UPPER CHESAPEAKE HEALTH SELF-LEARNING PROGRAM

1. UPPER CHESAPEAKE HEALTHSELF-LEARNING PROGRAM ANNUAL SAFETY EDUCATION PROGRAM December 2011 Fire, Safety, Infection Control, TB, Legal Compliance, HIPAA, Communication Assistance, Risk Management, Occupational Health & Team Member Injury Reporting, Patient Safety, and other important information including the Management of Unsafe Behavior Supplement for those requiring this update/review.

2. UCH is accredited by The Joint Commission • The Joint Commission standards deal with quality of care issues and the safety of the environment in which the care is provided. • When an individual has concerns about patient care and safety in the hospital, that the hospital has not addressed, he or she is encouraged to contact the hospital’s management. • If the concerns cannot be resolved through the hospital, the individual is encouraged to contact The Joint Commission • You may address your concerns to: Division of Accreditation Operations Office of Quality Monitoring The Joint Commission One Renaissance Boulevard Oakbrook Terrace, IL 60181 • You may also send the concerns by • Fax: 630.792.5636 • Telephone: 1.800.994.6610 • Email: complaint@jointcommission.org • Medical staff and team members reporting safety or quality of care concerns to The Joint Commission are immune from any disciplinary or punitive action taken by UCH.

3. PURPOSE: • To provide a review of pertinent Fire, Safety, and Infection Control policies, patient safety, and other information. The supplement provides an annual review for those trained in Management of Unsafe Behavior. • To fulfill regulatory and The Joint Commission requirements for annual fire, safety, electrical safety and infection control review, including AIDS, Hepatitis and TB. • OBJECTIVES: • After Reviewing this Self-Learning Program or after attending an appointment with the Education & Resource Development Department, the participant will be able to: • Define the priority actions to take in fire and exposure to hazardous substance and chemical emergencies. • State the purpose of MSDSs in their work area. • State the number one method used to prevent the spread of infection. • Verbalize role in providing a safe environment for patients, visitors, team members, and self. • Discuss the prevention and spread of AIDS, Hepatitis B & C, and TB. • Discuss your role in communication assistance and legal compliance. • For management of unsafe behavior, discuss the alternatives to restraints.

4. Contributors • Lynne Adams, Director, UCMC QHIM – Privacy Officer • Amy Myers, Safety Manager • Todd Dousa, Safety Coordinator • Debbie Bittle, Director of Risk Management • Ron Green, Director, Clinical Engineering • Colleen Clay, Director, Healthcare Epidemiology & Infection Control • Barbara Finch, Director, Service Excellence and Resource Development • Thomas French, Director, Security Services • Jane Gordon, Director, HMH QHIM – Privacy Officer • Diane Campbell, Education Specialist • Lisa Karmel, Director, Guest Services • Karen Linderborn, Education Specialist, Course Coordinator • Mark Moody, Director, Occupational Health • Carolyn Phillips, Accreditation Coordinator • Cindy Triplett, Education Specialist

5. CONTENT: • Emergency Information • Fire Plan Review • Hazard Communication • Infection Control Overview • Occupational Health – Injury Reporting • Abuse Reporting • Legal Compliance & Communication Assistance • HIPAA Privacy & Security • Body Mechanics • Supplement: Management of Unsafe Behavior Update/Review REFERENCES: Available on UCH Intranet: Reference Library/ Policy Libraries Revised 6.01, 12.01, 12.02, 12/03, 11/04, 11/05, 11/06, 10.07, 10/08 , 12/09, 12/10

6. DIRECTIONS: • Review the 2011 SLP packet of information. • If you prefer to review the information with a member of the Education & Resource Development Department team, please call for an appointment. (UCMC - 2900 or HMH - 5344) • Complete the Post-Test on-line or as a hard copy. You may use the SLP or any of the references as resources. If you need assistance, contact the Education & Resource Development Department. • The ON-LINE post test is automatically graded and sent to the ERDD. If you did a hard copy of the post test you MUST RETURN the Post-Test answer sheet to the Education & ResourceDevelopmentDepartment office at UCMC or HMH immediately. • If you don't pass with an 80% your incorrect responses to the questions will be reviewed with you in writing/e-mail or in person by a member of the Education & Resource Development Department. • Upon successful completion of the Post-Test you will receive 2 contact hours of education credit AND fulfill your requirement for ANNUAL MANDATORY EDUCATION.

