Munroe Regional Medical Center 1500 SW 1 st Avenue, Ocala, FL PO BOX 6000, Ocala, FL 34478

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1 We believe in people and we believe in education. We want to make a difference in the lives of exceptional people who will go on to do extraordinary work for our community. Munroe Regional Medical Center 1500 SW 1 st Avenue, Ocala, FL PO BOX 6000, Ocala, FL Workforce Development Coordinator Phone (352) Fax (352)

2 *** MEMO *** June 1, 2014 Thressa Maier Workforce Development, MRMC All MRMC Clinical Rotation Students HANDS ON SELF STUDY Orientation Packet Hello everyone and welcome to the MRMC Self Study Hands On Orientation Packet. This self study packet will provide you with all of the MRMC orientation modules/information that will be required in order for you to enter the facility and perform your clinical hours. You are responsible for reviewing of the information in this packet carefully to ensure that you are knowledgeable and prepared as you begin to perform your rotation at MRMC. We look forward to having you at Munroe Regional Medical Center during your clinical rotation and wish you every success as you progress in your career path.

3 Forms to be completed and returned to MRMC: The following information be completed in its and returned to Workforce Development 2 weeks prior to your scheduled clinical experience: a. Intern Information Sheet b. Student Substance Policy Consent Form w/ Substance test results attached c. Student Background Consent Form w/ Background info/attestation letter attached d. Workforce Information Security Agreement e. Addendum 7 Disclosure and Authorization f. Flu Vaccination form (when rotating within applicable dates noted on the form) g. Self Study Module Answer Sheet h. Documentation that Immunization requirements have been met i. Student Health Insurance Statement of Coverage j. Application for Student Parking (Parking decals will be assigned and distributed as appropriate on site) ALL six (6) self study modules should be completed and answers placed on answer sheet. a. Bloodborn Pathogens for Student Orientation b. HIV / AIDS Orientation c. Infection Control Orientation Key Points / Notes d. Safety & Environment of Care e. Workforce Development Customer Service f. Facts about HIPAA You should review and be familiar with information in this file. You are ultimately responsible for thoroughly understanding material covered and information provided. Munroe Regional Medical Center Workforce Development Suite 202 c/o Thressa Maier 1500 SW 1 st Ave Ocala, Florida Address: Phone # Fax # ATTENTION: Thressa 352- * Documents may also be scanned and ed November 2015

4 Student & Faculty Handout MRMC Documentation Requirements / Revised Immunization Requirements at MRMC TB o Attestation Letter ACCEPTABLE or other form of verification from the school A negative TB skin test within the past year or, in the event of a positive TB skin test, a chest x-ray report stating no evidence of TB disease within the past year; OR provide evidence of no TB disease per negative result of interferon-gamma release assay blood test (T-Spot or Quantiferon Gold) within twelve (12) months of student activity at facility. Hepatitis o A completed series of Hepatitis-B vaccine, having begun the series, or informed refusal of the vaccine. Other Immunizations o Documentation of active or passive immunity to Measles, Mumps, Rubella, Rubeola, Diptheria, Pertussis, Tetanus, Hepatitis B and Varicella. Note: o o Student to provide Declination Form if refusing immunizations except TB. Titers please note that we do need either evidence of immunity via titers for Measles, Mumps, Rubella or history of two vaccinations. If the titer is negative the student does have the option to decline vaccination but we need to know status. Same will apply for Varicella unless there is evidence of vaccination or the exact date of medical diagnosis Background Check Requirements (dated within 12 months of rotation) Students & Faculty Background must include the following: o Office of Inspector General ( OIG ) List of Excluded Individuals o Licensure or Certification o Criminal records shall be checked at the Federal, State and Local levels. Attestation Letter ACCEPTABLE or other form of verification from the school NOTE: School to notify facility of any questionable activity that may appear on a student background check. Facility will review each individual on a case by case basis to determine eligibility for a student to perform clinicals, internship etc. at MRMC.

5 Substance Screening Requirements (dated within 12 months of rotation) RESULTS to MRMC w/ orientation packet Students & Faculty 9 Panel With Expanded Opiates, Meperidine, Fentanyl (this is the minimum) o Amphetamines o Barbiturates o Benzodiazepines o Cocaine o Fentanyl o Marijuana o Meperidine o Methadone o Opiates o Oxycodones o Phencyclidine (PCP) o Propoxphene NOTE: Any screening report that reflects any medication/drug that is not prescribed by a physician to the named student is an automatic termination of clinical rotation for the student at MRMC. Health, Liability & Workmans Comp Insurance Requirements Students o Health Insurance Attach copy of insurance card o Form provided for both insured and non-insured If covered under school policy please provide 1 copy of certificate of insurance for student group otherwise copy of individual student s certificate of insurance Professional Liability Coverage in the amount of $1 million per occurrence / $3 million aggregate of the occurrence type of coverage Faculty o Worker s Compensation If School is government entity, School shall maintain the government version of such insurance Documentation Charting Guidelines For students who have the ability to document within the medical record the following are the changes that need to take place beginning in the Fall (August 2014): Students should complete their charting Students should alert their instructor that charting is completed for co-signing Instructors should co-sign the student s charting after review Patient Care activities such as turning, vital signs, ambulation, AM/PM care, etc. do not require co-signature after competency has been demonstrated to the instructor. Nursing students who are in practicum/preceptorship phase of their education shall have their documentation co-signed by their RN staff preceptor.

6 Student/Faculty Specifics on Required Documents Student Required Documents: Orientation Packet (being updated to include new forms) i. MRMC Employees - If you are an employee of MRMC (you only need to complete the Compliance with Student Orientation Page with employee number) Computer Access Request Form (as applicable Nursing/ Respiratory Therapy) Immunization Records or Declination i. MRMC Employees will have to go to MRMC employee health department, sign a release form and get copies of immunization records. Substance Results i. Dated within 12 months of start of performing clinical rotation at MRMC (the same results may be used for re-entry as long as the date is in line with the 12 month period). ii. MRMC Employees - If you are an employee of MRMC you may use results from MRMC hiring process IF they are dated within 12 months of start of clinical rotation at MRMC. iii. MRMC Employees will have to go to MRMC employee health department, sign a release form and get copies of substance testing record. Background results i. Dated within 12 months of performing clinical rotation at MRMC (the same results may be used for re-entry as long as the date is in line with the 12 month period). ii. MRMC Employees - If you are an employee of MRMC you may use results from MRMC hiring process IF they are dated within 12 months of clinical rotation at MRMC. Substance Consent Form Background Consent Form Confidentiality Agreement Proof of health insurance Professional Liability Student provides own Student covered by school Faculty Required Documents: Orientation Packet Computer Access Request Form Immunization Records / Declination Substance Results i. Dated within 12 months of the new CHS orientation paperwork Background results i. Dated within 12 months of the new CHS orientation paperwork Substance Consent Form Background Consent Form Confidentiality Agreement

7 MRMC EMPLOYEES ONLY: Employee #: Date of Hire: Area Employed:

8 Name of School: Name of Facility Facility policy prohibits Students (as well as applicants, employees and contractors) from using Substances including, but not limited to, illegal drugs and legal prescription drugs without a current, legal and valid prescription. Alcohol may not be used in a manner that will cause Student to be impaired while at the Facility. Students shall be tested for Substances as directed by the School or the Facility. The Students are seeking Facility experience that is not granted to the general public. It is Facility policy to maintain a drug and alcohol free environment. By choosing to access the Facility through the program, the Student must agree to follow the Facility s substance abuse policy, including Substance testing. Any Student who chooses not to agree to this policy has chosen not to be in the program. No Student shall be in the program who: Has chosen not to comply with the Facility s or School s directives; Is unfit for duty; and/or Has not passed a Substance test within the twelve (12) months preceding Student s provision of Patient Care Services. The School shall: Cause each Student to complete Addendum 4 Student Substance Policy Consent Form; Provide the Facility with a copy of each Student s completed Consent Form or request Student to provide the completed Consent Form to the Facility; Conduct testing of Students through a licensed laboratory if School is responsible for Substance testing; and Provide to the Facility copies of each Student s test result, for every test, if School is responsible for Substance testing. Substance Testing may also be required by the Facility: When a Student is injured at the Facility; When a drug is not accounted for per Facility policy; For oversight of a Student who has previously completed a Substance rehabilitation program; For a Student who has been absent from the School or program for more than 30 days (except for regularly calendared school breaks); and When a Student appears to be unfit for duty.

9 I choose to: Agree with and follow the Substance Policy. To provide any specimen(s) and to authorize the School and Facility and any associated persons and/or entities to conduct tests for alcohol and drugs and to allow them to access and utilize Specimen and test information as needed pursuant to the Substance Policy and process. Release the School and the Facility and any associated persons and/or entities from any and all claims, causes of action, damages, or liabilities whatsoever arising out of or related to the Substance Policy and process. Student: Signature Printed Name Date Witness: Signature Printed Name Date As the parent and/or guardian of the Student named above, I hereby consent to and authorize the School and Facility and affiliated persons and/or entities to proceed as outlined above. Parent and/or Guardian s Signature Date Student s Printed Name Date

10 Name of School: Name of Facility Facility policy requires Students (as well as applicants, employees and contractors) to pass background checks before being allowed to access the Facility. The Students are seeking Facility experience that is not granted to the general public. By choosing to access the Facility through the program, the Student must agree to have a background check as described in the Student Affiliation Agreement and herein, as directed by the School or the Facility. Any Student who has chosen not to agree to this policy has chosen not to be in the program. No Student shall be in the program who: Has chosen not to comply with the Facility s or School s directives; Is unfit for duty; and/or Has not passed a Background test within the twelve (12) months preceding Student s provision of Patient Care Services. School or Facility shall complete each of the following background checks before Students may provide Patient Care Services at Facility: o o o Office of Inspector General ( OIG ) List of Excluded Individuals/Entities Facility shall not accept Students who have been suspended or disbarred from any applicable federal payer program. Appropriate screening tools include the Excluded Party Search System, another approved software program, and certain internet sites. License or Certification Facility shall not accept Students whose licenses or certifications have ever been suspended, revoked, terminated, or otherwise modified as to rights and privileges. However, if such sanctions resulted from use of a controlled substance and the Students have successfully completed a rehabilitation program, Facility may accept them so long as they undergo periodic substance abuse testing as determined by the Facility. Criminal Records Check School or Facility shall conduct criminal records checks on Students at the federal, state, and local levels before Student may be allowed to provide Patient Care Services at the Facility and thereafter as often as is required by law. The CEO of Facility will have the authority to make the final decision regarding the acceptance of any Student with a criminal record.

