Patient Bill of Rights “Patients have the fundamental right to receive considerate healthcare that safeguards their dignity and respects their cultural, psychological and spiritual values…” The Patient Self-Determination Act of 1990 What is it? • A Document based on a law that states the rights that patients have while in a facility • Available in 6 languages and Braille. Why is it Important? • The law requires that all patients or their proxy receive this information upon admission. • Patient Registration Department gives the patient the document. What do I do? • Verify and Document that the patient or proxy received the document. • Explain that these are their rights as a patient. • Ask them to read it. • Document on medical record that you did this. • Answer any questions they may have.

15. Vital Patient Care Issues Grievances What is it? • A verbal or written complaint that cannot be promptly resolved to the patient’s satisfaction by staff present Why is it important? • It is a patient right • It is a customer service issue. What do I do? • Try to promptly resolve the issue by the staff present (with-in your scope of practice). • If not resolved, give patient the options of talking to the Patient Rep, Manager, or Administrative Supervisor, or to the Office of Health Facility Complaints (OHFC) listed in the Patient Bill of Rights Vulnerable Adult What is it? • All patients in a health care facility are considered to be vulnerable. Why is it important? • It is a MN Statute/ law. What do I do? • If patient alleges Abuse, Neglect, Harassment or Maltreatment while hospitalized- • Assure patient safety immediately • Report to Patient Rep., Manager, or Admin. Supervisor • Complete Patient Safety Report • Give report to Admin. Supervisor or the Internal Reporter (Social Services) • If Domestic Violence refer to Social Services or Advocate

16. Vital Patient Care Issues Informed Consent What is it? • Informed decision making and consent is required for all medical procedures and treatments with more than slight risk, or that may change the patient’s body structure. Why is it important? • To assure that the patient has adequate information in order to engage in informed decision making regarding their treatment. Use of the Verification of InformedConsent Form is required to verify all surgical, invasive cardiac, endoscopic procedures and any procedure requiring biopsy of tissue or use sedation which results in loss of protective reflexes. What do I do? • Hospital staff preparing the patient for the procedure will verify the procedure, site or side, and the patient’s understanding of the proposed procedure and document on this form. The form is a two sided form – one side is completed by the MD, the other side is signed by the patient and witnessed by hospital staff.

17. Vital Patient Care Issues And Finally… Sentinel Events – A sentinel event is defined as “any unanticipated death or serious injury resulting in a major permanent loss of function not attributed to natural course of affected person’s illness or underlying condition – or – an event such as infant abduction, hemolytic transfusion reaction, surgery on wrong patient, wrong body part, medication error resulting in a life threatening affect on health status”. All employeesare responsible to immediately report to their supervisor any patient events that met the definition of a sentinel event and complete the appropriate form. An initial investigation will occur within the first 36 hours of the event. A “near miss”is a significant event that could have been a sentinel event. These should also be reported so that processes can be re-evaluated to prevent future misses or sentinel events.

18. Advance Directives (AD) Key Points to Consider: • The admitting nurse must ask all inpatients if they have an Advance Directive (AD) and, if not, whether they would like additional information or assistance. • No patient is required to have an AD. • Completing an AD while the hospitalized may not always be the most appropriate time or place. It may be more appropriate for the patient to take the forms home following discharge so the patient has the option to discuss their wishes with family, clergy and Medical physician. • DNR and DNI status is independent of, but can be a component of, Advance Directives. A patient does not need to have an AD to request DNR or DNI status, nor is DNR or DNI always a component of a patient’s AD.

19. Advance Directives (AD) Continued If the patient has an Advance Directive (AD): • Obtain a copy from the patient or their old medical record. If a copy is not available, document on the pathway your efforts to obtain the AD from the family. • Nurses should place the AD in the most current medical record and must verify that it: • Reflects the patients current wishes and • That it is a valid (written, dated, patient’s name and signature is notarized or witnessed, it contains healthcare directives and /or the names of the agent or proxy. • If a patient wants DNR or DNI status, contact the MD. An order from the physician is required prior to implementing DNR or DNI status. Verbal or telephone orders require two RNs. • If the nurse is unable to reach the MD or is unsuccessful in obtaining a response from the physician, they must communicate escalate the issue to a higher authority to obtain MD follow through.