7. I. EMERGENCY INFORMATION Dial 3333 THE NUMBER TO CALL on any Hospital Telephone to initiate EMERGENCY PROTOCOLS GIVE the operator your name & location and tell the nature of the emergency you are reporting! Code Phone

8. KNOW the CODES to ACTIVATE EMERGENCY RESPONSES: CODE RED: Fire, Smoke, or Excessive Heat - Get fellow Team Members to help, pull the fire alarm AND dial 3333. “RACE” and “PASS” help you remember what to do. CODE BLUEA: Cardiopulmonary Arrest, Adult CODE BLUEC: Cardiopulmonary Arrest, Child 8 years old or younger CODE PINK: Attempted or Actual Infant/Child Abduction CODE GREEN: Disruptive or Combative Person Requires response by team members and security to protect the person from harming self or others CODE GREEN SHELTER-IN-PLACE: Armed. Threatening person inside building Called if someone threatens another person with a deadly weapon or shots are fired inside the building CODE PURPLE: Security Response Urgent A security matter that requires only Security Officers to response. The matter is urgent, but not critical in nature CODE YELLOW: Disaster Event Report to your department and follow the UCH and Department Emergency Operations Plan

9. How do I access the Emergency Plans? The Emergency Operations Plan is located in UCH Intranet – from the UCH Intranet site home page, go to “Resources” at the top of the page and select Emergency Management (Code Yellow), 2010 Emergency Operations Plan.” This plan covers many internal and external events. Some emergency situations are covered by separate plans. These include: Bomb Threat, Fire (Code Red), Evacuation, Hazardous Materials Spill & Infant/Child Abduction (Code Pink). These are found on the Intranet in the Reference Library under Policies & Procedures in the Environment of Care Manual. Know your role in a Disaster! REPORT to your department and follow the UCH and department Emergency Operations Plan.

10. What is Emergency Management? POLICIES & PROCEDURES are designed to do four things: 1) MITIGATION – actions to reduce the chance of or lessen the impact from a disaster event. 2) PREPAREDNESS – equipment, policies & training to enable quick and effective response 3) RESPONSE – implementing plan in reaction to an unplanned event or drill in a coordinated, successful manner. 4) RECOVERY – getting back to normal business after a major disaster event.

11. Types of Emergencies / Disasters 1)EXTERNAL - The facility is not damaged, but it requires the hospital to prepare for potential impacts, including loss of power, reduction of external services or the potential to receive any casualties. Examples are hurricanes, floods, tornadoes, radiation releases, civil disturbance, building collapse or transportation disasters. 2) INTERNAL - The facility has a failure of a critical system that could potentially affect patient care or normal operations. Examples are fire, water shortages, power loses, explosions, or acts of violence.

12. Prepare through training drills and awareness of the plan. KNOW your role as part of both the hospital plan and your departmental plan. Manage resources and make decisions based on the needs of the community and our patients, working closely with local emergency agencies. Give the best care to the greatest number of patients with a coordinated effort by all. What is our PLAN?Written policies and procedures assist us in responding to an emergency. Drills are held at least twice a year to practice a quick and appropriate response. The GOALS:

13. The BOMB THREAT PLAN advises team members in the steps to take in the event of a bomb threat. As a review, these are the steps you would take if you receive a BOMB Threat over the telephone: • Try to keep the caller on the phone as long as possible, and • Ask questions to gather information, such as where exactly is the bomb located (questions to ask can be found in the yellow Environment of Care Quick Reference Chart). • Write down as much information as you can remember about the caller as well as specific information regarding the bomb. • Dial, or have a co-worker dial, 3333 immediately to report the situation.

