OnLine Faculty Orientation

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On-Line Faculty Orientation
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Greetings

• On behalf of SJHS, WELCOME! We are pleased to
  provide a worthwhile clinical rotation for your
  students. In order to provide quality care for
  our patients, we will adhere to certain mandatory
  requirements that JCAHO, OSHA, HIPAA, and legal
  counsel have recommended. Based on this, we are
  required to request certain information from you
  on an annual basis.
• To communicate this necessary information,
  please review this entire presentation and
  complete the acknowledgement agreement. A
  faculty handbook and student handbook should be
  printed as orientation tools to accompany this
  presentation. If this is your first clinical
  group at SJHS please contact me for information
  regarding unit orientation at 859-313-4493 or
  marjoriefuller_at_catholichealth.net
• Thank You, Margie Fuller

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Faculty Responsibility

• Prior to the first day of the clinical rotation,
  each instructor should review the orientation
  handbook with the students. This handbook
  outlines general information on basic procedures
  utilized at SJHS. On the last page of the
  handbook is a form that must be signed by the
  student and faculty/preceptor. Please turn this
  completed information into the education office
  at the Saint Joseph Office Park.

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Resources
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SJHS Directors

• Medical-Surgical
• LaJava Chenault
• Critical Care Telemetry
• Jennifer Drumm
• Pharmacy
• Eric Miller
• Lab/Radiology
• Dennis Netzel
• Rehab Services
• Debbie Ison
• Women's Services
• Denise Hundley
• Emergency Services
• Marilyn Swinford

• Educational Services
• Rose Patrick
• Continuing Care Hospital
• Gwen Howard
• Respiratory Therapy
• Marlene Riggle
• Surgery (West)
• Linda Watt
• Surgery (East)
• Nursing Service Berea
• Pat Patton

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Clinical Nurse Specialists

• Debbie Griffith Critical Care (Surgical) Ext.
  1765
• Jennifer Drumm CC, ED, Cath Lab Ext. 1836
• Billie May Palliative Care Ext. 1988
• Debbie Kitchen Gerontology, 4A/5B Ext. 1168
• Marge McMillan Medical-Surgical Ext. 3229

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Clinical Educators

• CTVU(SJH),ICU (SJE), 3East (SJH)
• Cheryl Watson
• CCU/ICU-N S (SJH), 4MS (SJE), 3B
• Karen Cooper
• 2E, 4IC (SJH), 3 Tele (SJE), 5A
• Jan Hovekamp

• 3A, 4A,5A, 5B, 6 ONC (SJH)
• Tracey McFarland
• ED (SJE,SJB,SJH)
• Chrystal Hackney
• Heart Institute (SJH, SJE)
• Margaret Kramer
• Womens Care

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SJHS Policies Procedures

• Administrative, Patient Care Services, and Human
  Resources policies and procedures are all
  available on-line via the Intranet.
• Each department may have a department specific
  manual. Please inquire with the manager to review
  if necessary.
• Unit Specific Resource Manuals are located on the
  individual Units.

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Medical Library

• Librarian-Laurie Henderson (313-1677)
• Hours 8-430, M - F
• Located on the ground floor of the West Campus
• Multiple computers with printing capability
• Small conference room
• Textbooks, journals, and other research material
  available
• Small TV/VCR for in-library viewing

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The Intranet

• SJHS internal communication and resource site.
  Accessed only from a computer within the
  hospital. Click on Internet Explorer icon
  defaults to the intranet not internet
• Intranet resources
• Policies and Procedures-Click on PP Seeker
• Standing Orders/Consents
• Education-Patient Care Information (Click on
  Micromedex, Up To Date, etc.)
• Variance Reports (IRIS-Reporter)
• Clinical Care Site/VSDS
• Unit Specific Scopes of Service

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Documentation
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Multi-Disciplinary Forms

• Admission History Record-PCS-III-40E
• Patient Flow Sheet-PCS-III-43F
• Medication Administration Record
  (MAR)-PCS-III-28C
• Interdisciplinary Consult and Education Record
  and Discharge Record-PCS-III-53A
• Care Maps/Care Guide-PCS-III-63
• Medication Reconciliation Sheet
• Please refer to the listed policy for detailed
  information.
• Policies can only be accessed on the in-hospital
  intranet.
• Intranet instructions are also listed in the
• faculty handbook.