11 The information I have disclosed to the School and Facility is true, correct and complete. I understand that any misrepresentation, falsification, omission or deception of material facts may cause my application to be rejected or any program participation terminated. I authorize the procurement or release of a consumer report or investigative consumer report about me. I understand this report may include information such as my character, general reputation, personal characteristics or mode of living, criminal, credit, and professional licensure certification. I authorize any entities or individuals with which I have been associated to supply the School and Facility and their agents with this background information and I release any entities or individuals from all liability whatsoever related to the information or its furnishing. I also authorize the School and Facility and their agents to contact any government or private entities or persons to verify the validity of any documentation. Student: Signature Printed Name Date Witness: Signature Printed Name Date As the parent and/or guardian of the Student named above, I hereby consent to and authorize the School and Facility and affiliated persons and/or entities to proceed as outlined above. Parent and/or Guardian s Signature Date Student s Printed Name Date

12 ADDENDUM 7 DISCLOSURE AND AUTHORIZATION I authorize the Facility, the School and any persons and entities associated with them, to conduct background investigations which will include the obtaining of Investigative Consumer Reports and Consumer Reports. Such investigations may include seeing information about me such as my employment(s), personal history, education, character, general reputation, criminal, licensure/certification, credit and driving histories. I also authorize, without reservation, the obtaining of information from other persons and entities (such as other employers, companies, schools, government entities and credit agencies) for information about me, and for those persons or entities to release that information, without reservation. Print legal first, middle and last name Social Security Number DOB Driver s License # & State Issued Health License/Certificate # & State Issued 1

13 Workforce Information Security Agreement I understand that the facility or business entity (the Company ) in which or for whom I work, volunteer or provide services, or with whom the entity for which I work has a relationship (contractual or otherwise) involving the exchange of health information, has a legal and ethical responsibility to safeguard the privacy of all patients and to protect the confidentiality of their patients health information. Additionally, the Company must assure the confidentiality of its human resources, payroll, fiscal, research, internal reporting, strategic planning, communications, computer systems and management information (collectively, with patient identifiable health information, Confidential Information ). In the course of my employment / assignment at the Company, I understand that I may come into contact with this type of Confidential Information. I will access and use this information only when it is necessary to perform my job related duties in accordance with the Company s Privacy and Security Policies, which are available on the Company intranet. I further understand that I must sign and comply with this Agreement in order to obtain authorization for access to Confidential Information. 1. I will act in the best interest of the Company and in accordance with its policies, procedures and Code of Conduct at all times during my relationship with the Company. 2. I understand that I should have no expectation of privacy when using Company information systems. The Company may log, access, review, and otherwise utilize information stored on or passing through its systems, including , in order to manage systems and enforce security. 3. I understand that I have no right to any ownership interest in any information accessed or created by me during my relationship with the Company. 4. I will practice good workstation security measures such as locking up diskettes when not in use, using screen savers with activated passwords appropriately, and position screens away from public view. 5. I will only access or use systems or devices I am officially authorized to access, and will not demonstrate the operation or function of systems or devices to unauthorized individuals. 6. I will: a. use only my officially assigned user ID, password, etc. b. use only approved licensed software. c. use devices with virus protection software. d. report theft or loss of mobile devices (cell phones, PDAs, laptops, etc.) that store Confidential Information within 24 hrs. 7. I will never: a. share or disclose user IDs or passwords, nor will I ask others to do so. b. use tools or techniques to break or exploit security measures. c. connect to unauthorized networks through the Company s systems or devices. d. knowingly include, or cause to be included, any false, inaccurate or misleading entry in any record or report. 8. I will not disclose or discuss any Confidential Information with others, including friends or family, who do not have a need to know it. 9. I will not in any way copy, release, sell, loan, alter, or destroy any Confidential Information except as properly authorized. 10. I will not make unauthorized transmissions, inquiries, modifications, or purgings of Confidential Information. 11. I will practice secure electronic communications by transmitting Confidential Information only to authorized entities, in accordance with approved security standards. 12. I will only access electronic systems to review patient records for which my job responsibilities have a legitimate need to access for treatment, payment or healthcare operations. 13. I will notify my manager or appropriate Information Services person if my password has been seen, disclosed, or otherwise compromised, and will report activity that violates this agreement, privacy and security policies, or any other incident that could have any adverse impact on Confidential Information. 14. Upon termination, I will immediately return any documents or media containing Confidential Information to the Company. 15. I agree that my obligations under this Agreement will continue after termination of my employment, expiration of my contract, or my relationship ceases with the Company. 16. I understand that violation of this Agreement may result in disciplinary action, up to and including termination of employment, suspension and loss of privileges, and/or termination of authorization to work within the Company, in accordance with the Company s policies. The following statements apply to physicians and contracted entities using Company systems containing patient identifiable health information: 1. I will insure that only appropriate personnel in my office will access the Company s electronic systems and I will annually train such personnel on issues related to patient confidentiality and access. 2. I will accept full responsibility for the actions of my employees who may access the Company s electronic systems and Confidential Information. I acknowledge that I have read this Agreement and I agree to comply with the terms and conditions stated above. Signature (Employee, Consultant, Vendor, Office staff, Physician) Facility Name Date Printed Name Dept.

14 Student Health Insurance Statement of Coverage Name of Student: Program: School: Graduation Date: Yes - Student has health insurance coverage a. Attach proof of health insurance (insurance card etc.) b. Sign Acknowledgement of Student Financial Responsibility below No - Student does NOT have health insurance coverage a. Student acknowledges that student is responsible for any and all medical cost incurred in the event medical treatment/services are needed at any time during clinical rotation b. Sign Acknowledgement of Student Financial Responsibility below Acknowledgement of Student Financial Responsibility I (STUDENT), understand that in the event I need any type of medical care or treatment while performing clinicals at MRMC (FACILITY) I shall be ultimately responsible for the cost of said medical care and treatment needed by FACILITY. Initial emergency outpatient medical care and initial treatment for injuries and illnesses sustained and suffered while in the performance of said clinicals at the FACILITY will be rendered from the FACILITY to the individual STUDENT and FACILITY shall bill STUDENT S health insurance policy for all reasonable costs incurred for said treatment. The FACILITY does not assume responsibility for any third party sources. The FACILITY does not assume responsibility for any charges by any private physician for any care rendered to the STUDENT while in said FACILITY. In the event that the STUDENT does not have health insurance coverage the STUDENT understands and acknowledges that they shall be responsible for all medical care and treatment charges incurred, both to hospital and physician, that may be rendered as a result of an injury sustained while performing his or her clinicals at the FACILITY. Furthermore STUDENT acknowledges that in the event any medical bills incurred that remain outstanding and not paid will be sent to a collections agency and STUDENT will no longer be able to perform clinicals at FACILITY. STUDENT SIGNATURE DATE June 2014

15 EMPLOYEE HEALTH SERVICES NATIONAL HEALTHCARE SAFETY NETWORK (NHSN) Acute care hospitals participating in the Centers for Medicare and Medicaid Services Inpatient Quality Reporting Program are required to report the number of associates who receive or decline Influenza Vaccinations. This number includes all employees on payroll, licensed independent practitioners (i.e., physicians, advanced practices nurses, physician assistants affiliated with Munroe but not on payroll), students, trainees and volunteers aged 18 or older as specified by NHSN Centers for Disease Control and Prevention. Only Non-Employed Healthcare Personnel who will physically work at Munroe for at least one (1) day between September 1, 2014 and March, 2015 should complete this form. If you have received Flu vaccination through another provider other than MRMC Employee Health Services or if you have declined flu vaccination, please complete the following: NAME (PRINT): EMPLOYEE OR SS# AFFILIATION STATUS (Check): Physician Advanced Practice Nurse Physician Assistant Student Name of School Affiliate Volunteer Volunteer Number Other (Specify) RECEIVED FLU VACCINE (Attach documentation): Date received: Name of Provider: DECLINED FLU VACCINE (Check Reason): History of a severe allergic reaction to eggs or other vaccine component(s). History of Guillain-Barre Syndrome within 6 weeks after a previous Flu Vaccination. Other (please indicate): SIGNATURE: DATE: RETURN COMPLETED FORM TO MRMC EMPLOYEE HEALTH SERVICES (EHS) AT: 1500 SW FIRST AVE., OCALA, FL OR FAX TO BY 4/1/15 FLU-CDC NHSN

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17 STUDENT PARKING REMINDERS Parking: Services Provided Safety and Security Phone Numbers: STOP Any violation of the parking regulation may result in the student losing parking privileges and/or clinical privileges at MRMC.