14. Code Green Shelter in Place • Designates a Hostile Person and/or Possible Weapon • In the event of any dangerous criminal activity within our facilities, there may be an immediate need to communicate hospital-wide that everyone should seek shelter and avoid public areas. • Situations may include a hostile person, use of a deadly weapon, a shooting, a serious assault, an escaped forensic patient and/or a hostage situation. • Team Members should find the closest lockable room and barricade inside far from the door. Cell phones should be set to vibrate or silent.

15. Code Green Shelter in Place • Take immediate action: • Inform people in your immediate surroundings to follow you to a secure area, such as an office or the closest area that can be locked. • Team members that are not responsible for direct patient care should try to exit the building if not in the affected area. Clear clear public waiting rooms and hallways if in the immediate area. • DO NOT attempt to shut patient room doors as in a Code Red; protect YOURSELF. • The cafeterias will be secured. • The gift shop and conference rooms in use should be secured by those inside these areas. • When hospital security has been advised by law enforcement and administration, an ALL CLEAR announcement will be made using overhead paging and text pagers. Once the incident is over, return to your workplace and report to your manager.

16. Code PINK Code PINK is an actual or attempted infant or child abduction. All UCH team members will need to be watchful for ANYONE attempting to leave the unit/facility with an infant or child in any fashion. ALL TEAM MEMBERS are to respond immediately to the nearest exit or hallway. BE ALERT for any suspicious person(s) carrying any package – not just an infant or child!

17. Code PINK To help all team members be more alert to the “size” of the child involved in the situation, the following is included when a CODE PINK is called . . . • If the child is less than one, state to the operator when calling the CODE PINK to announce “Code Pink - Infant”. • If the child is over the age of one, state to the operator when calling the CODE PINK to announce “Code Pink – Age ____ (state approximate age of child)”.

18. CODE PINK . . . Team Members should pay attention to anyone: • Physically carrying an infant instead of using a bassinet. • Attempting to leave the facility with an infant on foot, rather than by wheelchair. • Carrying large packages (i.e. gym bag), particularly if they are "cradling" or "talking" to it. Notify Security Services IMMEDIATELY, if you observe any such behavior. If the person is attempting to leave the building, try to prevent them from leaving. Security Services phone numbers: HMH – 5314 UCMC - 2444

19. If a CODE PINK is in effect:Explain to all visitors who are unable to exit the facility that a security incident has taken place. Reassure them they will be allowed to leave as soon as possible and thank them for their cooperation.

20. Rapid Response Team (RRT) The RRT is a team of clinicians assist with assessment and treatment of a patient that has had an acute change in his/her condition. The RRT can be called ANYTIME. An ICU Nurse, a Respiratory Therapist, and the Intensivist/PA/NP, if needed, after the ICU Nurse asses the patient, will respond. The Primary Nurse is always a part of the team. The Stroke Facilitator will also be contacted if a stroke is suspected. Purpose: The RRT is a patient safety strategy that can “rescue” patients when their conditions decline. It can reduce the number of code blues and the inpatient mortality rate. To ACTIVATE the RRT dial ext 3333 and request the Operator page the RRT.

21. Rapid Response Team (RRT) The RRT will respond to a Rapid Response Team CALL in any location with the hospitals, and at UCMC on the ground floor of the ACC. The RRT will assume responsibility for the treatment of the patient if he/she is an inpatient. The ED will also respond to RRT calls in ancillary departments as well as the UCMC ground floor – the ED will assume responsibility for treatment of the patient is not an inpatient. Patients and family members can call the RRT directly by dialing ext. 3339 from any hospital phone and asking the Operator to call the RRT to the patient’s room. Encourage patients and family members to call whenever the patient is in an emergency medical situation and is unable to get the attention of the nurse; if there is a sudden worsening in the patient’s condition and the healthcare team is not present; or if there is a breakdown in communication over what needs to be done to treat them.

