UPPER CHESAPEAKE HEALTH SELF-LEARNING PROGRAM

UPPER CHESAPEAKE HEALTH SELF-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.

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: Telephone: 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.

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.

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

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

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 or HMH ) 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/ 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.

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!

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.

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.

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.

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.

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.

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.

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.

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.

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!

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) ”

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 – UCMC

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

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!

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

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 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

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

PASS Pull the pin Aim the nozzle Squeeze the handle
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

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.

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

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

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?

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.

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.”

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.

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, s 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 ext or pager 410 –

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”.

ELECTRICAL SAFETY IS EVERYONE’S RESPONSIBILITY!
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 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.

It’s your “RIGHT TO KNOW”
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.

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!

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 if you need further information.

“INFECTION PREVENTION
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!”

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 Let’s review some very important points...

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 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

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!

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.

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.

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 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

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

isolation sign posted on the patient room door.
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.

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.

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.

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

More Infection Prevention tips Prevention of Surgical Site Infections
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 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

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.

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.

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 (Kaposi’s sarcoma, certain lymphomas) opportunistic infections (Pneumocystis pneumonia, certain types of meningitis toxoplasmosis, certain blood infections, TB, etc.

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.

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.

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

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.

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.

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.

When you are exposed, it is called an Occupational
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.

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.

Have An Occupational Exposure?
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.

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.

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.

Risk of an Occupational Exposure?
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; Don’t let them become full. Do Not recap needles or place used needles on beds, overbed stands or in the mattress of a patient’s 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.

TUBERCULOSIS (TB) REGULATION: Every hospital is required by OSHA to have a copy of the federal standard 29 CFR 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.

When the body’s 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.

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.

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.

Perform the following outside of the isolation room:
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.

6. Turn the AIR-MATE HEPA unit on, place the unit around your waist
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 PATIENT’S ROOM

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.

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 PPD’s. 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 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.

Report of Occupational Illness or Injury
V. Risk Management and Team Member Safety - Injury Reporting Report of Occupational Illness or Injury 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 or on pager

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.

UPPER CHESAPEAKE HEALTH REPORT OF OCCUPATIONAL ILLNESS OR INJURY
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

What if you may return to work, but have restrictions?
Contact Risk Management at ext or by pager 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.

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 – It’s to protect your health!

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 patient’s well being. It is Everyone’s Responsibility to Identify potential hazards Report unusual or unsafe situations or unexpected outcomes Manage situations where an adverse event occurs Prevent it from reoccurring

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.

…More on Patient Safety Reporting of conditions that can, or have caused harm to our patients and visitors is everyone’s 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: HMH:5671 or UCMC:3102.

Safety & Security Remember 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.

Recognizing Victims of Abuse
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.

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.

Legal Compliance is one way we . . .
VII. Legal Compliance Let's Review Legal Compliance Legal Compliance is one way we . . . . . . act with integrity and earn the trust of those in our community. . . . are responsible corporate citizens.

There are Three Key Elements of the Legal Compliance Plan
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. Monitoring to assure that we are in compliance with regulations. Monitoring includes Organ Donation, Advance Beneficiary Notices, Transfers to other hospitals and other activities. Reporting of concerns and/or questionable activities.

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 . . .

USE Send an anonymous message by . 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.

Review of HIPAA Privacy
VIII. HIPAA Privacy Review of 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. HIPAA protects the security and privacy of all medical records and other health information that is used or shared in any form - Paper, electronic, or verbal.

HIPAA Privacy LAW HIPAA is Federal Law and compliance is mandatory.
Patient information must be protected through conscious effort at all times no matter where you are! The ONLY exception is when information is shared in order to provide care, treatment and payment for services

Protected Health Information
The health information that is covered under HIPAA is called Protected Health Information or PHI. PHI is any information, whether spoken, electronic or written, that relates to the past, present, or future physical or mental health or condition of an individual, as well as the provision or payment related to that health care. PHI is health information created or received by a covered entity, regardless of form, that could be used directly or indirectly to identify the individual. Covered entities include hospitals, care providers, third party payers, such as insurance companies, and anyone who processes health information.

Maintaining Privacy of PHI
Where is PHI found? Paper Records of health information: Medical Records/Patient charts Faxed copies of medical information. Computer (electronic) information of files: Information read off of a computer screen Information transmitted over the Internet Laptops and hand held devices such as PDAs. Video or audio tape Photographs

Protecting Patient Information
UCH polices protect PHI Information that relates to a patient’s health cannot be used unless authorized by either the patient or someone acting on the patient's behalf, or unless permitted by regulation. Access to information is limited to only those individuals who need the information for a legitimate purpose. HIPAA ensures that an individual's health information may only be used for health purposes.