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Departmental Forms

• Each department has specific documentation forms.
  Please contact the unit manager or the clinical
  educator for the area to review.

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Infection Control

• Hand Hygiene
• SJHS follows CDC hand hygiene guidelines
• Alcohol-based hand cleansers are as effective as
  soap and water

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Alcohol-Based Cleansers

• Use before and after all patient care unless
  hands are visibly soiled
• Apply cleanser to hands and rub until dry. Use
  only a small amount- too much product will not
  evaporate and will result in a slimy or sticky
  feeling
• Do not alternate with soap and water-this will
  result in an increase in chapping and drying of
  the skin

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Alcohol-Based Cleansers

• Let the patients see you use the product-it is a
  great patient satisfaction practice.
• Offer alcohol hand rub to patients prior to meals
  and after bathroom visits-also to family members
  who provide care.
• Pay close attention to nail beds and finger nails

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Artificial Nails

• CDC guidelines discourage the use of artificial
  nails in patient care settings. Bacteria can
  build up under the artificial nail, thus
  increasing the risk of bacterial contamination.
• SJHS policy states No artificial nails or
  extenders are to be worn by RNs, LPNs, Physical
  Therapists in direct patient care.

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Radiation Safety

• Minimize time in radiation area
• Dosimetry Monitoring
• Do not place your body in the direct path of an
  x-ray field
• Wear lead aprons when around x-ray
• Stay as far from the source of radiation as
  practical

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MRI Safety

• Magnet is always on
• Move patient from the scanner to the holding room
  in the event of a Code Blue
• NO metal objects in the MRI scan room because it
  can cause serious injury/death
• Only MRI SAFE oxygen tanks and regulators are
  allowed in the MRI area. Patient beds and IV
  pumps are not MRI SAFE. Pumps must be removed
  prior to entering the MRI scan room.

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Isolation Categories
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Standard Precautions

• Assume all patients/body fluids are potentially
  infectious.
• Perform hand hygiene before and after contact
  with patient or patients environment
• Dispose of bio-hazardous waste in the proper
  container (sharps in sharps containers, etc.)
• Use sharps safety products and work practice
  standards to prevent exposures

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Standard Precautions

• Perform hand hygiene before and after each
  patient contact.
• Use Personal Protective Equipment (PPE) whenever
  there is a possibility of exposure to blood or
  body fluids (wear mask and eye protection when
  patient shows signs/symptoms of respiratory
  infection)
• Report all exposures immediately to your
  supervisor
• Clean all patient care areas regularly with the
  hospital disinfectant. Clean all spills
  immediately
• Handle soiled linen as little as possible and
  place in covered hamper

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Transmission-Based Precautions

• Serves the following functions
• Prevents the spread of infection
• Controls the spread of communicable diseases and
  drug resistant organisms

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Contact Isolation

• For patients with known or suspected diseases or
  conditions transmitted by direct contact with the
  patient or patients environment
• Examples include
• MRSA
• VRE
• Clostridium difficile
• Shigella
• Head and body lice
• Viral conjunctivitis
• Deep skin infections

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Contact Isolation

• Wear gloves every time you enter the room. After
  glove removal perform hand hygiene.
• Wear a gown when performing patient care
  activities or when in contact with patient
  environment. When the patient has diarrhea, a
  colostomy, an ileostomy, or wound drainage, wear
  a gown.
• Dedicate a thermometer and blood pressure cuff to
  the patient.