22. Rapid Response Team (RRT) There are additional Rapid Response Team: A Pediatric Rapid Response Team (PRRT) can be called when there is a need to assess a pediatric patient in any area of the hospital. A PRRT if for children and adolescents up to the age of 18. A PALS nurse and a Respiratory Therapist with ACLS responds. At UCMC a pediatric hospitalist, a pediatric nurse and the 1 West charge nurse respond. The STEMI RRT includes the Primary Nurse, ICU Nurse, RT, EKG Tech, IV Team Nurse, and the Intensivist as first responders. The ICU nurse is to take the STEMI medication box to the bedside. The OB STAT Team can be called to respond to OB emergencies . The team is consists of designated Family BirthPlace team members as well as pediatric hospitalist, anesthesiologist, respiratory therapist and other clinical team members as needed.

23. RESPONDING to Emergencies for all other areas on Campus • For All Other Areas on Campus: Upper Chesapeake Health will provide immediate medical support and evaluation to those individuals requiring medical attention while on Upper Chesapeake facility grounds. The on-campus emergency response is intended to determine the need for medical treatment and provide for safe transport to an appropriate treatment area in a safe and timely manner. • Notification: This notification can come from hospital personnel, visitors, physicians, law enforcement agencies and guests passing through the campus. • Once a team member is notified of an emergent situation, they will contact the Switchboard by dialing extension 3333. • The Switchboard will call a Rapid Response to the location of the emergent event. • The Switchboard will then contact the Emergency Department and the Security Department (each will immediately respond to investigate the situation). The Switchboard will notify the Administrative Coordinator if on duty. • The Emergency Department and Security Department team members will respond to the area according to policy. • On campus emergency policy and procedure is being moved to the Rapid Response Policy and will soon be updated on the UCH Intranet Reference Library • If a UCH team member is either on or off duty, and encounters an emergency situation on the hospital premises, UCH requires the individual to assist in the emergency until relieved by the RRT or EMS. FYI – AEDs (Automatic External Defibrillators) are now located in the ACC and the Physician Pavilions

24. II. FIRE PLAN REVIEW CODE RED Every TEAM MEMBER MUST know and understand WHAT to do when a Code Red is called! Every TEAM MEMBER MUST know and understand WHAT to do if they discover a Fire or Smoke! Every TEAM MEMBER MUST know and understand WHAT to do if they smell or see smoke, or feel excessive heat in an area that should not be HOT!

25. There are 4 steps that are CRITICAL and can be remembered by the word RACE RRescueanyone in immediate danger AAlarm: Sound the ALARM – Get fellow Team Members to help! Pull the Fire Alarm and Dial 3333 Tell the operator the exact location of the fire. Get fellow Team members involved to help respond. (Note: Pull stations are at doors to stairs or outside, and nursing stations) CContainthe fire: - Close Doors & Windows EExtinguishthe Fire if it is no larger than a waste basket AND you can do so without endangering yourself, OR Evacuateif there is an overhead announcement to do so from your area or a supervisor tells you to.

26. NEVER DELAY IN REPORTING A FIRE Never delay in reporting SMOKE • SEE FIRE --- INITIATE Code Red • SEE SMOKE --- INITIATE Code Red • SMELL SMOKE? • Attempt to locate the origin of the smell. • If you investigate and think the smoke is from a fire activate the pull alarm and CALL 3333. • NOTIFY your supervisor or Facilities Services if you can’t locate the smell or don’t think it is related to a fire. By knowing what to do and responding effectively, you enhance our Fire Protection Plan and provide a safe environment for our patients and fellow team members

27. EXTINGUISHING A FIRE REMEMBER – DO NOT fight the fire if it is larger than the size of waste basket OR if there is excessive heat or smoke. KNOW the Class of Fire you have- Class A – Common combustibles (paper, wood, cloth–things that leave an ash) Class B – Flammable liquids or gases Class C – Electrical (energized electrical equipment) TYPES of Extinguishers available- Class B & C ONLY Class ABC

