UPPER CHESAPEAKE HEALTH SELF-LEARNING PROGRAM

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UPPER CHESAPEAKE HEALTHSELF-LEARNING PROGRAM

• ANNUAL MANDATORY
• EDUCATION PROGRAM
• December 2009
• Fire, Safety, Infection Control, TB, Legal
  Compliance, HIPAA, Risk Management and Team
  Member Injury, Patient Safety, and other
  important information including the Management of
  Unsafe Behavior Supplement for those requiring
  this update/review.

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• 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 hospitals 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 [phone]
• Telephone [phone]
• Email complaint_at_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.

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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. Verbalize what to do in
the event of an on premises emergency. Discuss
your role in Legal Compliance. For management of
unsafe behavior, discuss the alternatives to
restraints.
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Contributors

• Lynne Adams, Director, UCMC QHIM Privacy
  Officer
• Amy Myers, Safety Manager
• Vickie Bands, Director of Community Outreach
• 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
• Sandy Hagelin, Education Specialist
• Cindy Montgomery, Education Specialist
• Mark Moody, Director, Occupational Health
• Carolyn Phillips, Accreditation Coordinator

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• CONTENT
• Emergency Information
• Fire Plan Review
• Hazard Communication
• Infection Control Overview
• Risk Management and Team Member Safety
• Abuse Reporting
• Legal Compliance
• HIPAA Privacy Security
• Body Mechanics
• Emergency Response
• Supplement Management of Unsafe Behavior
  Update/Review

• REFERENCES Available on UCH Intranet UCH
  Policies
• Environment of Care Plan
• Exposure Control Plan Infection Control Program
• Policy and Procedure Manuals

Revised 6.01, 12.01, 12.02, 12/03, 11/04, 11/05,
11/06, 10.07, 10/08 , 12/09
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• DIRECTIONS
• Review the 2009 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 Resource Development
  Department office at UCMC or HMH by January 15,
  2010.
• 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.

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I. EMERGENCY INFORMATION
Dial 3333
Code Phone

• 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!

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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 BLUE A Cardiopulmonary Arrest, Adult
• CODE BLUE C 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
• NEW Code Green Shelter-in-Place should be
  called if someone threatens another person with a
  deadly weapon.
• 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 Emergency Management Plan
• Report to your department and follow your
  departmental plan.

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How do I access the Emergency Plans?

• The Emergency Operations Plan is located in UCH
  Intranet from the UCH Intranet site home page,
  in the blue menu to the left go to Emergency
  Management. 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 under Policies
  Procedures in the Environment of Care Manual.
• Know your role in a Disaster! REPORT to your
  department and follow your departmental plan.

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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.

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Types of Emergencies / Disasters
1)EXTERNAL - The facility is not damaged, but it
requires the hospital to treat and possibly admit
many casualties. Examples are hurricanes, floods,
tornadoes, radiation releases, civil disturbance,
building collapse or transportation
disasters. 2) INTERNAL - The facility MAY be
damaged and there may be injury to patients and
team members. Examples are fires, water
shortages, power loses, explosions, or acts of
violence.
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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

• 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.

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• 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.

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NEW 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.

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NEW Code Green Shelter in Place

• Within the first 5 minutes of a serious,
  potentially life-threatening emergency situation
  dial 3333 and report a crime in progress
• 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.
• Nursing team members or those in clinical areas
  should attempt to secure the unit/department by
  closing unit entrances and patient room doors.
• Team members that are not responsible for direct
  patient care, and if you see a safe opportunity
  to do so, exit the building. Team members should
  clear public waiting rooms and hallways.
• 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.

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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!

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Code PINK

• To help all team members be more alert to the
  size of the child involved in the situation,
  the following will now be 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)

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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

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If a CODE PINK is in effectExplain 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
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CODE RED
II. FIRE PLAN REVIEW

• 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!