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Contact Isolation

• Limit the movement of the patient perform
  procedures in their room when possible.
• Teach the patient and family about hand hygiene.
• Communicate the need for contact precautions to
  all departments/staff.
• Frequently clean the room and patient care
  equipment using the hospital approved
  disinfectant.

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Airborne Precautions

• For patients with diseases or conditions
  transmitted by airborne droplet nuclei including
• TB
• Chicken pox
• Measles
• SARS
• Smallpox

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Airborne Precautions

• Keep the door closed.
• Limit all persons entering the room. (provide a
  surgical mask for visitors).
• Wear a N-95 respirator prior to entering the
  room. (Ensure you have been fit-tested for the
  respirator).
• Communicate airborne precautions to all
  departments and staff.

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Droplet Precautions

• For patients with known or suspected diseases or
  conditions transmitted by droplets produced
  through coughing, sneezing, talking, or laughing
• Illness examples
• Pertussis
• Influenza
• Virulent bacterial infections
• Meningitis
• Diptheria

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Droplet Precautions

• Place a surgical mask on the patient or give them
  tissues to cover their mouth when moving through
  the hospital.
• Place patient in a room with a door. Keep the
  door closed.
• Wear a surgical mask when entering the room to
  perform patient care.
• Maintain a distance of 3 feet (arms length) if
  not wearing a surgical mask.

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Drug Resistant Organisms

• Things to remember
• Frequent hand hygiene
• Minimize indwelling time of invasive catheters
• Monitor the antibiotic appropriateness
• Observe proper isolation techniques
• Reduce risk of transmission through proper
  communication

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JCAHO NPSGs

• Goal 1 Improve the accuracy of patient
  identification
• Goal 2 Improve effectiveness of communication
  among caregivers
• Goal 3 Improve the safety of using medications
• Goal 7 Reduce the risk of health care-associated
  infections.
• Goal 8 Accurately and completely reconcile
  medications across the continuum of care
• Goal 9 Reduce the risk of patient harm resulting
  from falls
• Goal 13 Encourage patients active involvement
  in their own care as a patient safety strategy.
• Goal 15 The organization identifies safety risks
  inherent in its patient population
• Goal 16 Improve recognition and response to
  changes in a patients condition

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Goal 1 Improve the Accuracy of Patient
Identification

• Have patient state their name and birth date
  (check armband) prior to meds, blood transfusion,
  lab specimen collection, any procedures or
  treatments.
• Prior to OR and invasive procedures, perform a
  TIME-OUT , ask patient to state their name,
  birth date, and planned procedure (check
  armband).
• Verify necessary paperwork in chart and
  equipment/supplies are ready.
• Check armband and verify with MAR, chart, or order

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Goal 2 Improve the Effectiveness of
Communication Among Caregivers

• Final verification process prior to start of any
  surgical or invasive procedure
• Time-out confirms
• Correct patient
• Correct procedure and position
• Correct site
• Readiness of the team
• ( Requires documentation)

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Goal 2 Improve the Effectiveness of
Communication Among Caregivers

• Verification and documentation of all
• Verbal and Telephone Orders and/or Critical Test
  Results
• Example of Telephone Order Read Back Verified
• TORB Dr. Smith/P. Jones, Office Clerk/Any Nurse
  R.N.
• Example of Verbal Order Read Back Verified
• VORB Dr. Smith/Any Nurse R.N.
• CRITICAL LABS Read back verified by MD to RN
• RBV/Dr. Smith/Any Nurse RN

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Goal 2 Improve the Effectiveness of
Communication Among Caregivers

• Use standardized abbreviations, acronyms and
  symbols. Do NOT use prohibited abbreviations,
  acronyms or symbols within the medical record.

