Health Care Guidelines: Implementing Treatment & Symptomatic Management

1. Health Care Guidelines: Successfully Implementing Treatment Guidelines And Symptomatic Management Guidelines Gary Strokosch, MD Medical Specialist Humanitas, Inc Jennie Williams, BSN, RN Health & Wellness Manager Oneonta JCC

2. Health Care Guidelines (HCG)- Introduction - • HCGs provide accepted practices for managing common health problems • HCGs may be used as is, or modified by the center’s providers

3. Benefits of HCGs • They provide evidence-based scientific rationale to support decisions regarding health staff treatment of students. • They decrease the possibility of medicolegal concerns for health staff and providers. • They provide non-health staff with direction for action, especially when the health staff is not available or not on center. • They hopefully avoid unnecessary transport to the local emergency room.

4. Health Care Guidelines- online link - • https://supportservices.jobcorps.gov/health/Pages/HCGuidelines.aspx • HCGs are no longer called Health and Non-Health Standing Orders. However a vestige of that terminology remains in PRH 6.11, R2 (b).

5. Health Care Guidelines- Two Types - • Treatment Guidelines (TGs)—for Health Staff • Symptomatic Management Guidelines (SMGs)—for Non-Health Staff

6. Health Care Guidelines- Two Types - • 65 Treatment Guidelines (TGs): • 54 medical – July 2015 • 6 mental health – Jan 2014 X5 / Mar 2014 X1 (dep/bipolar) • 1 TEAP – Mar 2014 • 4 oral health – Nov 2013 • 30 Symptomatic Management Guidelines (SMGs): • 24 medical – July 2015 • 2 mental health – July 2015 • 1 TEAP – Mar 2014 • 3 oral health – Aug 2012 NB: The HCGs are organized on the JC website in alphabetical order – they are not numbered

7. Center ProvidersResponsible for Approving and Signing HCGs • Center Physician (± Physician Assistant) • Nurse Practitioner: • Supervised Practice (12 states)* • Collaborative Practice (17 states)* • Independent Practice (21 states + DC)* • Center Dentist • CMHC • TEAP Specialist *https://www.aanp.org/legislation-regulation/state-legislation/state-practice-environment

8. Job Corps Policy(Commonly Cited in ROCA Reports) • All HCGs shall be approved and signed annually by the appropriate provider. • Current signed and dated HCGs shall be kept in the HWC. • Annually submit a memorandum to the Regional Office indicating which (if any) HCGs have been modified. Copies of the modified HCGs or health staff authorizations are sent to the Regional Office for approval.

9. Annual Submission- Definition - • Contract date for contract centers • July 1 for Forest Service centers

10. Additional Policy About Training(See PRH-5: Exhibit 5-4) • New non-health staff must receive training in the use of SMGs within 90 days of employment and annually, followed by a personal authorization. • New health staff must receive training in the use of TGs within 90 days of employment, followed by a personal authorization.

11. Training Example From Oneonta JCC

12. NON-HEALTH STAFF need a GUIDE for common symptoms • Support student health care • How to treat symptoms • Who to call • WHEN to CALL OCN

13. Training • Physician Authorization • Personnel File

14. Symptomatic Management Guidelines for Non-Health Staff • Organized by symptom • Each guide includes “When to Contact On-Call RN” • Alphabetized • Guides are Standing Orders

15. Where are Symptomatic Management Guidelines? • S DRIVE in computer • ILS office • Each dorm ILA office • Health & Wellness Center

16. WHEN IN DOUBT: ON-CALL RN DECIDES OSS CONVENIENT CAREWeekday: 8AM to 7PMWeekend: 9AM to 4PM • EMERGENCY? • URGENT CARE? – call RN EARLY • CAN BE HANDLED IN JOB CORPS FOXCARE WALK IN EVERYDAY 8AM to 5PM.

17. Some emergencies beyond On-Call RN • Call 911 first • Choking & CPR • Big bleed you can’t stop • Shock • Follow dispatcher advice • Notify On-Call RN when squad takes over

18. THREAT LIFE/LIMB Severe ALLERGIC Hive/SwellWith Trouble Breathing Call 911 give epi pen Poisoning Call poison control, Follow instructions Then RN & transport Open fracture or bleeding doesn’t stop w/ 10 minutes direct pressure Call 911 don’t move can’t transport bleeding Major head trauma Call 911Persistent vomiting Call RN & transport Actively homicidal CALL 911 police Actively suicidal CALL 911 then notify on-call RN VS: Wounds might need stitches Call on-call RN & transport

19. KEEP IN MIND: • ILA & ILS can assist a student with his own • ASTHMA INHALER or • EPI PEN following FIRST AID guide.

20. Actions you might need to take: • Call 911 • Crowd control • CPR / First Aid • HR, B/P, R • Report to CD, DO, HWM, family if minor • Report – filed in Student Health Record

21. How to Report to the On-Call RNWho/What/When

22. Urgent Issues • URGENT = NOT life/limb threat • ON-CALL RN DECIDES • Timely care within 24 hours • Could move toward emergency or… • Pain can become unbearable or... • May self resolve. Ex: Diarrhea/vomiting, Anxiety

23. Urgent Response • First: Call On-Call RN who decides who will eval: • ER • Urgent Care • MD • Mental Health • Dentist • Write injury report • Date & time