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There are 4 steps that are CRITICAL and can be
remembered by the word
RACE
R Rescue anyone in immediate danger A Alarm
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) C Contain
the fire - Close Doors Windows E Extinguish
the Fire if possible AND if it is no larger than
a waste basket AND you can do so without
endangering yourself, OR Evacuate if
there is an overhead announcement to do so from
your area or a supervisor tells you to
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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 CALL
• 3333 and activate the pull alarm.
• NOTIFY Facilities Services and/or notify your
  supervisor or manager if you cant locate the
  smell or dont 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
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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, cloththings
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
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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

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• 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 to another smoke compartment on the
  same floor, or to another floor, if an EVACUATION
  is called overhead.

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• 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
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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

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SPECIAL ISSUE CLOSING OXYGEN VALVES

• 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?

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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 drill is not in your department or
work area.
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SPECIAL FIRE SAFETY TOPIC INTERIM LIFE SAFETY
MEASURES (ILSM)

• 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.

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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.

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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 _at_ ext. 3120 or
  pager 410 588 - 0643.

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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.
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A word about Electrical Safety . . .
ELECTRICAL SAFETY IS EVERYONES 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 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.
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III. Hazard Communication
What is Hazard Communication?
It is information and education to INCREASE your
awareness about chemical hazards in your
workplace!
Its 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.
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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

READ ME!
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CONTROL / MINIMIZE YOUR EXPOSURE

• Know your product.
• Ask your supervisor if you dont know.
• Keep your work area clean.
• Practice safe work habits.
• Use Personal Protective Equipment, if needed.
• Dont 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.

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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 EVERYONES RESPONSIBILITY!
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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

Lets review some very important points...
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HAND HYGIENE The MOST important measure to
prevent the spread of infection!

• Perform hand hygiene by using the waterless hand
  sanitizer .
• 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
  Clostridium difficile
• 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

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Keep yourself safe from germs - follow OSHAs
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 - - -
• ITS THE LAW and it is meant to
• protect you from infection!

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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 is
  part of safe work practices.

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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.

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ALERT FOR CLINICAL AREAS UCH 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 patients
  room door
• Place an isolation sticker on the spine of the
  patients 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

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ALERT FOR CLINICAL AREAS UCH Isolation Policies
Lets 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

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ALERT FOR CLINICAL AREAS Isolation
categories continued . . .

• Contact Precautions
• Prevent the spread of infections that are
  transmitted from skin-to-skin contact or contact
  with a contaminated object, i.e., MRSA, VRE other
  MDRO (Multi-Drug Resistant Organisms)
• used for known or suspected C. difficile. Be
  sure to check must wash with soap and water off
  on isolation sign for C-diff.
• Team members visitors must wear gown gloves
  if they touch anything in the patient room
• 3. Droplet Precautions
• Prevent the spread of infections that are
  transmitted by large-particle droplets that can
  be created by certain medical procedures or by
  coughing, talking or sneezing, i.e, influenza.
• Team members must wear a surgical mask when
  providing patient care
• Patient must wear a surgical mask when out of the
  room
• REMEMBER For all categories of isolation, read
  and follow the instructions on the
• isolation sign posted on the patient room door.

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PREVENT NEEDLE STICKS/SHARPS INJURIES

• Dispose of needles and sharps in puncture
  resistant containers immediately after use.
• Use needle safety devices properly engage safety
  devices immediately after use of sharp
• NEVER re-cap a used needle by hand.
• NEVER leave needles or sharps exposed or
  unsecured.
• NEVER practice hand to hand transfer of any
  sharps place sharps on a neutral field to avoid
  this type of transfer.
• This applies primarily in areas such as the OR
  and ED.

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MORE INFECTION CONTROL INFORMATION

• KNOW the location and review the Bloodborne
  Pathogens
• Exposure Control Plan
• It contains information specific to your job.
  
• The plan is located in the Infection Control
  Manual on the intranet
• Review the task list that applies to your
  area.
• The plan is reviewed and revised annually.
• You are responsible for knowing about any
  changes
• that occur.
• HANDLE contaminated or potentially contaminated
  waste
• according to procedure ensuring that it is
  identified properly, i.e.
• RED BAG, Bio-Hazard Label, etc.