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Prohibited List (Do Not Use Anywhere Within
Medical Record)
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Goal 3 Improve the Safety of Using Medications

• Always identify the patient using name and date
  of birth (2-identifier system)
• Always triple check medications
• Chart medications immediately after administering
• Double-check calculated doses or flow rates
  consider having another nurse or pharmacist check
  your calculations

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High-Alert Medications

• Potassium Chloride
• Neuromuscular Blockers
• Intravenous calcium
• Benzodiazepines
• Chemotherapy
• Lidocaine
• Vasoactive substances

• Parenteral narcotics
• Theophylline
• Anticoagulants (heparin)
• Insulin
• Magnesium Sulfate
• Digoxin

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High-Alert Medication Issues

• Anticoagulants should not be administered for 2
  hours after an epidural catheter is removed
• Heparin doses that are miscalculated or sliding
  scale orders that are misinterpreted
• Benzodiazepines (sedatives) should be
  administered with caution to identified sleep
  apnea patients

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High-Alert Medication Issues

• Teaching the patient and family that IV PCA is
  controlled by the patient and only the patient
  should be pushing the button for pain relief
• Nurses should avoid multiple forms of
  pharmacologic pain management for a patient (e.g.
  administering oral narcotic pain meds to a
  patient with an epidural)

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How Can Nurses Minimize Medication Errors?

• Complete the Medication Reconciliation Form
• If in doubt check it out!
• If unsure about a medication or a dose, contact
  the pharmacy before administering
• Carefully read all drug labels
• Never borrow medications from another patient
  or from drugs that need to be returned to the
  pharmacy

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How Can Nurses Minimize Medication Errors?

• Verify secondary tubing is unclamped after
  hanging
• Use only standardized abbreviations
• Always read back telephone orders to ensure
  accuracy
• Always clarify unclear verbal or written orders
• Never assume the physician has more information
  than you

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Medication Safety

• Label all medications, medication containers
  (e.g., syringes, medicine cups, basins) or other
  solutions on and off the sterile field in
  operative and other procedural settings

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Goal 7 Reduce the Risk of Health Care-Associated
Infections

• CDC Guidelines
• Use alcohol rub upon entering and exiting
  patients rooms, prior to and after procedures
• Manage as sentinel events all identified cases of
  unanticipated death or major permanent loss of
  function associated with a health care-associated
  infection
• Wash hands with soap and water if visibly soiled
  or exposure to C-diff/anthrax or caring for an
  immuno-suppressed patient

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Goal 8 Accurately and Completely Reconcile
Medications Across the Continuum of Care

• Accurate documentation of all meds upon
  admission, transfer, and at discharge
• Place medication reconciliation form under MD
  order section in the medical record
• Fax to pharmacy once reconciled

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Goal 8 Accurately and Completely Reconcile
Medications Across the Continuum of Care

• Greatest risk at transitions of care
• Admission
• Transfer to lower or higher levels care
• Medical-surgical to critical care
• Critical care to surgery
• Telemetry to critical care
• Discharge

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Goal 9 Reduce the Risk of Patient Harm Resulting
From Falls

• Use interventions when patient is cognitively
  impaired
• Consider bed exit alarm
• Ambualarm
• Bed check at SJE
• Assess and re-assess frequently
• Place falling star outside patients door on
  M/S and telemetry

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Goal 13 Encourage Patients Active Involvement
in Their Own Care as a Patient Safety Strategy

• Define and communicate the means for patients to
  report concerns about safety and encourage them
  to do so
• Safety posters/brochures placed in patient rooms
  and waiting areas

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Goal 15 The Organization Identifies Safety Risks
Inherent in its Patient Population

• Identifying individuals at risk for suicide

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Goal 16 Improve Recognition and Response To
Changes in a Patients Condition

• Rapid Response Team (SJH/SJE/SJB/SJMS)
• Activate by calling the hospital emergency number
  (SJH/SJE1111 SJB66 SJMS68)
• Team consists of a critical care RN and/or ARNP
  and a respiratory therapist

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IV Use and Care
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IV Infections

• Infections associated with the use of
  intravascular devices represent 10-20 of all
  hospital-acquired infections

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CDC Guidelines

• Support the use of alcohol in IV port. It is
  necessary to wipe the IV port every time,
  regardless of whether the package was just
  opened.
• Alcohol-based hand lotions should be used as
  often as possible to cut down on bacterial
  infections that may be caused by hands

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Aseptic Technique?