20. Advance Directives (AD) Continued If the patient does not have an Advance Directive: The admitting nurse must ask if the patient wants additional information – • If the patient says no, document on pathway. • If the patient says yes, provide with Allina Advance Directive booklet. • If the patient has questions or requests assistance, consult chaplain, social worker, administrative supervisor, or a member of the ethics committee. Remember patients are not required to complete the form. • If a patient says yes, but they would like to take it with them, document on pathway. • If the patient chooses to complete the form then place the completed form on the front of the chart and inform the physician.

21. Information for New-Employee Staff Assigned to Patient Care Dress Standard • Nametag with employee name, job title and photo must be located at or above waist level on employee at all times. • All clothing must be neat, clean, well fitting, non-transparent, in good condition. Employees are to be free of offensive odors (including cigarette smoke, perfumes and colognes). • Appropriate barrier clothing, including masks and eyewear, is work in accordance with infection control precautions. • You may wear scrub uniforms or dresses, culottes, or pants and tops with sleeves, except ceil blue. A warm-up jacket with any matching print is acceptable. Wireless Phones • All caregivers will sign out a phone at the beginning of the shift. • Return phone prior to the end of the shift. • Answer phone, identifying self by name and title. • Confidentiality is to be maintained at all times. • Clean phone with disinfectant prior to use and throughout shift.

22. Information for New-Employee Staff Assigned to Patient Care PATIENT SAFETY Physical Safety • Call lights will be placed within easy reach of the patient. • Beds will be kept in low position. • Bed wheels will be kept in locked position except during transport. • Floors will be kept free of spills. • All ambulatory patients will use foot coverings. • Restraints/seclusion will be implemented following the Patient Care Policy on restraints and seclusion. Equipment • Faulty equipment is reported to Facility Operations or Bio-Medical Departments immediately and tagged “out of service”. • Equipment brought from home by patients is limited to personal care items, such as electric razors and hair dryers, and must be checked by Bio-Med. Risk Management Safety Reports • Any incidents with a potential or actual adverse occurrence involving patients, families, visitors, volunteers, physicians, employees, or students must be reported. “Patient Visitor Safety Report” is the tool used to document the event. • A visitor with an obvious injury due to an incident on hospital property is to be encouraged to be evaluated by a physician in the Emergency Department. • Notification of incident is to include the charge nurse, department manager and/or the administrative supervisor.

23. Information for New-Employee Staff Assigned to Patient Care STAFF SAFETY Personal Injury and Potential Health Hazards • Questions or incidents related to personal injury or potential health hazards are to be referred to Occupational Health Services and/or Administrative Supervisor. Responsibility of Non-Employee Nurse • Non-employee nurses will function within the guidelines identified by the unit charge nurse in accordance with the hospital policies and procedures. • Non-employee nurses will not be responsible for:Charge nurse functions PROCESS FOR WORK ASSIGNMENTS • Report to the Staffing Office 30 minutes prior to the start of the assigned shift. You will need to show your nursing license and picture identification prior to getting your assignment. Failure to provide your nursing license will • CPR certification is verified prior to assignment. • Check with the charge nurse for assignment and if this is new unit for you then orientation to the physical layout of the unit is needed, as well as any populations specific considerations. • Complete billing slip/timecard and signature before you leave the PCU. Then present completed billing slip to the staffing office.for a signature before leaving the facility. • The Administrative Supervisor must approve all overtime prior to working overtime.