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More Infection Prevention tips

• Prevention of Central line associated bloodstream
  infections
• Use CVC insertion checklist with each line
  insertion
• Avoid use of femoral site if possible
• Be sure dressing is dry and secure
• Scrub the hub each time accessing line
• Assess need for line daily document remove
  when line
• is no longer needed

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More Infection Prevention tips Prevention of
Surgical Site Infections
Before During Surgery Before During Surgery
patient pre-op bath with antiseptic solution antibiotics within 1 hour of incision
follow procedure for surgical hand scrub wear proper surgical attire
do not remove hair from operative site unless necessary if hair is removed, do in pre-op area using electric clippers
use chlorhexidine to prep surgical site allow prep to dry prior to incision
do not routinely flash sterilize instruments minimize traffic in out of the OR

After Surgery After Surgery
disinfect hands before caring for wound make sure dressing is dry intact
follow procedure for dressing changes d/c prophylaxis within 24 hours of surgery end time
51
IMPORTANT INFORMATION FOR REVIEW BY ALL TEAM
MEMBERS Review of AIDS, HIV, Hepatitis B,
Hepatitis C, and TB

• AIDS and HIV Fact Sheet
• AIDS is caused by a virus called HIV (Human
  Immunodeficiency).
• AIDS stands for Acquired Immunodeficiency
  Syndrome.
• HIV infects certain cells of the immune system
  called T-helper cells.
• HIV can kill these cells, and then a person can
  develop other serious diseases.
• HIV is in blood and other body fluids
• The virus is in the blood, semen, vaginal
  secretions, cerebrospinal fluid, synovial fluid,
  pericardial fluid, peritoneal fluid, amniotic
  fluid, saliva in dental procedures, and any body
  fluid that is visibly contaminated with blood.
• The virus can be there even if the person has no
  symptoms of AIDS or HIV infection. People who are
  infected with HIV will carry the disease for the
  rest of their lives.

52

• People at highest risk of HIV infection are
• Drug users who share needles
• People who have received blood transfusions
  infected with HIV, including people who have
  hemophilia.
• Anyone who has sex with a man or woman who has
  HIV or AIDS, or who is at high risk for HIV or
  AIDS.
• Babies born to mothers who have HIV.

HIV is spread by exposure to blood and body
fluids. HIV can be spread during sex, by sharing
dirty needles to inject drugs, from mother to
baby (before or during birth, or by breast milk),
by getting stuck by a dirty needle, or by getting
blood or other infected body fluids onto a mucous
membrane (mouth or eyes) or onto broken skin.
The virus is not spread by casual contact such as
living in the same household or working with a
person who carries HIV, shaking hands, hugging,
or sharing food or drink.
53
Incubation Period and Period of
Communicability Although the time from infection
to the development of detectable antibodies is
generally 1-3 months, the time from HIV infection
to diagnosis of AIDS has an observed range of
less than 1 year to 10 years after infection.
The period of communicability is unknown but is
presumed to begin early after onset of HIV
infection and extend throughout life.

• Early Symptoms to look for
• fever
• weight loss
• swollen lymph glands in the neck, under arms and
  in the groin area

• Late Symptoms to look for
• white patches in the mouth (thrush)
• certain cancers (Kaposis sarcoma, certain
  lymphomas)
• opportunistic infections (Pneumocystis pneumonia,
  certain types of meningitis toxoplasmosis,
  certain blood infections, TB, etc.