Safeguards Safeguards protect the privacy and confidentiality of our patients Ensure that information is kept out of public view/access Maintain the confidentiality of your computer access codes - log off computers when you are no longer able to secure the computer information and NEVER share passwords. Routine audits of electronic medical record access are done to ensure that patient privacy is protected. Team members that do not maintain patient confidentiality and/or do not adhere to UCH HIPAA policies and procedures are subject to the disciplinary process and possible termination.

HIPAA Privacy Patient Choice
At the time of admission, patients are provided with information about HIPAA -the Notice of Privacy Practices Patients may chose to be CONFIDENTIAL - these patients will not be listed in the Hospital Patient Directory and we MUST keep their presence in the hospital CONFIDENTIAL. Patients electing to be confidential will have a “c” on their admission record indicating their status. All patients admitted to UCH are not confidential until they indicate their wishes to be confidential

HIPAA Privacy Officers
HIPAA requires that each covered entity have a Privacy Officer. The Privacy Officers at UCH are: UCMC and ACC: Lynne Adams, Director of QHIM/UCMC HMH: Jane Gordon, Director of QHIM/HMH To contact the PRIVACY OFFICER, send an to the “Privacy Officer/HIPAA”. This is no anonymous You will receive a reply to your question or issue.

Electronic Security Under HIPAA
Security of electronic systems is essential to the continued normal business operations of UCH and is mandated by HIPAA The Electronic Security Policy resides in the Administrative Policy Manual Security standards, password systems, remote access to the UCH network are all covered in the policy

Security Awareness & Training
Security Reminders We must ALL be diligent and aware of possible vulnerabilities of electronic transactions, maintenance of virus updates, awareness and implementation of new policies, etc. Protection from Malicious Software Team members are responsible for reporting and handling the receipt of an unusual or suspect file through ; including steps to clean/quarantine it.

Security of Workstations
Workstation Use Computer systems in public access areas must use privacy screens and have limited password protected access to network resources when not in use

Access Control: PASSWORDS
Each user is assigned a unique identifier Password standards are defined in the “HIPAA Security Policy” All sign-ons require dual authentication = user name & password Signing of electronic documents requires a third level authentication = use of PIN Passwords consist of a minimum of 8 characters & requires a mix of alpha and numeric characters “Strong” passwords mixing letters and numbers are preferred Avoid whole words, common names or well known information All password access will be subject to auditing and revocation at the request of any UCH Director. Passwords will be reissued every 90 days Users requiring a password reissue MUST have a confidentiality agreement on file and provide two methods of identification (birthdate and last four digits of the SS#) in the event that a password is lost and must be revalidated

Access Control Automatic Logoff Remote Access
In order to protect EPHI, UCH requires sign off by the user immediately upon completion of computer usage. Workstations automatically log-off the user after specified periods of inactivity, or require log-in of the same user from a screen-saver. Remote Access Remote access is provided for UCH team members and affiliates at the request of a Director. All remote connections are under the purview of the NSE and requires director level approval prior to utilization All remote connections will be subject to monitoring and routinely audited.

Transmission Security
Encryption UCH has implemented encryption/decryption technology in order to protect their EPHI during transmission. Encryption of electronic transmission of PHI is in place for all communications on an open network (i.e. the internet). Encryption and A major risk organizations is the use of by providers with patients, health plans and other providers. Security of the UCH system is extremely important and every team member’s responsibility.

UCH Policy: Information Security
Printing EPHI should not be printed, photographed, videotaped, copied or reproduced in any way without a defined requirement and any copying should be limited to the minimum necessary to achieve the requirement at hand NEVER leave EPHI hardcopies unattended in an unsecured area Discard hardcopies in secure recycling bin

Photographs and/or videos may be taken by a physician or at their direction under any of the following conditions: With the consent of the patient or the patient's personal representative; or For internal educational purposes only, to include confidential peer review; or For patient care, such as wound documentation and monitoring. Photographs and/or videos will not be re-disclosed or transmitted in any format outside of UCH without the patient's or the patient's personal representative's documented consent.

The ing of sensitive electronic data and EPHI should be avoided whenever possible. EPHI should only be communicated via under the direction of a Department Manager. EPHI sent via must be sent via a password protected document attachment. The password for the document must be communicated via a separate medium with the receiving party.

Remote Workers Users accessing the UCH system remotely are responsible for ensuring that remote devices are not at risk to spread viruses or malicious software or capture or track information exchanged during the session of remote connectivity. Team members and affiliates working with EPHI remotely will be subject to auditing, remote observation of sessions and session termination as required to protect UCH EPHI. All EPHI accessed from a remote location must remain within the UCH network and not be downloaded or printed at the remote site unless clearly required to provide patient care or enable financial processes related to providing patient care.