28. Another 4-Step Word for Using an Extinguisher PASS • Pull the pin • (before you approach the fire) • Aim the nozzle • (at the base of fire) • Squeeze the handle • (start about 6-10’ from the fire) • Sweep side to side

29. What to do if an Inpatient Unit Patient Room Smoke Detector Alarms UCMC ONLY • All UCMC Inpatient Room smoke detectors are connected to the Nurse Call system. If activated the following will occur: • Individual smoke detector will alarm inside patient room. • A “critical alarm” will ring through the nurse call system to all nursing CISCO phones and to the console at the nurses’ station on the unit with the fire/smoke. • The Switchboard Operator will receive notification of the specific room number with fire/smoke. • If an inpatient unit smoke detector alarms inside a patient’s room, go to the patient room where the alarm is sounding. Follow RACE acronym. • Rescue anyone in immediate danger • Alarm – Activate manual pull station, Call 3333, Notify Team Members in area of fire. (even if you do not see or smell smoke) • Contain – Close and latch all doors. • Extinguish – Extinguish small trash can size fires. • Evacuate – If there is an overhead announcement to do so from your area or a supervisor informs you to.

30. ALSO REMEMBER: • Fire Exits & Smoke Doors must NEVER be blocked and must remain closed during a fire/smoke event • Keep stairs and corridors clear at all times – NEVER store objects in halls, even if objects are on wheels. • Reassure patients and visitors that Code Red is in effect and we are taking appropriate action. • You may need to explain what a Code Red is: “We are taking precautions as there may be a fire or smoke in the hospital – we will keep you informed” • Team Members assigned to non-patient care areas should remain in their department, if not the fire zone. • Team Members assigned to patient care areas should return to their unit. Be prepared to evacuate patients and visitors to another smoke compartment on the same floor if the fire is nearby.

31. AND: • If in the Code Red location, take charge of the area and provide leadership to Team Members. • Designated Team Members from Facilities & Security will report to the Code Red scene. Have a Team Member wait in the main corridor to direct respondents to the Code location. Get Facilities to help cut power to electrical equipment that is on fire, if needed. • Oxygen, gas or other devices that could aid in the spread of fire should be shut off (see Patient Care Area slide for more on oxygen shut-off). • Keep telephone lines open during any emergency by not using them unless absolutely necessary. Avoid calling the switchboard if you can get information any other way – they are VERY busy during a code. REMAIN CALM

32. SPECIAL ISSUES – PATIENT CARE AREAS Nursing Team Members • Report to your nursing unit promptly • Account for all patients • CLOSE doors to patient rooms • Inform patients and visitors that the Fire Plan is in effect and to stay in their room until they receive further instructions • Be reassuring and calm • Clear hallways of all items • Be ready to implement evacuation procedures

33. Respiratory Care Team Members Report to scene to assist with O2 valve shut-off Nursing Team Members Charge Nurse or Clinical Nurse Manager takes charge of O2 issues, if Respiratory TM does not arrive Oxygen shut-off priorities Identify any patients with a critical need for O2 Assess the proximity of fire and risk to piped O2 Balance the two risks - do any patients need tank O2 prior to shutting valve AND is there time to do so without severe fire risk? SPECIAL ISSUE – CLOSINGOXYGENVALVES

34. Remember: Treat every Code Red as an emergency, even if you think it is a drill. Drills save lives as they help us rehearse emergency procedures. All departments must clear hallways and close all doors during fire drills, even if the event is not in your department or work area.