• Do you always wash your hands between patients?
• Do you always wash your hands before working with
  IVs?
• Do you wipe off your IV ports with an alcohol
  wipe before accessing every time?
• Do you label your IVs and look at your expiration
  dates?
• Do you wear gloves when you start an IV?

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Starting a Peripheral IV

• You must wash your hands and wear gloves.
• Chloraprep is applied at the site using a back
  and forth motion for 30 seconds and allowed to
  dry. Do not wipe off. Groin site requires 2
  minutes
• If you start the IV, you MUST label it with the
  date, time and initials. Document in nurses
  notes.
• Clave and extension must be used

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Peripheral IV Care

• Hospitalized patients must have an extension
  tubing placed (no direct running of fluids
  through the hub).
• Avoid antecubital IV placements for long-term
  therapy.
• IV site assessment must be documented once a
  shift. Check for redness, swelling, pain, etc.
• Check IV placement date (part of routine
  assessment)

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Peripheral IV Site Guidelines

• IV may stay in place if functioning properly up
  to 96 hours.
• Look for signs of redness, swelling, and
  infiltration prior to any IV medication
  administration.
• Change the dressing if it is wet or bloody.
• If IV is kept in longer than 96 hours a Doctors
  order MUST be obtained.
• Capped peripheral IVs are to be flushed q 8 hours
  and documented on the MAR.
• Assess your IVs frequently. There are over
  300,000 catheter related peripheral IV infections
  annually according to the CDC!!!!

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IV Solutions

• All IV bags must be labeled
• Bags from pharmacy have a label and expiration
  time. Date and Time them when they are hung.
• Commercially prepared and pharmacy prepared bags
  IV bags, may only hang for 24 hours and have a
  label placed on them.

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IV Tubing

• IV tubing and bags that are hanging must be
  labeled.
• If you hang the tubing YOU must label it.
• IV tubing that is NEVER disconnected from the
  patient is good for 72 hours.
• If disconnected and hanging on the IV pole 24
  hours (antibiotic tubing)
• TPN/ tubing is changed every 24 hours.
• Lipids may now hang up to 24 hours!
• Blood or blood product tubing- maximum 4 hours.
  This tubing does not have to be labeled. Throw it
  out after 4 hours
• NEVER leave IV tubing uncapped!

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Biopatch Use

• Place on central lines (including PICCs) after 24
  hours of insertion
• Cleanse the central line insertion site for 30
  seconds with a back and forth motion Allow
  Chloraprep to dry completely prior to Biopatch
  application
• Place Biopatch BLUE SIDE UP with slit towards the
  end of the catheter not towards the insertion
  site
• Biopatch good for 7 days if it does not get wet
  (white ring present) or bloody
• If a Biopatch is stuck dont pull wet with NS
  and then remove

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CLC 2000 Adapter

• Positive pressure adapter used for central lines.
• Placed on the lumens of all PICCs to help
  prevent the line from clotting off
• Line must be flushed q 8 hours with NS before and
  after meds do not use needles
• Heparin is not used in central lines or PICCs to
  maintain patency
• White end of the CLC 2000 must remain popped out-
  not indented. Disconnect the syringe before
  clamping the IV (white part of the CLC will
  indent if you dont)
• Change every 7 days

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Central Venous Catheters

• Used for 14 days- then assess for a more
  permanent line (PICC, Groshong, etc.)
• Sterile technique with barrier precautions on
  insertion is the 1 way to prevent a central line
  infection

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Peripherally Inserted Central Catheter (PICC)

• Placed by specialized contracted nurse at the bed
  side or in Radiology
• Requires an order and a consent form
• Placed using central line sterile barrier
  precautions

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Indications for PICC Placement