54
Hepatitis B Fact Sheet Hepatitis B is an
infection of the liver caused by a virus. The
virus is in blood and other body fluids. The
virus can be found in the blood, semen, vaginal
secretions, cerebrospinal fluid, synovial fluid,
pleural fluid, pericardial fluid, peritoneal
fluid, amniotic fluid, saliva in dental
procedures, and any body fluid that is visibly
contaminated with blood. Once infected the virus
can be found in the blood for several weeks
before symptoms start until several months later.
Five to ten percent of adults and up to 90 of
babies who catch Hepatitis B will go on to carry
the virus in their blood and other body fluids
for the rest of their lives -- and can continue
to pass the virus on to others. Hepatitis B virus
is spread by exposure to blood and body fluids.
The virus can be spread by sex, by sharing dirty
needles used to inject drugs, by getting stuck
with a dirty needle, or by getting blood or other
infected body fluids onto a mucous membrane
(mouth or eyes) or onto broken skin. The virus
also can be passed from mother to baby, usually
at the time of birth. The virus is not spread by
casual contact such as shaking hands or hugging.
55
People at higher risk of Hepatitis B infection
are - Drug users who share needles. - Anyone who
has sex with a man or woman who has Hepatitis B
or is a Hepatitis B carrier. - Anyone who has
multiple sex partners. - Babies born to
mothers who have the virus. - People who are on
kidney dialysis or are hemophiliacs. - People
born in Asia, the Caribbean, South America,
Africa, the Pacific Islands, and American
Indians and Native Alaskans (the risk extends to
their children). - Health care workers, dental
care workers, emergency workers, laboratory
workers, and others who have contact with blood
and body fluids. - People who live with a person
who is a Hepatitis B carrier.
56
Incubation Period and Period of
Communicability The time from infection to the
development of the appearance of the Hepatitis B
antigen is 45 to 180 days. It can be as short as
2 weeks and rarely as long as 9 months. All
persons who are HBsAG positive are potentially
infectious. About half of people who catch
Hepatitis B never feel sick. Symptoms to look
for - tiredness - loss of appetite - fever -
vomiting - yellow eyes and skin (jaundice) -
dark urine, stool light in color
57
Hepatitis C Fact Sheet Hepatitis C is an
infection of the liver caused by a virus. The
virus is in blood and other body fluids. The
virus is found in the blood, semen, vaginal
secretions, cerebrospinal fluid, synovial fluid,
pleural fluid, pericardial fluid, peritoneal
fluid, amniotic fluid, saliva in dental
procedures, and any body fluid that is visibly
contaminated with blood. It was formerly know as
non A, non B Hepatitis. People at higher risk of
Hepatitis C infection are - Drug users who
share needles - People who are on
kidney dialysis - Health care workers,
dental care workers, emergency workers,
laboratory workers, and others who have
contact with blood.
58
Hepatitis C virus is spread by exposure to blood
and body fluids. The Hepatitis C Virus is spread
by exposure to blood and possibly other body
fluids. The virus can be spread by sharing dirty
needles used to inject drugs, by receiving blood
transfusions contaminated with Hepatitis C or by
getting stuck with a dirty needle.
Incubation Period and Period of
Communicability The time from infection to
development of the appearance of infection is
usually 6 to 7 weeks but can range from 2 weeks
to 6 months. The period of communicability is
from 1 to 2 or more weeks before the onset of the
first symptoms. Infectiousness may persist
indefinitely in most persons.
59
Hepatitis C - Symptoms to look for - Loss of
appetite - Vague abdominal
discomfort - Nausea and
vomiting - Sometimes yellow skin and
eyes (jaundice)

• REMEMBER
• The Hepatitis B vaccine is offered to team
  members who are at risk for occupational exposure
  to blood or other potentially infectious
  materials.
• It is free of charge and is administered in 3
  injections.
• The vaccine is not made from blood products you
  cannot get AIDS or Hepatitis from the vaccine.
• Contact Occupational Health for more information
  about the vaccine.

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In the event that you receive a needle stick, are
cut by contaminated glass, or are exposed to
blood or a potentially infectious body fluid,
report it immediately to the Occupational Health
Nurse and your Supervisor. A Report of
Occupational Injury or Illness MUST be filed and
designated procedures must be followed as defined
in the Exposure Control Plan.
When you are exposed, it is called an
Occupational Exposure to Blood or Body Fluids.
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What is An Occupational Exposure?

• An occupational exposure is any skin, eye, mucous
  membrane, or parental contact with blood or
  another potentially infectious materials.
• The source patient is the individual with whom
  the team member has had an occupational exposure.