Portable Electronic Storage Devices (PESD)
Definition – any device capable of storing electronic data and is easily or regularly transported outside of the primary facilities. Devices (include but are not limited to) – laptops, tablets, floppy disks, USB drives, CD-ROMs, DVD-ROMs, PDAs, memory cards or external drives (thumb drives)

Use of Portable Electronic Storage Devices (PESD)
Efforts should be made to avoid the transport of electronic data whenever possible. All devices and data being removed from UCH premises must be done so with the knowledge and permission of a department Director or other senior leader. All portable devices should have password protection enabled if available. All sensitive and EPHI files transported must be password protected. When possible, all sensitive and EPHI files transported must be encrypted. Electronic data should never be copied to and left on a personal device such as a home PC or other remote system where it may be recovered later. Any loss of device or data belonging to UCH, its customers, patients or associates should be reported immediately via the ETS system for review by the appropriate bodies.

UCH Security Officer As with HIPAA Privacy, there is assigned security responsibility. AT UCH the VP of IT is responsible for overall Electronic Security UCH has identified a designated Network Security Engineer (NSE) reporting to the IT VP The UCH NSE is Rick Buchman

PRACTICE HEALTHY BODY MECHANICS:
IX. Body Mechanics USING PROPER BODY MECHANICS AND MOVING TECHNIQUES CAN KEEP YOUR BACK HEALTHY AND HELP PREVENT INJURIES. PRACTICE HEALTHY BODY MECHANICS: Use good posture when you stand, sit and walk. SITTING - Keep your feet rested on the floor with hips and knees bent at a 90 degree angle REACHING - Keep feet “shoulder width apart”, get close to the item you are reaching for, and DON’T TWIST at the waist to reach the object - MOVE your entire body through the reach. LIFTING –Size up the load before lifting. Keep your back straight and lift by bending and straightening at your knees and hips; keep load close to your body. Get help or use a cart or lift when lifting an object, if possible. Before lifting a patient, identify the need for a Hover Matt. Get help to avoid patient and self injury. AVOID INJURY - Whenever possible, use assistive equipment, lifts, slide-boards, HoverMatts, a buddy, etc. to reduce the risk of injury and provide comfort to the patient.

REMEMBER: Use your HEAD, not your back!
GENERAL ADVICE: • Use good posture and ergonomic resources to prevent injury and strain on the body. • If standing or sitting for prolonged periods of time change position and/or shift weight every 10-15 minutes. • It is better to push something then pull it. • Stress and poor diet can contribute to back problems; Eat healthy and participate in an exercise program. • Keep your work environment safe and free of hazards that may lead to injury. • Help each other for patient safety and to protect yourself from injury. REMEMBER: Use your HEAD, not your back!

RESPONDING TO On Campus Emergencies
X. Emergency Response RESPONDING TO On Campus Emergencies Understanding “On Campus Emergency” It is an emergency that occurs outside of the Hospital on our premise, either in a non-clinical office not associated with a hospital service or on the grounds of one of our Hospitals. For example, the emergency may occur in one of our parking lots, on a sidewalk near one of our buildings, in an office on an upper floor in the ACC, etc. Each UCH Team Member, whether off duty and on hospital premises or on duty, who encounters an emergency situation, will assist in the emergency. More information can be found in the Administrative Policy Manual - “On Campus Emergencies” Policy. FYI – AEDs (Automatic External Defibrillators) are now located in the ACC and the Physician Pavilions

What are you to do if you come upon or are told by someone that an on-campus emergency is occurring?
Contact, or have someone contact, the Switchboard (Operator) immediately who will notify the Administrative Coordinator if on duty. The Switchboard will contact the ED who will respond. An RN, an ED Tech and, if possible, a physician will take a bag/valve/mask device and respond to the scene. A portable emergency kit may also be dispatched to the scene from the ED. Security Services will assure that there is two way radio communication between the scene and the ED. ED personnel will assess the need of the patient, initiate emergency care, and request additional support as needed, including EMS support through activation of 911. Security Services will also notify the Administrative Office during normal business hours. The UCMC Hospital Code Team WILL respond to a Code Blue (A) or Code Blue (C) emergency in the Garden Level of the ACC!

XI. Supplement: Aggressive Patient Management
For Team Members trained in Aggressive Patient Management/ Management of Unsafe Behavior This is your annual review/update! All Nursing and Admitting Team Members and Security Officers MUST complete this section SKIP this section if you have not had this training - Go To SLIDE 127 -

Main Goals when Dealing with Aggressive Persons:
Prevent/Decrease the chance for agitation/aggression. Recognize anxiety! It is well documented that aggression arises from a frustration of desires/needs. Be aware of early signs of anxiety and aggression . Be prepared to interact quickly to defuse the situation. Be supportive and show concern. Address frustrations. Defuse the situation. Maintain safety for all parties involved; the acting out person, team members, patients, and visitors. Be aware of the need to adhere to patient’s rights. Use direct approach and set limits. Respond to violence. Approach the person calmly using a supportive stance, confidence, and a low key attitude. A combative person should be contained using non-violent crisis interventions and a team effort. Knowledge by team member of basic self defense is documented to reduce the number of assaults and severity of injury. Reduce tension. After the incident use therapeutic rapport to debrief the incident. Discuss what happened, how it was handled, what went well and what could be improved.