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19 2014 Self Study Hands ON Orientation HIPAA Environmental Care/Safety Customer Service Infection Control Bloodborne Pathogens HIV / AIDS

20 Revised April 2014 As a student/instructor in a clinical training program at Munroe Regional Medical Center, you are required to learn about the health information privacy requirements of the federal law called Health Insurance Portability and Accountability Act (HIPAA). The HIPAA Act of 1996 (Effective on April 14, 2003) was created and designed to help protect the privacy and security of health information. When you are at any of Munroe Regional Medical Center facilities for clinical training, you are covered by the Privacy Rule as a member of that facility s workforce. In addition to this training, your training site may require you to complete Privacy Rule training. When you are at a training site, you must follow that site s policies and procedures, including those concerning health information privacy. The rule requires strict regulations of medical information management and includes rules for: Privacy Security Transaction Code Sets Identifiers Healthcare Activities Covered Under HIPAA Regulations : Treatment - generally means the coordination of healthcare and related services among healthcare providers Payment - encompasses the various activities of healthcare providers to obtain payment or reimbursement for their services. Healthcare Operations - are certain administrative, financial, legal, and quality improvement activities of Munroe that are necessary to run our business. HIPAA YEAR-END REPORT FOR 2010 We have listed the disciplinary actions enforced against associates during FY2010. were giving out for privacy violations (loss of pay for the day and not eligible for a merit increase for the next year or a bonus) HIPAA HOT TOPICS Q & A FROM FY 2013 I look at another employee s or patient s information when I am not involved in their care? HIPAA 2013 FORECAST Social networking will continue to grow as a privacy problem (facebook, twitter, etc). New rules (i.e., Red Flag and HITECH rules ) have made privacy or security violations even more serious. We will have a zero tolerance for noncompliance HIPAA is no longer a cute name but can cause severe reputation and financial damage to Munroe L.T. Slaughter CHIEF AUDIT AND COMPLIANCE OFFICER/ PRIVACY OFFICER

21 HIPAA requires Covered Entities (CE) any health care provider, health care clearinghouse or health plan that electronically maintains or transmits health information pertaining to an individual to adhere to the privacy and security regulations. This includes: Healthcare clearing houses. Health Plans Healthcare providers who transmit health information in connection with a transaction. Business partners not regulated directly by HIPAA. CE need to enter into a contract with business partners covering a chain of trust, so they won t inappropriately disclose patient identifiable data. - generally means the coordination of healthcare and related services among healthcare providers. - encompasses the various activities of healthcare providers to obtain payment or reimbursement for their services. - are certain administrative, financial, legal, and quality improvement activities of Munroe that are necessary to run our business. 1. by including covered entities business associates into its privacy provisions. 2., in some cases to the media, the Secretary, and the Secretary will make available to the public on HHS s public website a list of covered entities involved in a breach. 3. an increased civil monetary penalty that is divided into three tiers. 4. i. The new legislation also significantly increases the existing civil monetary penalties for each violation. Civil penalties now generally range from $100 to $50,000 per violation, with caps of $25,000 to $1.5 million for all violations of a single requirement in a calendar year. ii. The severity of the penalties increases based upon the cause of the violation and the violator s level of knowledge regarding the violation: : Violator had no knowledge (and by exercising reasonable diligence would not have known) of the violation : Violations due to reasonable cause : Violations caused by "willful neglect" that were corrected : Violations caused by "willful neglect" that were not corrected 2

22 HIPAA Criminal Penalities have Dramatically Increased As for the a person will be guilty if that person knowingly and in violation of wrongful disclosure of PHI : 1. Uses or causes to be used a unique health identifier; obtains PHI relating to an individual; and discloses PHI to another person. 42 U.S.C. 1320d-6. That person can be fined 2. If the crime was committed under false pretenses, that person can be fined The most severe criminal penalty is imposed when an offense is committed with intent to sell, transfer, or use PHI for commercial advantage where that person can be fined You can go to JAIL from ONE TO TEN YEARS if you are personally involved in a HIPAA BREACH!!! Huping Zhou, a licensed cardiothoracic surgeon in China who was working at the UCLA School of Medicine as a researcher, was sentenced in late April 2010 to four months in jail after pleading guilty to charges related to looking at patient medical records he was not authorized to view. Compliance with HIPAA is Munroe must : Inform patients of their privacy policies. Provide training to staff, students and volunteers regarding the HIPAA regulations. Non-compliance with HIPAA is a federal offense. Munroe could face penalties from $25,000 to $250,000 and possible imprisonment of responsible employees, students or volunteers; those penalties also affect the individual healthcare worker. Violations of the privacy regulations will result in disciplinary action ranging from verbal warnings to termination of employment. If a student is in a violation, this would include a loss of clinical privileges at MRMC is our Chief Audit and Compliance Officer /Privacy Officer. If there are any privacy related issues/violations you can report them on the privacy line at or call him directly at (352) Additionally, you can call the Ethics Line at to report anonymously. To assist in remembering these complex rules here is Protected Information Disclosures Notice of Practices Business Agreements and for Disclosures 3

23 Protected Health Information (PHI) is individually identifiable health information transmitted or maintained in any form or medium including oral information. This information may relate to a person s health, to the health care provided, or to payment for health care and includes demographic information. Name Birth date Address Phone number Fax number Names of relatives Photos Medical record number Social Security # Addresses Health information (e.g., lab results, medical history) The Privacy Rule requires you to safeguard PHI at your training site. Use the following practice to ensure Privacy Rules compliance: If you see a medical record in public view where patients or others can see it, cover the file, turn it over or find another way to protect it. When you talk about patients as part of your training, try to prevent others from overheating the conversation. Hold all conversations, unless emergent, about patients in a private area. DO NOT discuss patients while you are in elevators or other public areas. When medical records are not in use, store them in offices, shelves or filing cabinets When you throw away documents containing PHI place them in the shredder box located in each area/unit. remove patient documents containing PHI, disposal of documents with PHI remove the patient s/clients official medical record form the training site (do not throw away items, with patient identifiers on them). (Dining Room, elevators, home, etc.) (make sure you verify the number) You may use PHI, without patient authorization; at the training site for purposes of treatment. However, you may not further disclose PHI in any form to anyone outside of the training site, without first obtaining written patient authorization or de-identifying the PHI. This means you may not, for example, discuss or present PHI from a training facility with or to anyone, including classmates or faculty, who was not directly involved in your training at the facility, unless first obtaining written authorization from the patient. Therefore, you AS LONG as the covered entity has applied reasonable safeguards and has implemented the minimum necessary standards. The Privacy Rule grants individuals the right to receive adequate notice of a covered entity s policies and procedures regarding its use and disclosure of PHI. The notice must be in plain language, must describe the types of use and disclosures of PHI, what the individual s rights are with respect to PHI, what the organization is required to do with PHI and what complaint procedures exist. Must be provided to the patient no later than the date of first service delivery, except in an emergency treatment situation. Must make a good faith effort to obtain the patient s written acknowledgement of receipt of the Notice. 4

24 1. Patient is assigned a PIN number for friends and family to call in and obtain PHI about the patient s treatment (PIN Policy). 2. Patient has a right to request restrictions of use and disclosure of PHI. This is the No Information Patient at Munroe. 3. Patient must give a signed authorization form before providers can disclose PHI outside of treatment, payment and healthcare operations. 4. Patient may request to correct or amend PHI. 5. Patient can request access to his or her personal medical records 6. Patient can ask for a report of all non-routine uses and disclosures of PHI (accounting of disclosures) A HIPAA regulated business relationship occurs when certain specified services are provided to a covered entity by a third party, which requires the covered entity to exchange PHI. These include services provided by: Law firms Actuarial entities Collection agencies Accounting firms Consulting firms Financial Services Contract management companies Accreditation entities Utilization review organizations There are two main types of disclosures: 1.Disclosures with an Authorization Form (properly signed by the patient) The patient sends medical records department a properly signed authorization form and they will release the requested information. 2.Disclosures allowed by HIPAA but require tracking in Disclosure Management System (DMS). These include releases to the Health Department, CDC, ACHA, OIG, court mandated subpoenas, release of information to police, etc. (These are releases without an authorization form). Patients are allowed to request an accounting of disclosures of their PHI for a six-year period. This does not include disclosures that are made via a valid authorization or when it is treatment, payment or healthcare operations. It does include disclosures (when an authorization is not required) that are made to, but not limited to, the following: State and local departments, CDC, OSHA, Child abuse or neglect, FDA, Workman Compensation Insurers, Oral communications (outside TPO are included) To assist in remembering these complex rules here is Disclosure of protected health information must be limited to the minimum amount necessary to accomplish the intended purpose. Access based on job category or function. Does not apply to treatment. Does not apply to disclosures pursuant to an individual s authorization Documented IRB or Privacy Board Approval. Preparatory to Research. Research protected Health Information of Decedents. Limited Data Sets with a Data Use Agreement. Research Authorization must meet (different requirements than a normal authorization). 5

25 Munroe Regional can send information to patients about it s own services (This is not considered marketing). We have to get an authorization if we send another company s information to patients about a product or service. A covered entity is allowed to use or disclose demographic information and information about the dates of service provided to an individual (not the treatment information) for the purpose of fund raising activities. Patient may request (in writing) to have a bill or other information sent to another address, be called at work, post office box, etc. Authorized individual acting on the behalf of the individual in making health care decisions. For incapacitated/unconscious patients, a designee may authorize/object to release of information to media (i.e., HIPAA states that when opportunity to object to disclosure cannot be practicably provided because of patient s incapacity, a covered healthcare provider may disclose information if it s in patient s best interest or is consistent with prior expressed preference. Information included on police logs (i.e., transport or car accident victims to a hospital, etc.) are considered matters of public record. However, HIPAA mandates that hospitals accord patients involved in matters of public record same privacy rights as other patients. For example, a reporter must have name of a car accident victim before hospital can provide any patient information. 6