• Most exposures do NOT result in HIV infection.
  The risk of becoming infected with HIV after a
  needlestick or cut from a HIV positive source is
  about 1 in 300.

62
What Should I Do If I Have An Occupational
Exposure?

• An occupational exposure is considered a medical
  emergency. You must contact OCCUPATIONAL HEALTH
  immediately so that evaluations of your exposure
  can be done and medical treatment (if applicable)
  can be provided.
• If it is after 4pm Monday Friday or on a
  weekend, contact the Administrative Coordinator
• Wash the exposed area with soap and water and let
  it bleed freely. If you are splashed in the
  eyes, mouth or nose, rinse the area thoroughly
  with water.
• Complete a Report of Occupational Illness or
  Injury according to the instructions later in
  this packet.

63
What Happens Next?

• The Occupational Health Nurse or Administrative
  Coordinator will provide first aid and determine
  if an occupational exposure has occurred.
• If an exposure occurred, a Rapid HIV test will be
  done on your blood sample. The source patient
  will be asked to consent to the same blood test.
  If the source patient is unable to give consent
  and no next of kin is available to consent, or
  the patient refuses to give consent, their
  previously drawn blood in the lab will be tested.
  The source patient must be told if this is done.
  
• Follow-up HIV testing is recommended for a
  positive rapid HIV test. The testing is done at
  6 weeks, 3 months and 6 months after the
  exposure. This will be done in Occupational
  Health at no cost to you.

64
Is There Medication I Can Take?

• If the rapid HIV test is positive, you will be
  given medication. This medication is called post
  exposure prophylaxis (PEP).
• Studies have shown that if PEP is taken within
  the first two hours of an exposure it may reduce
  your risk of becoming infected with HIV.

• If you take this medicine, you will be referred
  to an infectious disease specialist within five
  days of your exposure.
• Testing, medication and physician appointments
  are provided to you at no cost.

65
What Can I Do to Lower my Risk of an
Occupational Exposure?

• ALWAYS wear gloves when handling blood or body
  fluids.
• Empty needle boxes when they are two thirds full
  Dont let them become full.
• Do Not recap needles or place used needles on
  beds, overbed stands or in the mattress of a
  patients bed.
• Use needle safety devices appropriately.
• Take your time and always be aware of what you
  are doing! We care about you and your Safety.

66
TUBERCULOSIS (TB)
REGULATION Every hospital is required by OSHA
to have a copy of the federal standard 29 CFR
1910.1035. A copy is located in the Safety
Office. The hospitals must also have a
TB Exposure Control Plan and a Respiratory
Protection Program. Please review these
procedures to follow to protect yourself from
exposure to TB.
TB is caused by bacteria named Mycobacterium
tuberculosis. This bacteria is so small that it
can float on particles of dust in the air.
Someone who has untreated TB disease can spread
this bacteria when he/she coughs, sneezes, or
talks. This provides a way for the organism to
become airborne. Someone may then inhale the
organisms into his/her lungs. Infection depends
upon the number of TB bacteria in the air. Once
the bacteria get into the lungs, it may spread
throughout the body. When you have a healthy
immune system, your body limits the spread and
inactivates the organism. This occurs 4-12
weeks after exposure. The only sign you may have
is a positive skin test (PPD). A positive PPD
test alone does not mean you have TB disease or
are contagious.
67
When the bodys immune system is too weak to
control the organism, TB becomes active. This is
sometimes referred to as either latent TB or TB
disease. About 10 of the population with TB
infection (PPD) go on to develop disease. TB
usually occurs in those who have HIV infection,
the elderly, and those who are receiving
chemotherapy. It usually occurs within 6-12
months after infection. At this point, the
person is infectious and the TB organism is in
the sputum.
Normally, when a person is diagnosed with TB,
he/she is admitted to the hospital, placed in
isolation, and treated with certain medications.
This person could be hospitalized 3 days to 2
weeks. Six months of therapy is required to
eradicate the disease. 50 of people with TB fail
to complete therapy which may lead to
reactivation of disease and even drug resistance
(MDRTB). This means that the organism was
partially destroyed and developed resistance to
the drugs that were used previously. The disease
can no longer be treated with the normal drugs.
68