24. SELF SELECT SHEETS GO BACK TO WELLNESS EVERY WEEK – SEND BINDERS MONDAY @ LUNCH

25. Non-Urgent • Use: • Symptom Management Guidelines • Self-Select Meds • Self-Select Binder

26. NON-URGENT: HOW TO UNDERSTAND YOUR ILS vs ILA POWERS -

27. THE SYMPTOM GUIDES SHOW YOU HOW TO USE YOUR POWERSSAFELY AS A PROFESSIONAL

28. Symptomatic Guides • Guide you on: • Medications • ILS gives ALL allowed OTC meds PLUS + all ILA meds. • ILA gives only Tylenol & Ibuprofen & assists with life saving meds like Asthma inhaler, EpiPen • Treatments • “…drink 2 glasses of warm water…” • “…BRAT DIET - NOTIFY CAFETERIA: Bananas, Rice, Apple juice (or white grape juice) and toast or graham crackers…” • When to call on-call RN

30. WHAT ARE YOUR POWERS? PERSONAL AUTHORIZATION FOR NON-HEALTH STAFF FUNCTIONS IN ABSENCE OF HEALTH STAFF MEMBER Name: ___________________________________ Title________ (CIRCLE ONE) LEVEL: 1 LEVEL: 2 PLUS! ALL OF ILS LEVEL 2 POWERS

31. WHAT ARE YOUR POWERS? PERSONAL AUTHORIZATION FOR NON-HEALTH STAFF FUNCTIONS IN ABSENCE OF HEALTH STAFF MEMBER Name: ___________________________________ Title________ (CIRCLE ONE) LEVEL: 1 LEVEL: 2

32. Keep In Mind • Ibuprofen = Motrin & Advil • Motrin can hurt your stomach – take with food or milk – or just after a meal.

33. How to use the Symptomatic Management Guidelines EXAMPLE: Abdominal Pain

34. Symptomatic Management Guidelines for Non-health StaffAbdominal Pain • Authorized non-health staff may manage abdominal pain as follows: • Sudden & severe abdominal pain, or associated w/ fever 101, vomiting blood, blood in the bowel requires urgent evaluation by a clinician. THAT MEANS CALL RN. • Students with abdominal pain should avoid solid food, but may take small amounts of clear fluids. • Do NOT offer student acetaminophen or ibuprofen for abdominal pain.

35. Continued • For mild abdominal discomfort caused by INDIGESTION, offer student antacid Calcium Carbonate 420mg "ALCALAK" equivalent to TUMS-EX 500 mg, 2 tablets four times/day. ILS ONLY! • For mild abdominal pain caused by CONSTIPATION: Encourage student to drink 2 large glasses of warm water on rising and 2 glasses of warm water at ~ 7pm. Encourage fluid intake. Encourage student to choose whole grains, fresh fruits and vegetables and to take time in bathroom with bowel movement. • For mild abdominal cramps caused by DIARRHEA (3 loose BMs in 24hours), offer the student BRAT DIET - NOTIFY CAFETERIA: Bananas, Rice, Apple juice (or white grape juice) and toast or graham crackers). Increase fluids. May have half strength orange juice/ half water in sips. • For abdominal cramps associated with menstrual bleeding, refer to the Symptomatic Guidelines for Menstrual Cramps.

36. When to Contact Health and Wellness Staff • Refer ALL students with abdominal pain for FOLLOW UP at Health & Wellness. • If student experiences abdominal pain that is • sudden and severe, or • associated with fever > 101 degrees F • persistent vomiting • vomiting of blood, or • passing blood in the bowel movement • CALL on-call RN immediately.

37. SYMPTOMATIC GUIDEILS / ila / SAFETY DIFFERENT AUTHORIZATION NOW

38. HERE IS HOW IT WORKS

39. Any Authorized Staff Helps With Asthma Inhaler = First Aid

40. But Only ILS & HW Staff Assist with/Observe Other Meds Like…. Alcalak

41. OVER THE COUNTERMEDS OBSERVED

42. Any Authorized Staff Can Make AvailableTylenol Or Ibuprofen SELF SELECT SHEETS ONE SHEET PER STUDENT

43. SELF SELECT SHEETS GO BACK TO WELLNESS EVERY WEEK STARTS JUNE 1st

44. PRESCRIPTION MEDS OBSERVED

45. Any Authorized Staff Can Use “MOR” to Observe Student Take Own MedicationILS is Preferred

46. MOR Medication Observation Record 15000000 BLOSSOM DOGWOOD SYNTHROID levothyroxine #A1720005 One 125mcg tab every am by mouth PENICILLIN 1/1/2020 7:30am blossom d. wisemann Wise Mann

47. CONTROLLEDNARCTICMEDS OBSERVED

48. SAFETY STAFF & ILS Can Use “CMOR” To Observe Student Take Narcotic CONTROLLED MED OBSERVATION RECORD

49. CMORControlled Medication Observation Record 15000000 BLOSSOM DOGWOOD KLONOPIN #A1720005 One 25mg tab every am by mouth 1/1/2020 7:30am 10 9 blossom d. wisemann Wise Mann

50. CMORUsually, you’ll get a “Locked Package”. You won’t know how many are in the package. 15000000 BLOSSOM DOGWOOD One 25mg tab every am by mouth KLONOPIN #A1720005 IN LOCKED PACKAGE TOOK 1 PILL blossom d. wisemann Wise Mann 1/1/2020 7:30am