• Hyeremesis gravidarum
• Cholecystitis
• Pancreatitis
• Bowel Obstruction
• Ulcerative Colitis

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PICC Exclusion Criteria

• History of chronic renal failure
• Creatinine gt 2mg/dl
• Diabetic with history of proteinuria
• PICC placement could diminish the chance of a
  potential AV shunt for the patient

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PICC X-Ray Confirmation

• X-Ray must be done after placement
• 3-5 of central lines nationally have problems
  (pneumothorax, hemothorax etc.)
• Start IV fluids after confirmation of the tip is
  known.
• Document X-Ray confirmation in the nurses notes.

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PICC Post-Insertion Complications

• Catheter embolus (PE)
• Hematoma at site
• Phlebitis- catch early!
• DVT
• Infection
• Nerve Injury
• Abscess

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PICC Clotting Prevention

• SJHS Protocol
• Flush all lumens q 8 hrs with 10 ml of NS
• After blood draws use 20ml of NS
• Declotting agents are contraindicated so take
  extra care to flush the lumens

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Thrombosis S/S

• Edema of affected hand, arm, shoulder and/or neck
  
• Tenderness in area
• Inconsistent flow

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Statlocks

• Place on PICC lines to decrease movement of
  catheter
• Apply skin protectant and allow to dry 10-15
  seconds
• Place catheter in the plastic doors of Statlock
  and anchor by removing adhesive backing
• Apply a sorbaview or large tegaderm over the site
  
• Change every 7 days
• Remove with alcohol wipe (prevents skin tears)

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PICC Dressing Example
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PICC Line Blood Draws

• Blood can be drawn through the CLC 2000 adapters
• Flush line with 10 ml of NS before drawing blood
• Discard initial 6ml of blood (10 ml if heparin
  present)
• Flush with 20 ml of NS after complete

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PICC Line Removal

• Requires MD order (RNs only allowed to remove)
• Have patient lay down and perform Valsalva
  maneuver
• Withdraw PICC with smooth gentle pressure in
  small 1 inch increments. Do not pull on catheter
  if you meet resistance. Apply a sterile dressing
  and wait 20-30 minutes. A warm compress can be
  applied. If continued resistance is met, call the
  physician.
• Apply pressure until bleeding has stopped and
  label the occlusive dressing which remains in
  place for 24 hours
• After discontinued assess and document the tip of
  the catheter.

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Port-a-Caths

• Assess port type
• Regular port
• Double Lumen
• Power port
• Know what length of needle is needed (¾ inch. I
  inch, 1.5 inch, etc.)
• Do not access if you have not been checked off
  with someone who is experienced with port-a-caths

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Port-a-Cath Power Port

• Document this in the Kardex
• Ask patient if they have a Power port card or
  bracelet
• Used to power inject contrast during CT scans
• Radiology can do a scouting X-Ray to see if it is
  a power port. It has the shape of a triangle and
  3 bumps can be palpated

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Port-a-Caths

• Make sure line can draw back blood if not why
  not? A dye study may need to be ordered - Get an
  MD order to use the line if it flushes but does
  not draw back before IV administration
  (extravasation can happen).
• Make sure the needle is the correct type. Needles
  may stay in place 7 days with the Biopatch and
  CLC 2000.
• Make sure the needle does not rock and is not too
  short
• Deaccessing 500 units of heparin needed (order
  from pharmacy). Hold on to the bottom wing and
  pull straight up

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IV Care Summary

• Wash your hands when entering and exiting a
  patients room
• Wash your hands before working with IV lines
• Wear gloves when starting IV lines
• Use sterile technique with central lines
• Use alcohol wipes before accessing an IV port

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Thank you for your time and effort to familiarize
yourself and your students with Saint Joseph
Health System

• Please remember to complete and return via fax or
  interdepartmental mail
• Required documents from both Handbooks to
  Educational Services
• On-line rotation evaluations
• Fax [phone]