• WHAT CAN WE DO TO PROTECT
• OURSELVES FROM EXPOSURE?
• It is important to identify the disease early -
  Be alert for the following symptoms
• - Productive cough for greater than 3 weeks -
  Weakness/lethargy
• - Coughing up blood - Night sweats
• - Weight loss - Loss of appetite
• - Fever
• Diagnostic test for TB should be done -- Skin
  test (PPD), and if positive, followed by a chest
  x-ray. If the chest x-ray is positive, a sputum
  test is done for TB.
• If TB is suspected or known, isolate the
  patient. Airborne isolation is used.
• Notify Facilities Management when placing a
  patient on airborne isolation so they can check
  the negative air pressure of the room.

69
WHAT CAN WE DO TO PROTECT OURSELVES FROM EXPOSURE
to TB?

• Anyone who enters the room must wear special
  RESPIRATORY PROTECTION, either a PAPR or N95
  respirator.
• The PAPR is a Powered Air-Purifying Personal
  Respirator. Only certain team members who have
  been fit tested in the last 12 months are allowed
  to use the N95 respirator. All other team
  members must use the PAPR.

70
For those team members who are trained in the use
of the PAPR, please review the following
information . . . All other team members, please
proceed to SLIDE 72.
Use of the PAPR When a patient is placed on
Airborne Precautions, all health care workers
entering the room must wear a PAPR. The team
member must have prior training on the use of the
PAPR. PAPRs are obtained from Biomed. No more
than three are required. Also, obtain the cart
which contains the hoods, surgical caps and
antimicrobial wipes. Perform the following
outside of the isolation room 1. Visually
inspect the AIR-MATE HEPA unit and the breathing
tube for any damage. 2. If any damage is noted do
not use the item - return it to Biomed and
obtain another unit. 3. Visually inspect hood
for any damage. If damaged, dispose it and
obtain a new one. 4. Turn on the AIR-MATE HEPA
unit to assure that an adequate air flow is
generated
at the end of the
breathing tube. THE PROTECTION AFFORDED BY THE
SYSTEM CAN BE NEGATED BY USING A SYSTEM WHICH HAS
VISIBLE DAMAGE.
71
5. Connect the breathing tube to the hood. Be
sure it is seated properly. 6. Turn the AIR-MATE
HEPA unit on, place the unit around your waist
and fasten the waist belt at a position that is
comfortable. BE SURE AIR-MATE HEPA UNIT IS
TURNED ON PRIOR TO ENTERING THE ROOM
7. Place a surgical cap over your hair then place
the hood over your head. 8. Check the fit of the
hood by doing the following a. Check that
the elastic and sweatband encircles your head.
b. Check that the face seal is pulled down under
your chin and is hugging your face.
c. Check that the air flows to the front of the
hood.
IF THE HOOD IS NOT WORN PROPERLY YOU WILL NOT BE
PROTECTED! DO NOT TURN THE UNIT OFF WHILE IN THE
PATIENTS ROOM
72
9. The AIR-MATE HEPA system should be removed in
the following manner a. Remove the
hood. b. Disconnect the breathing tube from
the hood. c. Remove the HEPA filter unit from
your waist. d. Turn off the HEPA filter
unit. 10. Inspect the entire unit for any
evidence of contamination or damage. Remove
light contamination by wiping the area with a
disinfectant. A grossly contaminated unit
is to be returned to Central Sterile in a red
bag and replaced with another one. 11.
Wipe/decontaminate the hood between team members
by wiping it out with an antimicrobial wipe
that MUST NOT contain alcohol. DO NOT USE
ALCOHOL WIPES. A grossly contaminated hood is to
be discarded. 12. Store the unit in the
anteroom on the cart or shelf. Note When
isolation is discontinued, return the unit,
breathing tube, hoods and cart to Biomed. If
you have been assigned a hood, decontaminate the
hood and store in the designated area on your
unit. NOTE Each unit will be replaced every 3
days with a fully charged unit by
Biomed.
73
THERE ARE SEVERAL UCH Team Member HEALTH ISSUES
that you need to remember
1. Team Members are to have a PPD done upon
employment, but only those at risk team
members (those with patient contact) are required
to have annual PPDs. 2. If you are exposed
to someone with TB who was not properly isolated,
the Occupational Health nurse will contact
you. You may get tested depending on when
your last PPD was done. You would be tested
again in 10 - 12 weeks. This is to see if you
were infected. 3. If you should develop any of
the symptoms listed above, contact Occupational
Health.
If you have any questions about TB and/or need
any additional information on the content of this
section of the packet, contact the Healthcare
Epidemiology and Infection Control office at
extension 5047 or 3106.
74
Report of Occupational Illness or Injury
V. Risk Management and Team Member Safety -
Injury Reporting
If YOU Experience an On-The-Job INJURY or
ILLNESS, Please follow these steps IMMEDIATELY