26 Red Flag Rules (Effective 11/20/2010) The Federal Trade Commission (FTC) adopted regulations in 2000 implementing the Federal law commonly known as the Red Flags Rule. In 2008, the World Privacy Forum found that the number of Americans identifying themselves in government documents as victims of medical identity theft had tripled in just 4 years to more than a quarter-million in MSNBC.com The FTC estimates that as many as nine million Americans have their identity stolen each year. Victims of medical identity theft face possible complications when their medical history is confused with that of the thief, including: Erroneous medical bills Loss of insurance benefits Unnecessary medical procedures Inability to obtain health, life, or disability insurance Harm caused when treatment is based on incorrect information The Red Flags Rule requires creditors that offer/maintain covered accounts to adopt a written identity theft prevention program to: warning signs of identity theft (Red Flags) in day-to-day operations Take steps to the crime (alleviate) the damage it causes If a health care provider allows for payment on medical services provided to a patient after those services were provided and/or over a period of extended payments, the health care provider is considered a. What is the Red Flags Rule? Important Definitions An effective identity theft prevention program equips employees to recognize and respond to Red Flags so that identity theft may be prevented or mitigated. A is defined as a pattern, practice or specific activity involving a patient that indicates the possible existence of identity theft. are most likely to detect Red Flags during the process of: Registering/authenticating new and current patients Submitting claims for payment and billing patients Medical records review Customer service Collecting debts In order to comply with this Federal law, we take the following four steps: 1- Identify the Red Flags for our business 2- Set up procedures to detect Red Flags 3- Respond to Red Flags to prevent theft or mitigate harm done 4- Update our Identity Theft Detection and Prevention Program as needed to keep it current, and educate staff 7

27 Understanding the privacy rules is an important part of HIPAA compliance at Munroe. How the information is stored, transmitted and accessed by staff is also an important factor. This section will address the security rules. As you remember, security standards are part of the Administrative Simplification requirements under HIPAA. Munroe has implemented security programs that meet the security rule requirements. We have addressed following administrative and technology requirements: 1. Physical Security Measures. 2. Technical Security Services. 3. Technical Security Mechanisms 4. Administrative Procedures 5. Sharing information with other Organizations/Individuals The privacy rules identify what information is protected. They also define when and how that information may be used or disclosed. The security rules identify steps to take to secure PHI that is in electronic format. These rules help to make sure processes are in place to protect the information covered by the privacy rules. It makes sense to have written procedures in place to help the facility understand not only what needs to be protected, but also how to protect it. Think about all of the things want to keep private! For example, bank accounts, , and your health records. While you may want to keep this information private, without proper security, it may be easy for anyone to get access to the information and possibly cause problems for you! 1. : the actual hands-on access to computer hardware, systems, areas and buildings. 2. : The process to identify the access and type of information individuals may access and see on computer systems. 3. Processes that automatically monitor activity and report suspicious activity. 4. : The documented policies and procedures that define the steps the facility will take to address physical security, technical security services and technical security mechanisms. The procedures should also address other items identified in the security rules such as monitoring and auditing and sharing PHI with others. Together, these requirements define the basic level of security that must be in place in a facility in order to comply with HIPAA. As with privacy requirements, the facility will need to identify someone or some department to be responsible for security. This person or department will need to make sure the facility complies with these requirements. This person or department will also be responsible for providing training to all system users in the facility. Munroe management and the Information Protection Committee has selected to be the You will need to know his name and can contact him with any HIPAA security related questions. HIPAA security violations can be reported through the 8

28 The purpose of the is to help protect the physical computer system, building and equipment from: Fire Other natural and environmental hazards Unauthorized access These measures include locks, keys, badges or cards that unlock doors and other steps to restrict access to computer systems and facilities (e.g., passwords). Physical security also includes administrative processes As with privacy requirements, the facility will need to identify someone or some department to be responsible for security. This person or department will need to make sure the facility complies with these requirements. This person or department will also be responsible for providing training to all system users in the facility. Workstations, computer systems, and printers need to be secured from unauthorized viewing or use. A screen saver that hides the data being viewed should automatically turn on after a period of inactivity. If the employee leaves the computer, he or she should log out of the system.. Written policies and procedures should address how media (e.g., CD-ROMs diskettes, etc.) is created, maintained, accessed, stored and destroyed. The security standards require written procedures to deal with the receipt and removal of hardware and/or software to and from the facility. Information stored on backup tapes, s, CD-ROMs, microfilm, microfiche and other formats must be protected to the same standards as the original data. Special security measures need to be enforced on home computers that will access PHI. This would include items such as passwords to prevent access by other family members and virus protection software. Often, when people think of information security, they only think of information that is maintained on a computer system. Unfortunately, this is not the only area where security is a concern. For example, PHI may also be found on fax machines, copiers and printers. Security must also be considered when discussions are held in public places (elevators, cafeterias, nursing stations, etc.). Conversations with both staff and patients/visitors may result in the disclosure of PHI if someone overhears the conversation. We have designated trash bins throughout Munroe where all PHI information is to be placed for it to be shredded. You must use your professional judgment to ensure trash is placed into the correct bin. If you have questions, you should refer to your policies and procedures or ask your supervisor for assistance. Technical security services focuses on the steps and procedures that must be in place to: Protect information Control access Validate the identity and authorization of users Some of the processes used to promote compliance with the technical security services rules include: Computer system access, such as passwords. Assigning security levels based on user identity or job responsibilities. Proper identification of individuals and entities requesting access to PHI. 9

29 The primary purpose of technical security mechanisms is to protect all electronic information that is transmitted over a communications network. This would include electronic detection and prevention for unauthorized interception or receipt of information or data. For example, some of the technical security mechanisms that may be in place in your facility include: Alarms that alert IT/IS of unusual system activity. Audit trails that record system activity as it occurs. Event reporting to track certain items such as alarms or the completion of system tasks. Entity authentication, which is the electronic process to verify the user is authorized to access the system. Under the security rules, written policies, procedures and processes must be in place. The primary purpose of the procedures is to identify how to protect information from improper access, use and disclosure. This will help employees understand what they can do to protect information and data. Specifically, these requirements need to address the three components of information security we have just reviewed: The written policies and procedures and practices that your facility will need to have in place include, but are not limited to, the following: *Adding, changing or deleting user access based on job responsibilities. This includes monitoring to make sure the right access level is assigned. For example, it would be improper for a maintenance worker to have any access to medical records. Use and assignment of individual user IDs and passwords. How to access the computer system and/or PHI in the event of an emergency (e.g., a power outage or computer virus attack). Identifying how records are processed that contain PHI. This includes all processes from creation or receipt of the record through destruction or disposal of the record. The security requirements state that all system users must be trained on their responsibilities to make sure security is maintained. Every person should know and understand the security practices and procedures they should follow. If you have any questions, you should ask your supervisor for help. Auditing is the process of selecting a certain element or item for review and then gathering data regarding that element or item over a period of time to determine if the process is working as expected. Auditing can help the facility identify trends, such as improvements in privacy and security practices. It can also identify problems that may exist and identify the need for additional user training. Both monitoring and auditing play important roles in helping the facility comply with HIPAA requirements. Monitoring and auditing for security standards is the same as monitoring and auditing processes for privacy and for compliance programs in general. Monitoring is the process of reviewing activities on a regular basis, such as daily audit trails, data transmissions, etc. Monitoring can best be used for early detection of potential problems so corrective actions can be taken. We have full audit trail capabilities of all information systems at Munroe. We can see what you are accessing and who is doing it. This audit capability lead to the termination of the five individuals previously noted. See the next example of what the reports look like. L.T. Slaughter Chief Audit and Compliance Officer/Privacy Officer 10

30 Example of Audit Report Audit Report Wed Dec 23 11:22:33 EST 2009 Event ID User ID Source ID Network ID , 200_GUI (ID 1), Execute, Success ABC123:Name Slaughter, LT K:Security Level 100:Department 8311 COMPLIANCE:Appli cation Patient Administration, Data Accessed,, Access / use, Medical record number,, A ,,,, Account No.,, A , In the Privacy section, we reviewed information regarding how PHI may be shared between the facility and Business Associates. Similar requirements are needed for the security standards. Under the security standards, an addendum to or additional wording has to be added to the Business Associate Agreement. This additional wording to the agreement is used for the facility to contract with other parties when they exchange or transmit electronic information. The terms of the contract require each person or organization to protect the data integrity and confidentiality of the data exchanged.. Let s look at an example: Munroe has created a database that contains PHI for patients with Blue Cross insurance coverage. Blue Cross can dial into this database to obtain information for their records, such as the patient s current address or load information such as eligibility lists. Under the HIPAA regulations, a Business Associate Agreement with the added security elements would be necessary since electronic information is being exchanged. To ensure that the HIPAA privacy and security regulations are followed by all Munroe associates, the Information Protection Committee has developed the Information Protection Disciplinary policy. Protected health information (PHI) is confidential and protected from access, use, or disclosure except to authorized individuals requiring access to such information. Attempting to obtain or use, actually obtaining or using, or assisting others to obtain or use PHI, when unauthorized or improper, will result in counseling and/or disciplinary action up to and including termination. All Munroe information systems have audit logs that show what you have accessed. This information will be used in a HIPAA investigation. Depending on the nature of the breach, violations at any level may result in more severe action or termination Levels I-III are considered to be without malicious intent; Level IV is considered to be done with malicious intent At Level IV, individuals may be subject to civil and/or criminal liability 11