Underlying Factors of Patient Behaviors
The potential for aggressive behavior is higher in patients with underlying issues which include: Hospitalization. Being in the hospital may increase feelings of fear, anxiety, vulnerability, and perceived (actual) loss of control/power. Anger about being in the hospital (i.e.: their body isn't functioning the way it is supposed to). Non-compliance with medication. History of violence. History of drug/alcohol abuse. Dementia or delirium as a result of a disease process such as, head injury, fever, hypoglycemia, or other electrolyte imbalance. Investigate to determine if addressing the underlying issue may correct the tendency toward aggressive behavior.

VERBAL INTERVENTION TIPS AND TECHNIQUES:
DO: Listen sincerely Remain calm. Be aware of your body language and non-verbal messages. Give directives, enforce limits, keep language simple. Isolate the situation as much as possible, avoid audiences. Be consistent. DON’T: Overreact. Get into a power struggle. Make false promises. Be threatening. Use jargon; it tends to confuse and frustrate.

Remember restraints are used only as a last
resort to control a situation. They should be used only after alternative interventions such as providing companionship or supervision, changing or eliminating bothersome treatments, modifying the environment, reality orientation and psychosocial interventions, or diversionary techniques have been attempted (and documented) and deemed inappropriate for the situation. If the situation is so out of control that there is no choice but to immediately restrain the person, the situation and why alternatives were not appropriate must be documented in detail. The KEY is SAFETY and DOCUMENTATION!

Types of Restraint: Restraint for Behavioral Management Purposes: These are to be used as an emergency measure to protect the patient against harm to self or others. Restraint for Non-Behavioral Management Purposes: These are to be used to directly support medical healing. Examples would be to prevent a patient’s access to an IV line, dressing, airway device attached to a ventilator, use of a roll belt if assessed as a high risk for falls, etc. They are only to be used when other less restrictive interventions were attempted and did not work to prevent the interference.

Alternatives to Restraints for Behavioral Management
Calm Environment Time out Quiet area Dim lights Contact with team member

Alternatives to Restraints for Non-Behavioral Purposes
Music Running water (fountain) TV/reading material Family members Activity Apron Bed, chair or body alarms

Prisoner Patients Law enforcement officer is responsible for maintaining control of the patient. They should not interfere with medical treatment of patient. Handcuffs ARE NOT a hospital restraint or seclusion. Handcuffs are managed by the law enforcement officer. Law enforcement personnel receive training regarding hospital expectations.

Your Role with Prisoner Patients
Responsible for checking for skin breakdown around handcuffs Responsible for checking for proper body alignment while the patient is in handcuffs

REVIEW: Use of Restraints
- : REVIEW: Use of Restraints Restraints for Behavioral Management are used as a last resort to prevent harm to self or others. Restraints for Non-Behavioral Management Purposes are used as a last resort to promote medical healing. Examples would be preventing access to an IV line, dressing, etc. PRN orders ARE NOT ACCEPTED and are not to be transcribed. Restraint orders must be renewed at least every calendar day or as noted in the specific policy.

Clinical Interventions for someone in Restraint/Seclusion
Patient needs to be in full view at all times (Behavioral Management Purposes ONLY) RN documentation of observation of patients q15 minutes (Behavioral Management Purposes ONLY) Assess & attend to any special needs Circulation & alignment checks of restrained extremities – adjust restraints and massage extremities as needed Range of Motion Offer toileting Offer fluid & nourishment Bathing & oral hygiene offered/provided Ongoing assessment of need for restraint/seclusion to continue

Dealing with an aggressive person is a TEAM EFFORT
Call a CODE GREEN by dialing 3333. Tell the operator your name and location. NEW: Code Green Shelter in Place – Hostile person/possible weapon

Be sure to answer the questions on the Post-Test for this supplemental
section. If you have any questions, contact the Education and Resource Development Department.

YOU HAVE COMPLETED THIS MANDATORY EDUCATION PROGRAM
CONGRATULATIONS YOU HAVE COMPLETED THIS MANDATORY EDUCATION PROGRAM NOW… Assess your knowledge by taking a Post Test on line or using a hardcopy of the test. If you take a hardcopy of the test, return the test to the Education and Resource Development Department at UCMC or HMH by January 15, 2010 Thank you!

UPPER CHESAPEAKE HEALTH SELF-LEARNING PROGRAM

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