• If you have an On-The-Job injury or illness
• Report to Occupational Health, your supervisor,
  or the Administrative Coordinator
• IMMEDIATELY.
• They will assess your injury and may refer you
  for further treatment.
• Complete Section I of the Report of
  Occupational Illness or Injury prior to the end
  of the
• shift during which the illness/injury
  occurred. If you are unable to complete the
  form, your
• supervisor or his/her designee will assist you
  in completing the form.
• Have your Supervisor or the Administrative
  Coordinator review and sign the form.
• Forward the yellow copy of the completed form to
  the HMH Risk Management office
• prior to your departure from UCH for the day.
• Send any doctor's notes you may receive to the
  Occupational Health Nurse Office.
• Send any and all medical bills/receipts that you
  receive to the HMH Risk Management
• office.

If you have any questions about reporting a team
member incident or about workers compensation,
please call the Risk Management Coordinator at
443.843.5334 or on pager 410.588.0372.
75
Special Tip for ALL On-The-Job Injuries and
Illnesses
The review of your injury to determine if you are
eligible for workers compensation cannot begin
until Risk Management is notified or receives
your Report of Occupational Illness or Injury, so
please complete and forward the form immediately.
76
The FORM you will fill out is available in your
work area. It is divided into three sections.
UPPER CHESAPEAKE HEALTH REPORT OF OCCUPATIONAL
ILLNESS OR INJURY
Section I
Team member fills out the detailed information as
requested on the form
Section II
Occupational Health Nurse or Triage Nurse
completes this section covering the outcome of
the occurrence and follow-up
Section III
Supervisor Follow-up
FORM 24901
77
What if you may return to work, but have
restrictions?

• Contact Risk Management at ext. 5334 or by pager
  410.588.0372 IMMEDIATELY.
• Upper Chesapeake has a Transitional Duty Program
  that allows team members who were injured on the
  job to return to work, providing UCH can
  accommodate the restrictions.

78
REMINDER

• ALL injuries must be reported to the Risk
  Management Office and to the Occupational Health
  Nurse. This includes
• Team Members
• Physicians
• Agency Staff, and
• Contract Staff
• Always complete a Report of Occupational
  Illness/Injury form Its to protect your
  health!

79
Patient Safety is our Top Priority and YOU are
the Key

• Every Team Member plays an important role
  ensuring a safe environment
• You are the Experts in your field!
• You can identify Policies, Procedures Practices
  that can create safe conditions for our patients
  well being.
• It is Everyones Responsibility to
• Identify potential hazards
• Report unusual or unsafe situations or unexpected
  outcomes
• Manage situations where an adverse event occurs
• Prevent it from reoccurring

80
Patient and Visitor Safety What and How to
Report Events
What is a Reportable Event Adverse
Event/Incident/Error/Near Miss Any happening
that is not consistent with the routine care of
our patients or the routine operation of the
facility. It can also be the existence of
circumstances that can cause harm if left
unchanged. Examples Patient or visitor falls
medication or treatment errors even if it did not
impact or reach the patient(but it might next
time if left unreported and unchanged) The
Goal of Reporting With reported events, we focus
on identifying and improving the processes that
are found to have contributed to the event. We
recognize that people can and will make mistakes,
so we must redesign the process or avoid human
errors and mistakes.
81
More on Patient Safety Reporting of conditions
that can, or have caused harm to our patients and
visitors is everyones responsibility!