31 Misdirected faxes & s Failing to log-off or close or secure a computer with PHI displayed. Leaving a copy of PHI in a non-secure area. Dictating or discussing PHI in a non-secure area (lobby, hallway, cafeteria, elevator). Munroe management will notify the Director and Privacy Officer. Disciplinary action may include re-training, verbal or written warning for the first offense. Sharing ID/password with another co-worker or encouraging co-worker to share ID/password. Repeated violations of Level I. Disclosing PHI in a Social Network (I.e., Twitter, Facebook, or My Space). Munroe management will notify the Director and Privacy Officer. Disciplinary action may include re-training, verbal or written warning, a decision day or termination. Requesting another individual to inappropriately access patient information. Releasing or using aggregate patient data without appropriate approval for research, studies, publications, etc. Accessing or allowing access to PHI without having a legitimate reason. Giving access to your electronic signature (Care Manager). Accessing PHI due to curiosity or concern, such as a family member, friend, neighbor, coworker, famous or public person, etc. Repeated violations of previous levels. Posting PHI to Twitter, Facebook or any other social network. Minimum Disciplinary/Corrective, Action: Munroe management will notify the Director and Privacy Officer. Releasing or using data for personal gain. Compiling a mailing list to be sold for personal gain or for some personal use. Accessing or allowing access to PHI without having a legitimate reason and disclosure or abuse of the PHI. Tampering with or unauthorized destruction of PHI. Repeated violations of Level III. Munroe management will notify the Director and Privacy Officer. The Privacy Officer will notify the appropriate local, state or federal government entity.. Disciplinary action may include a decision day, termination and/or prosecution. 12

32 1. A covered entity under the HIPAA regulations is defined as any healthcare provider (hospital), clearing house or health plan that electronically transmit health information pertaining to an individual. a. True b. False 2. Non-compliance with HIPAA regulations is a federal offense. Munroe could face fines from $25, 000 to $250,000 and possible imprisonment of responsible employees. The penalties also affect the individual healthcare worker. a. True b. False 3. The privacy rule does not grant patients the right to receive adequate notice of Munroe s privacy policies and procedures regarding the use and disclosure of their information a. True b. False 4. A current Munroe employee (John) has been in a car accident and comes into the ED via ambulance. Several Munroe employees see him as he is treated and has X-rays taken. It is OK to call other individuals within Munroe and tell them that John got into an accident and what they saw? a. True b. False 5. Sam Thonen is the HIPAA Security Office at Munroe. a. True b. False 6. Protected Health Information (PHI) relates to information that can identify a patient and includes demographic information a. True b. False 7. The main parts of the HIPAA Security rule include the following: physical security, technical security mechanism, technical security services and administrative procedures. a. True b. False 8. Auditing and monitoring for the compliance with HIPAA standards is not very useful process. It is more efficient to wait until we have a BIG problem before we try to correct it. a. True b. False 9. The proper way to report a security violation is to call the Ethics line at a. True b. False 10. L.T. Slaughter is our Chief Audit and Compliance Officer/Privacy Officer. He is in charge of ensuring that Munroe meets all federal regulations (including the HIPAA privacy regulations). a. True b. False 13

33 Revised: February 2014 In order for a disease to go from person to person: The pathogen causing the disease must have a way to get out of the sick person The second person must then come in contact with the pathogen Finally, the pathogen must find a way into the second person Infection control measures stop this chain of events. When this happens in a health care facility, it is called a healthcare-associated infection This facility: - Monitors infections among staff, students and patients. Takes action to control outbreaks of Implements infection control programs as needed: hand hygiene, vaccines, etc. Provides engineering controls that remove hazards from the workplace (ie: sharps containers). Provides written policies and procedures for infection control. Good hand hygiene practices are the foundation of infection control- Hand hygiene lowers the risk of transmitting microorganisms from one person or site to another. Wearing gloves does not replace hand hygiene. Always use soap and water when hands are visibly soiled, or after removing gloves. You may use an alcohol-based hand rub when hands are not visibly soiled, in between washing with soap and water. When hands are visibly soiled, wash with soap and water- Wet hands with water and apply soap. With your hands lower than your elbows, rub hands together for at least 15 seconds. If your hands were contaminated, wash at least 1 inch above this area. Rinse and dry with a disposable towel. Discard the wet towel and grab a fresh dry piece of towel. Use the towel to turn off the faucet. When you are preparing to give patient care, gather all equipment after performing hand hygiene and before touching the patient. When using an approved alcohol-based hand rub- Apply the product to the palm of one hand (use the volume recommended by the manufacturer) and rub the hands together. Cover all the surfaces of the hands and fingers and rub until the hands are dry, at least 15 seconds

34 In an effort to educate family and visitors about the importance of hand washing, signs like this may be posted throughout the Medical Center. To comply with appropriate hand hygiene at Munroe Regional, Purell Individual Handwipes will be available for those patients who are bed-ridden only. ONLY USE facility-approved and supplied lotions Because: Some lotions may make medicated soaps less effective Some lotions cause breakdown of latex gloves Lotions can become contaminated with bacteria if dispensers are refilled For direct patient care staff and all other as identified: Artificial nails may be worn while on duty. This includes bonding, tips, wraps, gels, acrylics, overlays, tapes or inlay used to enhance natural nails Natural nails must be kept (not to exceed ¼ inch in length) Nail polish must be smooth, not chipped nail jewelry

35 Regulated Waste refers to contaminated items that could release blood or other potentially infectious material (). It also refers to contaminated sharps, pathological wastes and microbiological wastes. Regulated waste does not include: pizza boxes, gauze wrappers, flowers, etc. : Materials that carry pathogens that cause serious disease. These materials include human body fluids (e.g., semen, vaginal secretions, cerebrospinal fluid, synovial fluid, any body fluid visibly contaminated with blood).d, and any body fluid visibly contaminated with blood). Cleaning schedules vary according to the: Area of the hospital. Type of surface to be cleaned. Type of soil present. on walls, floors, and other surfaces are rarely transmitted to patients or personnel. Food and water sources are monitored to control these potential routes to infection. Food and drinks must be stored separately from blood or OPIM. In work areas where exposure is likely, do not: Apply cosmetics, lip balm, or contact lenses. Eat, drink, or put objects in your mouth. Minimize your risk of exposure by containing, removing, and disinfecting all blood or body fluid spills as quickly and effectively as possible. Wear gloves and other appropriate personal protective equipment (. Using PPE is important in stopping the spread of infection. If health care workers are at risk of coming into contact with blood, body fluid, secretions, and excretions (except sweat), non-intact skin, or mucous membranes, they should wear PPE. PPE includes gloves, masks, eye protection, and face shields that protect workers mucous membranes. PPE also includes gowns that protect workers skin and clothing from becoming soiled. When performing more than one invasive procedure on the same client, change your gloves between each procedure to prevent contaminating another body part, piece of equipment or environmental surface. Always check your PPE for damage each time you use it. When using more than one piece of PPE, don the equipment in the following order: 1.Gown 2.Mask or respirator 3.Goggles or face shield 4.Gloves When removing gowns or gloves, be sure to contain the pathogens by folding or removing it so that the inside of the gown or glove is on the outside of the removed gown or glove

36 1. Gloves 2. Goggles or face shield 3. Gown 4. Respirator There are two levels of precautions in healthcare facilities: Keep the hands away from the face Work from clean to dirty Limit the surfaces touched Change gown or gloves when torn or heavily contaminated Perform hand hygiene expands the concept of. Standard precautions apply to blood, all body fluids, secretions, and excretions ( except sweat ), non-intact skin, and mucous membranes. Standard precautions include additional measures to protect both and personnel from disease-causing germs. Standard precautions are used by all health care workers with all clients. Respiratory hygiene and cough etiquette Safe injection practices Infection control practices for special lumbar puncture procedures

37 Sneezing into your sleeve will trap the germs in the fabric fibers and they will die. Using a tissue also traps the germs but allows contamination of your hand. Dispose of tissue properly. Hand hygiene after contact with respiratory secretions Use of surgical masks on the coughing person as appropriate Spatial separation of more than 3 feet from persons with respiratory infections, which can be accomplished through such measures as having common waiting areas for persons with respiratory infections Health care workers should use masks for all procedures that involve the insertion of catheters or injection of material into spinal or epidural spaces via lumbar puncture procedures. Examples of these procedures are myelograms and spinal or epidural anesthesia. apply to patients with documented or suspected infections or colonization that are highly transmissible. Measures beyond standard precautions are needed to stop these infections from spreading to others. Transmission-based precautions include: They are used in addition to will I know a patient is on isolation precautions?????. that it is the pathogen and not the patient that is being isolated. The patient continues to have basic needs that must be met. Think about these needs when providing care. Organize your workload so you will be able to spend time with the patient during daily care. If family members visit patients in isolation, teach them how to use the precaution measures that are in place and explain how these measure stop the spread of disease. Encourage the patient in isolation to contact friends and family by phone. Required for patients known or suspected to be infected with microorganisms transmitted by airborne droplet nuclei. Examples: chicken pox, measles, tuberculosis, and shingles. Negative pressure rooms are vital to stopping the spread of airborne pathogens. The pressure in these rooms must be less than the pressure outside of the room. This keeps air from flowing out of the room into the hall. The door to an Airborne Precaution isolation room is to be kept closed at all times