24. Medication Safetyand Documentation Overview

25. Medication Safety Allina’s Nine Principles for Medication Safety • Do no harm – • The Five Rights – • Right Patient • Right Medication • Right Route • Right Dose • Right Time • Nothing is taken for granted • Communication – clarify, ask questions • Teamwork – work with MD, pharmacist and patient. • Report – chart significant patient information, medication given or omitted on Medication Administration Record (MAR) • Safety is a system • Engage the patient • Inform the organization – complete the Pt./Visitor Safety form, do not record your completion of this on the pts. medical record, do not speculate to the cause of the event on your charting • Learning is the goal of medication safety

26. Medication Safety Safe Delivery Principles • Protocols for high risk medications • NO stock KCL on units • Patient information @ point of care • Pharmacist on rounds • Allergy wrist bands • Computerized MAR’s • Bar coding

27. Medication Safety High Risk Medications • Heparin/anticoagulants (requires 2 signatures) • Insulin ( requires 2 signatures) • PCA Pumps (requires 2 signatures) • Antibiotics (IV) • Concentrated electrolytes (KCL) • Benzodiazipines • Narcotics • Chemotherapy Anyone Writing Orders – Please DO • Write clear legible orders • Date and time all orders • Print your name under you signature • Use leading zeros when writing decimals (0.1) • Telephone/Verbal order read back (TORB / VORB) Please DO NOT • Use trailing zeros (5.0) • Use felt tip pens • Order “renew home meds”

28. Information Services and Clinical Systems

29. Documentation Overview Mercy Hospital nursing units and Unity Hospitals ICU utilizes Eclipsys, a computerized medical record system. Unity Hospital nursing units utilizes a paper documentation system. There are general documentation consideration that pertain to both hospitals and both systems. General Documentation Guidelines • Date and time all entries • Write legibly and sign name and title (RN, LPN) • Validate all new orders RN only • Initiate and sign appropriate pathway/plan of care on admission • Assess and document changes in patient’s condition Daily-24 hour focus note-patient’s response to plan of care • All new orders must be co-signed by RN Each shift • review, update and sign ALL pathways • review and sign Referral/Transfer forms—Physician signs all pages • review and sign all Discharge Instruction • Focus note all unmet outcomes at discharge • ETOH Assessments per protocol

30. Documentation Overview Documentation Time Frames- These are Medical Surgical parameters – this differs on specialty units • Complete physical assessment within 2 hours • Admission History within 8 hours – reassessment of patient every 8 hours • Initiate Pathway within 2 hours - updated every 8 hours and individualized, including outcomes met and new interventions to address progress or lack of progress. • Patient Story: Updated every shift. All problems must have a related outcome on the pathway. • Pain Assessment: Upon admission, at least every 8 hours and upon discharge. Reassess after every pain medication or intervention administered. • Education Pages: Patient education documented, including evidence of learning reviewed every 8 hours. • Focus Notes: Upon admission, discharge, transfer, new findings, significant events, physician notification, response to plan of care at a minimum of every 24 hours. Use DAR format (D- data, A – action, R – response) • Initiate discharge plan within 24 hours of admission

31. Documentation Overview Other assessments areas and issues – (bolded titles are key focus items and are audited) • Bill of Rights • Advanced Directives/Health Care Directives • Domestic Abuse Assessment - Patient must be alone and completed within 24 hours. • Medication History • Functional Status Assessment • Nutrition Assessment • Skin Assessment determined by Braden Risk Score • Fall Risk Assessment • Latex Allergy Assessment • Pain Assessment and Management • Patient and family education • Assessment/Reassessment • Pathway is considered the Plan of Care • Discharge planning • Patient Transfer forms and EMTALA forms Utilize your colleagues and leaders on any and all documentation questions or concerns.

32. In Closing... Final Considerations

33. Department Specific Orientation Checklist • Minimally, your department specific orientation should include the following items: • Location of: • Crash Cart • Emergency Equipment • Fire Safety • Personal Protective Equipment • Evacuation Map • Orientation to: • Documentation process and related technology • Medication administration and related technology • Accessing policies, procedures and other resources • Hospital and unit care & quality improvement initiatives • Demonstration of quick release tie and application of locking restraints (required for anyone working with patients).

34. You Have Completed Part Two!Please turn in the checklist used for this training program to your manager or continue on to Part Three based on the directions from your manager. Press the “ESC” key to end