• Non Punitive Reporting Policy
• UCH recognizes that if we are to succeed in
  creating a safe environment for our patients and
  visitors, we must create an environment in which
  it is safe for caregivers to report and learn
  from Events and Near Misses.
• UCH promotes openness and requires that errors be
  reported, while ensuring that reporting errors be
  handled without the threat of punitive action.
• Remember to
• Complete an incident report in ETS (Event
  Tracking System) in Meditech before the end of
  your shift.
• Take immediate steps to prevent the event from
  happening again, then begin a thorough
  investigation to uncover the root causes and then
  correct the process.
• If the event is serious, or can lead to serious
  injury or death, follow the Sentinel Event
  Policy in the Policy Library and contact/page the
  Risk Manager immediately at exts HMH5671 or
  UCMC3102.

82
Safety SecurityRemember that Safety is our
First Priority as defined in our 4 Service
Excellence Standards

• Always wear your ID Badge.
• Ask for an escort by Security to your car if you
  are fearful of walking to your vehicle,
  especially after dark.
• Keep the doors of your car locked with windows
  up.
• Keep the valuables in your car out of sight.
• Keep yourself and other team members safe by
  being aware of your surroundings at all times -
  If you see something or someone suspicious,
  notify Security Services.

83
VI. Abuse Reporting
Recognizing Victims of Abuse

• The Abuse Reporting Policy is to protect children
  or vulnerable adults from abuse and to provide
  guidance to healthcare practitioners when
  fulfilling their moral and legal duty of
  reporting suspected and actual abuse.
• Adult victims of domestic violence are identified
  and team members intervene in their care in a
  manner that protects their safety and privacy.

84
Remember...

• If you suspect that a child or adult is the
  victim of abuse you will need to report this to
  the appropriate agencies in accordance with
  Maryland statue.
• If you work in a nonclinical department and
  overhear or suspect abuse please report this to
  the team member in charge of the patient's care,
  such as the RN.
• Please review the on-line policies and procedures
  for indicators for reporting suspected abuse and
  domestic violence.

85
Legal Compliance is one way we . . .
VII. Legal Compliance
Let's Review Legal Compliance

• . . . act with integrity and earn
• the trust of those in our
• community.
• . . . are responsible corporate
• citizens.

86
There are Three Key Elements of the Legal
Compliance Plan

1. Education to assure that team members are aware
   of laws and regulations related to the work we
   do. Examples are EMTALA, Medicare Secondary
   Payer Requirements, and HIPAA.
2. Monitoring to assure that we are in compliance
   with regulations. Monitoring includes Organ
   Donation, Advance Beneficiary Notices, Transfers
   to other hospitals and other activities.
3. Reporting of concerns and/or questionable
   activities.

87
What are the ways to question or report concerns?

• Talk to the person whose conduct raises the
  question in your mind.
• Talk to a supervisor.
• Raise the question with your supervisor or
  manager.
• Ask the Legal Compliance Officer (LCO).
• Or use the method on the next page . . .

88
USE EMAIL . . .

• Send an anonymous message by email. Sign in to
  Meditech using COMPLY to send the message
• For User ID type COMPLY for Password type
  COMPLY.
• A screen will appear and prompt you in entering
  the question or concern.

89
Review of HIPAA Privacy
VIII. HIPAA Privacy

• HIPAA, the Health Insurance Portability and
  Accountability Act of 1996, became effective
  April 2003.
• Security standards became effective April 2005
• The law ensures that a patient has the right to
  have his/her health information kept private and
  secure/confidential.