38 Precautions isolation room, you must wear: A fit-tested respirator A gown Gloves Required when the patient s illness is transmitted by direct patient contact or by contact with items in their environment. Examples: Gastrointestinal, respiratory, skin, and wound infections. Remember that even if you do not touch the patient, if you are touching objects in their environment: (water glass, TV remote, telephone, IV pole) you will need to utilize contact precautions. Apply standard precautions Wear a gown and gloves to enter the room Always use dedicated patient equipment (e.g., a disposable thermometer) Remove your gloves and gown and wash your hands before leaving the room Required when the microorganisms are transmitted by droplets generated by the patient during coughing, sneezing, talking, and performing procedures. The difference between airborne and droplet precautions is that droplets contained by droplet precautions are larger and therefore unable to remain in the air or travel through air for a long distance. Because these pathogens do not travel, a room with negative pressure and outside venting is not needed. To protect yourself and others: Apply standard precautions Wear a mask whenever you are working within 3 feet of the patient. pneumonia See Infection Control policy, Website & Resource manual for list of specific pathogens to isolate. we have developed a quick guide for all equipment that enters an isolation room. All equipment that enters and exits a room must be, to that particular patient s room, or. Please note the next slide and become aware of the items that may cause transmission of pathogens if not cleaned. EKG Machine Ultrasound Machine Endoscopy cart Other carts (phlebotomy) Bladder scanner Glucometer Glucometer Insulin Pen Doppler Walker, cane, wheelchair Specialty high-back chair Ventilator Bedside commode BIPAP/CPAP Suction Canister Feeding Pump Hemocult developer Patient nebulizer IV Pump SCD Machine items go from room to room after disinfecting items stay in patients room and move with patient after disinfecting until discharge items stay in room and move with patient after disinfecting until discharge used for disinfecting equipment in C. Diff room used for disinfecting all nonporous surfaces Disposable stethoscope Disposable thermometer Pen BP cuff Cups of ice

39

40 Munroe uses several disinfecting products throughout the organization. Be sure to read the labels on all disinfecting solutions regarding their Dwell Times Dwell times are defined as the time the solution must stay Visibly wet on the surface in order to properly disinfect. Example: When saniwipes are used to disinfect a surface, the Dwell time is 5 minutes the surface of the item that is being disinfected must stay visibly wet for 5 minutes. Sani Wipes Clorox Wipes Dimensions III HDQL 10 5 minutes 30 seconds 10 minutes 10 minutes Standard and universal precautions also help protect staff and patients from (MRO). These include: Methicillin-resistant (MRSA) Extended-spectrum beta lactamases (ESBL) Penicillin-resistant (PRSP) Vancomycin-resistant Enterococci (VRE) Employees could become infected or become and spread infection to other healthcare workers or patients. Accounts for 50-70% of all healthcare associated Staph. Infections. Usually presents as bloodstream, surgical site, pneumonia, and urinary tract infections. Has become an emerging community pathogen. Usually presents as skin and soft tissue infections. Highly resistant to most broad-spectrum antibiotics. Penicillin, semi-synthetic penicillins, cephalosporins, and cephamycins. Easily transmissible and limited number of antibiotics available for treatment. rom patient-to-patient via the hands of healthcare workers

41 Multidrug-resistant pathogens do not respond to usual treatment. Workers who are infected show the signs and symptoms of the disease, but carriers do not. Both those who are infected and carriers can spread the disease from person to person. Multidrug resistant pathogens are monitored by our infection control practitioners and if an increase in infections is noted, additional precautions may be taken. Cover your coughs and sneezes. Care for your wounds. Disinfect commonly touched items and surfaces in your home regularly. Wash clothing worn in the hospital separately from other laundry and in hot water. Keep your hands clean! Because healthcare workers may be exposed to pathogens in the normal course of their work, one infection prevention measure is the. As part of the affiliation agreement with your school/university, the University will ensure the health status of the student(s) entering this facility is compliant with the following requirements: Active or Passive Immunity to Pertussis Measles Tetanus Tetanus Mumps Rubella Hepatitis B Varicella Rubeola Negative PPD (two-step method) within the last year and updated yearly Seasonal influenza (Flu) is a highly contagious viral disease that is spread very easily from person-to-person, primarily by coughing and sneezing. The Influenza Season in the U.S. is from November to April each year. Influenza can cause fever, chills, headache, coughing, sore throat, runny nose, muscle aches, loss of appetite, dizziness and a sense of extreme fatigue. An individual is generally infectious about one day before and five days after symptoms begin. Approximately 30 to 50% of infected persons may not have symptoms, but they can still transmit the virus to others. In some instances complications from the flu can lead to pneumonia and death. This risk is not possible to estimate but may be increased for the elderly and for those with diabetes, heart, lung or kidney diseases. such as hand hygiene and sneezing etiquette serve to prevent the spread of influenza. Healthcare professionals are also encouraged to receive the influenza vaccine. The vaccine can prevent influenza (70-90% effectiveness among healthy people younger than 65 years of age). An injection of Flu Vaccine will not give you the Flu, because the vaccine is made from KILLED viruses. The viruses that cause influenza change often. Because of this, influenza vaccine is updated each year by replacing at least one of the vaccine viruses with a newer one. Protection develops about 2 weeks after the injection and may last up to a year. Influenza (also called Swine Flu) is caused by a new strain of influenza virus. It has spread to many countries. Like the seasonal flu virus, 2009 H1N1 spreads from person to person through coughing, sneezing, and sometimes through touching objects contaminated with the virus and symptoms are very similar. While the seasonal flu viruses change from year to year, they are closely related to each other. The 2009 H1N1 flu is a new flu virus. It is very different from seasonal flu viruses. Most people have little or no immunity to 2009 H1N1 flu. Groups recommended to receive 2009 H1N1 vaccine first are: Pregnant women People who live with or care for infants younger than 6 months of age Health care and emergency medical personnel Anyone from 6 months through 24 years of age Anyone from 25 through 64 years of age with certain chronic medical conditions or a weakened immune system

42 OSHA requires employers to develop an. This plan provides protection for all healthcare employees who might be exposed to blood-borne diseases. Our facility's exposure control plan and employee health policies explain how to report an exposure and what medical follow-up is available. OSHA requires that an employee be notified of the and the follow-up actions taken. When you have contact with blood or, immediately cleanse the area: Flush mucous membranes with a large amount of water. Wash exposed skin with soap and water. Report the exposure incident to your Workforce Development Coordinator immediately. Go to the emergency department, charges are the responsibility of the student Complete the evaluation and recommended follow-up. In the event of, you may use the Munroe Event Management System to document the occurrence. The Workforce Development Coordinator will in put the data and document into the EMS system after notification from student of an injury..) U.S. Department of Health and Human Services, Centers for Disease Control. Centers for Disease Control and Prevention. (1998).. Atlanta, GA: Author. accessed 7/27/08. Joint Commission on Accreditation of Healthcare Organizations. (2008).. Oakbrook Terrace, IL: Author. Tuberculosis Standards: CFR Respiratory Protection. Florida Administrative Code Chapter 64E Why Don t We Do It In Our Sleeve?. OtoRhinoLounsburgology Productions. Ben Lounsbury, MD. DVD,2005 Standard Precautions. Excerpt from: Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 207. Accessed 11/2/09 Vaccine Information Statement 2009 H1N1 Inactivated Influenza Vaccine 10/2/

43 1. Sarah has had a splash of blood in her eye. It is important that she does which of the following right away a. Cover the area with sterile gauze b. Flush the area with water right away c. Wipe the area with a tissue d. Nothing 2. The foundation of good infection control practices is: a. Washing Hands b. Antibiotics c. Isolation Rooms 3. Frequent touched surfaces like hospital bed rails are very likely to be contaminated a. True b. False 4. Wash hands with soap and water for at least seconds a. 10 seconds b. 20 seconds c. 15 seconds d. 25 seconds 5. The dwell time is defined as which of the following: a. The time that it takes for a pathogen to get out of the sick person and contaminate the second person. Fifteen seconds, the time it takes to effectively wash your hands b. The time the disinfecting solution must stay visibly wet on the surface in order to properly disinfect c. None of the above 6. Sarah asks, I don t understand droplet precautions. Before we go in, can you explain to me how droplet precautions differ from airborne precautions? a. Droplet precautions are used for adults and older adults. Respiratory precautions are used for infants and children b. Droplet precautions are used for patients who are at risk of frequently vomiting and diarrhea, whereas respiratory precautions are for respiratory disease c. There is no difference between the two. You use the same precaution measures with both. d. Unlike airborne precautions, droplet precautions are used with a pathogen that does not remain in the air and does not travel through the air for a long distance. 7. You will know if a patient is on isolation precautions. a. True b. False 8. It is acceptable to bring moisturizing lotion from home for the use at Munroe. a. True b. False 9. Artificial nails are permissible for direct patient care staff a. True b. False 10. Remove PPE in the following order: a. Respirator, goggles, gown, gloves b. Gown, respirator, gloves, goggles c. Gloves, goggles, gown, respirator d. There is no order

44 Workers in this facility have the potential to come in contact with blood and body fluids. Many diseases may spread through this contact. This self-study discusses the most common bloodborne pathogens that cause disease: the hepatitis B virus (HBV), the hepatitis C virus (HCV), and the human immunodeficiency virus (HIV). Established under the Occupational Safety and Health Act of 1970, the Occupational Safety and Health Administration functions within the U.S. Department of Labor to set and enforce workplace safety and health standards. They have a standard to address the potential for exposure to bloodborne pathogens. The is available at The requires employers, employees and students to work together to prevent the spread of blood-borne diseases. Blood-borne pathogens are germs that may be present in blood that are capable of causing disease. Diseases caused by the following 3 pathogens are of major concern to health workers: Human immunodeficiency virus (HIV) Hepatitis B virus (HBV) Hepatitis C virus (HCV) There are 3 diseases caused by these viruses: Acquired immunodeficiency syndrome (AIDS) Hepatitis B Hepatitis C You can be exposed to a blood-borne pathogens by performing task or being in an area where you might come in contact with blood or other potentially infectious materials (OPIM) Majority of exposures to blood-borne diseases in a healthcare facility are by direct exposure from needle sticks or other injuries from sharps. Some people, though not many, have been infected from splashing blood or other body fluid: Into the eyes, nose or mouth On broken or scraped skin Even one exposure to blood-borne pathogens can lead to serious and disabling diseases such as: Hepatitis Human Immunodeficiency Virus (HIV) You many not know you are infected with a blood-borne disease at the time of exposure. You may not realize it until years later. 1 Feb 2014 tmm