35. The Joint Commission tells us that when we have known disruptions to usual fire safety features, we must implement ILSMs Construction activities that interfere with Life Safety, such as those that block hallways, change exit routes or interfere with fire safety systems, are considered such “disruptions.” SPECIAL FIRE SAFETY TOPIC: INTERIM LIFE SAFETY MEASURES (ILSM)

36. Examples of ILSM Actions Disruption: Exit paths are temporarily changed ILSM: Know changes to escape routes (signage posted), make sure they stay clear Disruption: Fire detection, suppression or alarm systems are shut down for needed work ILSM: Rounds are made every two hours to look for possible fire safety issues (usually Security), control the storage of combustibles (good housekeeping), ensure emergency exits are unobstructed Disruption: The end of a hall is blocked, making a temporary dead-end. ILSM: Pay attention to signage informing occupants of the temporary condition and help remind patients and visitors in that area of that condition.

37. OTHER ILSM ISSUES Whatever the disruption may be, it is important that all Team Members understand the impairment and ILSMs. Please pay close attention to signage, emails from your supervisor and any other ILSM communications. There are a variety of other actions taken by Contractors, Facilities and Safety to ensure the safety of our patients, team members & visitors during life safety disruptions that will not directly involve you. If you have ANY questions, please contact your Safety Officer @ ext. 3120 or pager 410 – 588 - 0643.

38. The safety and well-being of our patients, families, visitors and team members are of paramount importance. Help to eliminate fire hazards by keeping your work area clean and free from non-essential combustible materials. Memorize the BASIC Fire Plan - “RACE” KNOW the location of all fire exits and how to get to them in the event of evacuation. KNOW YOUR RESPONSIBILITIES CLOSE DOORS Report fire hazards Keep hallways, stairs and exits clear at all times. Report all fires or suspected fires. KNOW where fire fighting equipment is and know how to use a fire extinguisher – “PASS”.

39. A word about Electrical Safety . . . ELECTRICAL SAFETY IS EVERYONE’S RESPONSIBILITY! ALL electrical equipment brought into our hospitals MUST be checked by Bio-Med (if clinical equipment) or Facilities (if not clinical) BEFORE use. A sticker will be applied when this check is done, which will give a date for a recheck, if needed. If you find any electrical equipment without a sticker or with an outdated sticker, inform your supervisor. REPORT any damaged or malfunctioning equipment: ~ DO NOT USE the equipment. ~ REMOVE it from use. - Put the ORANGE UCH “DEFECTIVE EQUIPMENT” tag on the equipment so that it is not used. Write down what is wrong, your department, your name and the date. - Take it to Facilities or Bio-Med or call and arrange for pick-up to make sure it will be fixed.

40. III. Hazard Communication What is Hazard Communication? It is information and education to INCREASE your awareness about chemical hazards in your workplace! It’s your “RIGHT TO KNOW” “Right to Know” LAW: The “Access to Information About Hazardous and Toxic Substances Act” gives team members a way to learn about chemical hazards in the workplace and how to work safely with these materials.

41. PRODUCT HAZARDS: Spills, Exposure and Poisonings Be aware that many products can contain hazardous ingredients. • Educate yourself on every product you use. Read labels. • Know where to get more information about hazards of a product. • (ANSWER – Material Safety Data Sheet / MSDS) • Know how to get an MSDS. • (ANSWER – It is on the yellow & black MSDS sticker on the phones. Some departments maintain hard copies in notebooks. Copies are maintained at both hospitals in Risk Management in case phones/faxes are not working) • MSDSs contain information on: • Chemical Identification & Hazardous Ingredients • Physical Data • Fire, Health & Reactivity Hazards • Spill Procedures • Personal Protective Equipment • Medical treatment for exposure READ ME!

42. CONTROL / MINIMIZE YOUR EXPOSURE • Know your product. • Ask your supervisor if you don’t know. • Keep your work area clean. • Practice safe work habits. • Use Personal Protective Equipment, if needed. • Don’t eat, drink, or apply cosmetics around hazardous products. • YOU need to know what to do for a spill of any chemical used in your department. • Each department with hazardous materials is responsible to keep spill kits readily accessible and fully stocked. • Contact your Safety Manager at ext. 3120 if you need further information.