45 Whether or not you become infected depends on: The germ having an entrance into your body The number and strength of the germs Your resistance to disease The blood-borne pathogens are contracted by exposure to infected blood or other potentially infectious material (OPIM) of a person who has the pathogen in their body. The most common exposures occur through: Sexual Contact IV drug users who share needles An unborn baby from its mother: The risk is lowered with appropriate prenatal treatment Infection to the baby can also occur through breastfeeding Exposure to infected blood in the workplace is not a common exposure risk, but it does occur HIV is a viral infection of the immune system: HIV infection attacks the immune system and robs a person of the ability to fight off other disease-causing germs. HIV is the virus that causes acquired immunodeficiency syndrome (AIDS). HIV be contracted by: - Contact with telephones, doorknobs, toilet seats, or from mosquito bites. - Eating food prepared by an individual diagnosed as HIV-positive. - Shaking hands, hugging, being coughed on, or sneezed on. - Donating blood. The risk of contracting HIV from a blood transfusion is extremely low. The blood supply is carefully tested. According to the Centers for Disease Control, the chances of becoming HIV positive when exposed to HIV through a needlestick are less than 0.3% (2005). The risk is less for blood splashes into mucous membranes or on broken or scraped skin. There is no vaccine to stop the spread of HIV. Symptoms do not usually occur until several years after the infection: A person can infect others even though he or she does not look or feel sick. HIV is usually spread to others when the infected person does not yet know he or she has the disease. A person can be tested (through urine, oral fluids, or blood) to see if he or she has been infected by HIV. These tests seek to determine whether the body has had an immune response to HIV. For this reason, the tests will not work right after exposure to HIV. The average time it takes to detect an immune response is 20 days, and although most people will show a response in 3 months, there have been rare cases in which an immune response did not show until 6 to 12 months. 2 Feb 2014 tmm

46 (HBV) is a virus that attacks the liver. In the U.S., 700, million persons are estimated to be infected with the virus. There were 2,890 cases of acute HBV reported in The estimated number of new HBV infections was apx. 18,800 Many people who are infected with the virus do not have symptoms. An infected person with no symptoms is still contagious and may spread the disease to others. Symptoms of Dark urine General feeling of illness Lightened stool color Nausea Loss of Appetite Yellow skin color Enlarged Liver Abdominal Pain A person can be tested to see if they are infected with HBV through a blood test. The average time it takes to detect an immune response is 4 weeks. Chronic puts a person at a higher risk for: Cirrhosis of the liver Liver cancer A vaccine for Hepatitis B is available through employee health services or your healthcare provider and effectiveness (immunity) is measured at the completion of the vaccination series. Medical treatment for this disease involves the use of drugs. If liver failure occurs, a liver transplant may be needed. If you are exposed to Hepatitis B through a needle stick or other sharps injury, your risk of contracting the disease is about 6 to 30 percent, if you have not had a series of three vaccinations. Only 5 to 10% of the adults infected with HBV will develop a chronic Hepatitis B infection. The risk is less for blood splashes into mucous membranes or on broken or abraded skin. Your risk drops to almost zero if you have had a successful vaccination series. Hepatitis C (HCV) is a virus that is similar to Hepatitis B and also attacks the liver. of HCV patients appear to have no symptoms. The virus may remain years before patients experience fatigue, loss of appetite, and abdominal pain. People who have the infection are contagious even if they have no symptoms. Out of every 100 persons who are infected with HCV, 75 to 85 may develop long-term infection, and may develop chronic liver disease. Approximately 3.2 million persons in the U.S. have chronic HCV infection. Infection is most prevalent among those born during , the majority of whom were likely infected during the 1970 s and 1980 s when rates were highest. If you are exposed to Hepatitis C through a needle stick or other sharps injury, your risk of contracting the disease is low. The CDC reports that of every 100 health care workers exposed to HCV through a needlestick, about 2 will become infected with HCV. There are several blood tests to detect HCV infection. Hepatitis C causes chronic disease in about 85 percent of the people who contract it. Hepatitis C is a major cause of cirrhosis of the liver and liver cancer. While there is no cure for Hepatitis C, the symptoms may be treated with antiviral drugs. Treatment usually leads to long-term improvement. 3 Feb 2014 tmm

47 Complications of hepatitis, both B and C, account for the majority of liver transplants in the United States. OHSA requires Munroe Regional to develop an exposure control plan (ECP). This plan provides protection for all associates and students who might be exposed to blood-borne diseases. Changes in technology that reduce or eliminate exposure. Documentation that safer medical devices are adopted if available. Input is obtained from all employees, including non-managerial employees responsible for direct patient care who are at risk of coming into contact with contaminated sharps. an employee exposure determination in every facility thatrmination in every facility that: Is made available to all employees Identifies healthcare worker classifications that have exposure to blood or other potentially infectious material (OPIM) Lists tasks or groups of related tasks that may result in exposure to blood or OPIM OSHA also requires our facility to provide employee protection measures that include: Adequate signage and labeling of hazards Availability of personal protective equipment Medical surveillance Provision of HBV vaccinations Provision of training Use of engineering controls and work practice controls The exposure control plan must also contain information regarding how this facility will: Implement standard precautions Provide the hepatitis B vaccination to healthcare workers Student are required to be vaccinated as part of the School/University Affiliation Agreement prior to clinical rotation Conduct post exposure evaluation and follow-up Communicate hazards to employees Maintain records of all of the above issues You are responsible for understanding the risk of exposure to blood or other potentially infectious materials at your workplace. When working with blood or body fluids Avoid splashing, spraying, spattering, and generating of droplets. Do not use your mouth to pipette or suction fluids. Use universal precautions or standard precautions as appropriate. Universal precautions treat all blood and other potentially infectious materials as if they were known to be infected with blood-borne diseases. Universal precautions protect the healthcare worker from blood-borne diseases and includes: Use of gloves, masks, eye protection, face shields and gowns as appropriate if exposure is possible. Use of engineering controls and work practice controls to limit exposure. 4 Feb 2014 tmm

48 Munroe Regional Medical Center uses the practice of standard precautions. Standard precautions include universal precautions as well as additional measures to protect patients and healthcare workers from disease-causing germs.. The intent of i is to protect the healthcare worker from blood-borne diseases. The intent of is to protect the healthcare worker and all patients from any disease-causing germs. precautions includes the use of personal protective equipment (PPE) when there is a risk of coming into contact with blood, body fluid, secretions, excretions (except sweat), non-intact skin, or mucous membranes. include: Gloves Masks Eye protection Gowns Face shields To minimize the risk of exposure to bloodborne pathogens, health care workers should know and follow the procedures established in their facility. PPE Using proper PPE These procedures include Maintaining proper hand hygiene Cleaning up spills properly Obeying engineering and work practice controls Working correctly with medical devices Place regulated waste in a receptacle that exhibits a. Regulated waste includes: Any solid or liquid waste presenting a threat of infection to humans Bloods Body fluids Contaminated sharps Laboratory or veterinary waste Other potentially infectious material Place regulated waste in a receptacle that exhibits a biohazard symbol. Regulated waste include: Supply packaging Pizza boxes Gauze not visibly soiled with blood or other potentially infectious material Soiled baby diapers without visible blood. Twist the top of the bag 5 Feb 2014 tmm. Wrap a piece of transpore tape around the twist

49 . Make a gooseneck in the portion of the bag from the top of the bag to the taped area around the twist. Wrap this off with transpore tape It is important to dispose of sharps in proper sharps containers. attempt to: Bend or break needles Recap needles Remove needles from sharps containers consider: Anything capable of puncturing, lacerating, or otherwise penetrating the skin as a sharp Dispose of sharps. Storage of biomedical waste shall not exceed. The period shall commence when the first non sharp item of biomedical waste is placed into a red bag or sharps container, or when a sharps container containing only sharps is sealed. *Do not place non-sharp items (i.e., alcohol wipes) in the sharps container. This creates the need to date the container to assure it is not stored greater than 30 days. Consider all linen as potentially infectious and place in yellow bags. Minimize your risk of exposure to blood or body fluid spills. Take the following actions as quickly and effectively as possible: Wear appropriate personal protective equipment Contain the spill Clean up and remove spill Properly discard all cleaning materials Disinfect the area In work areas where exposure is likely, : Apply cosmetics, lip balm, or contact lenses Eat, drink, or put objects in your mouth Practice good housekeeping by observing established practices, schedules, and procedures for cleaning and disinfecting work areas. Follow recommended practices for handling contaminated clothing and laundry. Bag soiled linens (including isolation linens) in approved bags. Double-bag laundry if the outside of the first bag is visibly soiled. Use proper containers for regulated waste. Healthcare workers suffer nearly 600, ,000 injuries annually with contaminated sharps. Use safety devices to eliminate or reduce risk of exposure to blood-borne pathogens: 6 Feb 2014 tmm Sharps disposal containers Self-sheathing needles Sharps with engineered sharps injury protections, such as needle-less systems