43. IV. Infection Control Overview SAFETY also includes providing an environment that minimizes the risk of infection for patients, visitors, team members and the community. Simon says “INFECTION PREVENTION & CONTROL IS EVERYONE’S RESPONSIBILITY!”

44. Important information before you start this Infection Control and Bloodborne Pathogen section • If at any time during the review of the Infection Control/Bloodborne Pathogen training you have any questions, please contact a member of the Healthcare Epidemiology and Infection Control Department. One of them is available 24 hours a day, seven days a week. • Call 3106, 3104 or 5047 • off-hours page 410.588.0407 Let’s review some very important points...

45. HAND HYGIENE: The MOST important measure to prevent the spread of infection! • Perform hand hygiene by using the waterless hand sanitizer . • when entering and exiting a patient care environment (cleanse in/cleanse out) • before and after contact with a patient or anything a patient has touched. • before donning gloves when preparing to perform patient care • before eating, drinking, smoking, applying makeup, or handling contact lenses. • before performing invasive procedures. • before medication preparation. • after removing gloves • Perform hand hygiene by using soap and running water if (scrub for 15-20 seconds): • Your hands are visibly soiled • You finished caring for a patient with Clostridiumdifficile • Your hands feel gritty after many consecutive uses of waterless hand sanitizer Other aspects of hand hygiene include: • Keep fingernails neat and clean and do not allow the length to exceed ¼ inch beyond the fingertip • Artificial nail enhancements are not permitted for any team member who provides direct hands-on patient care • Use the hospital approved lotion to help moisturize the skin

46. Keep yourself safe from germs - follow OSHA’s law! • OSHA states that • eating, • drinking, • applying cosmetics or lip balm, • handling contact lenses • are prohibited in work areas where • there is a likelihood of exposure to • blood or other potentially infectious • materials. • Be sure that you are following this in clinical areas, patient care areas, desks/counters and medication • carts/areas - - - • IT’S THE LAW and it is meant to • protect you from infection!

47. STANDARD PRECAUTIONS • Use STANDARD PRECAUTIONS in • the Care of All Patients • Prevent spread of bloodborne pathogens through the use of safe work practices used in all patient care activities. • Wearing Personal Protective Equipment (PPE) appropriate to the task you are performing.

48. USE Personal Protective Equipment (PPE) • PPE is available in all areas of the hospital. • PPE includes gloves, face protection, gowns, etc. • Wear appropriate PPE if you WILL or MAY come in contact with blood or potentially infectious materials. • FOLLOW established job procedures if you work in a job where contact with blood or potentially contaminated body fluids or contaminated material is possible. • Do not take shortcuts, DO NOT put yourself or our customers at risk. • For a detailed description of PPE and its use, please contact the Healthcare Epidemiology & Infection Control Department, the Safety Manager or the Risk Management Department.

49. ALERT FOR CLINICAL AREASUCH Isolation Policies • There are 3 categories of isolation used at UCH • All patients on isolation are to be placed in a private room • If a private room is not available, select an appropriate roommate. Refer to the Infection Control Policies and Procedures on the Intranet and review the Isolation Precautions Policy for guidance on roommate selection. • When initiating isolation be sure to complete the following: • Place an isolation sign on the patient room door • Place an isolation supply box on the patient’s room door • Place an isolation sticker on the spine of the patient’s chart • Enter into Meditech the category of isolation being used for the patient • Provide appropriate patient/family education and document • Follow policy for proper use of personal protective equipment • Dedicate equipment used for isolation patient if possible; if unable, disinfect equipment before use on another patient

50. ALERT FOR CLINICAL AREAS UCH Isolation Policies Let’s REVIEW the three (3) categories of isolation • Airborne Precautions • Prevent the spread of infections that are transmitted by small particle droplets that remain suspended in the air • The patient is placed in a negative pressure room and keep door closed. • Notify Facilities when a patient is placed on Airborne Precautions so they can monitor the ventilation in the room. • Team members wear a PAPR for patient care • If patient must leave room, patient is to wear a surgical mask while out of room