50 . Choose medical devices that: Do not jeopardize employee, students or patient safety. Make an exposure incident with a contaminated sharp less likely to occur. When you have contact with blood or other potentially infectious materials, clean the area: Flush with a large amount of water. Flush eyes with clean water, saline or sterile irrigants. Wash needlestick or sharps injuries with soap and water. Report the exposure incident to Workforce Development Coordinator immediately. Document routes, circumstances, and source of exposure in the emergency management system. Go to Emergency Department as soon as possible. The consists of four steps: Test the patient, who is the source, if they give permission. If they refuse, blood that is available in the lab may be tested without consent. Offer the exposed person baseline testing. Offer the exposed person treatment as needed. Offer counseling. The exposure and results of the follow-up is confidential and required to be kept in a separate medical record (employee health). The exposed person is notified of test results; the patient's identity is protected. Blood Borne Pathogens Best Practices Understand the protection provided to workers under this facility s exposure control plan. Know the risks in your work area. Properly dispose of regulated waste. If procedures change, updated trining will be provided. Use appropriate PPE. Receive the HBV vaccination series when it is offered. Use universal precautions and standard precautions as appropriate. Contact your supervisor immediately if you are exposed to blood or OPIM. For more information about blood borne pathogens, contact your supervisor. Joint Commission on Accreditation of Healthcare Organizations.. Oakbrook Terrace, Illinois 29 CFR CFR Florida Administrative Code Chapter 64E Exposure to Blood, What Healthcare Personnel Need to Know. CDC, Division of Healthcare Quality Promotion and Division of Viral Hepatitis. Updated 7/2003. Retrieved 7/28/08. Vaccine Information. 11/6/09. 7 Feb 2014 tmm

51 a. You should apply cosmetics, lips balm, or contact lenses b. You should not eat, drink or put object in your mouth c. There are no special consideration a. the number and strength of the germs b. your resistance to disease c. the germ having an entrance into your body d. all of the above a. True b. False a. HIV is similar to hepatitis B b. HIV is not a viral infection of the immune system c. HIV gradually robs a person of the ability to fight off other disease causing germs d. All of the above statements are true of HIV a. True b. False a. Wearing gloves replaces hand washing b. It is acceptable to go from patient to patient wearing the same pair of gloves c. You should protect yourself by practicing personal hygiene and washing your hands frequently d. I don t need to wash my hands as long as I don t touch the patient a. True b. False a. True b. False a. feet c. heart b. liver d. all of the listed 8 Feb 2014 tmm a. Wash exposed skin with soap and water b. Report the exposure to Workforce Development Coordinator c. Go to the Emergency Department for evaluation d. All of the above a. IV drug users cannot contract a bloodborne pathogen from sharing needles b. A bloodborne pathogen can be contracted from sexual contact c. An unborn baby cannot contract a bloodborne pathogen from its mother. d. All of the above statements are true of bloodborne pathogens a. Immune System c. Liver b. Kidneys d. Lungs

52 Approximately 27 years after the disease made it s first appearance, AIDS continues to pose a significant threat to public health. Overall, the number of people living with HIV is estimated to be 42 million through the year More than 1 million people are living with HIV in the United States. There is an estimated 56,300 Americans becoming infected with HIV each year. An estimated 49,273 Americans will be diagnosed with HIV infection in One in five of those people living with HIV is unaware of their infection. More than 18,000 people with AIDS still die each year in the US. This charts shows how adults and adolescents (aged 13 and over) living with AIDS most likely became infected with HIV. Just over 75% of adults and adolescents living with AIDS are men. Human Immunodeficiency Virus: The virus identified as the cause of AIDS : blood, blood products, lymph, semen, vaginal secretions, cerebrospinal, synovial, pleural, peritoneal, pericardial and amniotic fluids. Acquired Immunodeficiency Syndrome a disease of the immune system, caused by HIV, that is indicated by a set of symptoms that when combined with lab studies, meet the Center for Disease Controls case definition. AIDS develops after the HIV gradually lowers the body s defense, allowing an opportunistic infection to occur. Blood borne Pathogens: Germs that are contained in blood and body fluids Other Potentially Infected Material: Fluids or contaminated items that may contain bloodborne pathogens : Viruses, parasites, fungal and bacterial germs that usually don t cause any problems when you have a healthy immune system - First reported cases in United States were in homosexual white males in California and New York - Disease became known as AIDS United States and foreign health officials called the virus Human T-cell Lymphotrophic Virus III (HTLV-III) and Lymphadenopathy Associated Virus (LAV) - Antibody blood test available to screen and prevent transfusions - Scientists agreed on name for virus, (HIV) - Blood donors screened/tested to prevent further spread of the virus through transfusion 100,000 cases of AIDS reported in US Second 100,000 cases reported in US Cases peaked with the expansion of the case definition Dramatic drop in cases and deaths due to the use of antiretroviral therapy tmm 1

53 Origin of Aids Genetic research indicates that HIV originated in west-central Africa during the early twentieth century. AIDS was first recognized by the Centers for Disease Control and Prevention (CDC) in In the early 1980 s, AIDS was just beginning to appear around the world, probably due to Jet airplane travel Sexual revolution Multiple sexual partners Effective care for most sexually transmitted diseases (syphilis, gonnorhea) It takes several weeks for the body to mount an antibody response to a level that can be detected by the antibody tests. During this time, a person may actually be infected with HIV, but test negative. This period is known as the window or seroconversion period. Most HIV tests are antibody tests that measure the antibodies your body makes against HIV. When the initial test is positive, it must be confirmed with a follow-up confirmatory test before a final diagnosis of infection can be made. In most cases blood is used for the initial test but they can use other body fluids to look for antibodies to HIV. There are also rapid tests that produce very quick results, in approximately 20 minutes. is a group of health problems caused by the HIV. Being HIV positive or having HIV disease, is not the same as having AIDS. Acute Infection Clinical Latency AIDS After exposure to the HIV, it takes several weeks for the boyd to mount an antibody response. At that time many individuals develop a flu like illness. Symptoms occure in 40-90% of the cases and most commonly include fever, large tender lymph nodes, throat inflammation, rash, headache and/or sores of the mouth and genitals. the initial symptoms are followed by a stage called clinical latency. Without treatment, this second stage can last from about three to over 20 years. The average time from infection with HIV until major opportunistic infections and conditions begin is 10 years. The person has few or no symptoms at first, but near the end of this state start to exhibit fever, weight loss, gastrointestinal problems and muscle pains. During this early time you may not know you are infected, HIV disease becomes AIDS when your immune system is seriously damages. The individual begins to develop infections caused by bacteria, viruses, fungi and parasites that are normally controlled by the innume system. These are called opportunistic infections. HIV/AIDS is diagnosed through a blood test that measures the amount of CD4 cells you have and then staged based on the presence of certain signs or symptoms tmm 2

54 Most people infected with HIV develop specific antibodies within three to twelve weeks of the initial infection. While early testing is important if it is too close to the initial exposure, the results could be negative because of the delay in developing these antibodies. HIV antibody testing has been available since March The original intent of the HIV antibody blood test was to screen the nation s supply of donated blood. Now, an individual may be tested at any Florida county health department for a nominal fee or free of charge. Testing may be conducted anonymously or confidentially. Anonymous testing ensures that no identifying information about the patient is connected to the test results. Confidential testing links the name with the results. There are also rapid tests that produce very quick results, in apx. 20 minutes. The Centers for Disease Control now recommends routine HIV testing for patients age years during healthcare visits. In a study of 1,784 people who progressed to AIDS within 1 year of their initial diagnosis, 73% had visited a healthcare facility in the previous 8 years, but had not received a diagnosis of HIV. Many people who are HIV Positive do not get sick for many years. As HIV disease continues, it slowly wears down the immune system. Some people who are HIVB positive stay healthy for ten years or longer. The average time from infection with HIV until major opportunistic infections and conditions begin is 10 years. HIV is not spread easily. You can only get infected with HIV through infected blood or sexual fluids that have entered into your body. You can t get AIDS from mosquito bites, coughing or sneezing, sharing household items or swimming in a pool. Sexual Contact Sharing of contaminated needles and/or sharps Transfusion of Contaminated Blood or Blood Products From Infected Mom s to their infants Exposure to infected body fluids such as blood, semen, and vaginal secretions If HIV infected blood or sexual fluid gets inside your body, you can get infected. This can happen through an open sore or wound, during sexual activity or if you share equipment to inject drugs HIV can also be spread from a mother to her child during pregnancy or delivery. This is called vertical transmission A baby can also be infected by drinking infected breast milk. Adults exposed to breast milk of an HIV-infected woman may also be exposed to HIV. Encourage high-risk pregnant women of unknown status to be tested for HIV. Provide continued oversight to HIV-exposed newborns. The single best means of prevention is abstinence from sexual contact and drug use. You can reduce the risk of infection with HIV and other sexually transmitted disease by using barriers like condoms. If you use drugs, do not share equipment. If you are HIV-infected and pregnant, talk with your doctor about taking HIV drugs. If you are an HIV-infected woman, don t breast feed any baby. Protect cuts, open sores, and your eyes and mouth from contact with blood or body fluids tmm 3

55 Maintain Standard Precaution Designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection. Maintain Standard Precautions o Apply to Body Fluids Body Secretions (except sweat) Body excretions Non-intact skin Mucous membranes o Use Personal Protective Equipment o Utilize safety engineered equipment (i.e. needle-less system) o Report exposures immediately Most exposures to health care workers occur through: Needlesticks or puncture wounds from sharp objects Splashes on non-intact skin and/or mucous membranes Utilizing safety devices improperly. Using needleless systems and personal protective equipment (such as masks, gloves, face shields and gowns) properly is critical for effective prevention of work related transmission In 1988, the Florida Omnibus AIDS Act passed and the Florida Department of Health was given rule-making authority. Legal issues regarding HIV/AIDS have continued to be introduced in the Florida legislature. Confirmation of HIV results HIV results must be confirmed before they can be given to a patient. MRMC referral lab does that before the results are reported back to the area. MRMC s hospital attorney has stated that it is a physician s responsibility to do HIV counseling when performing and HIV test. Booklets are available on the Patient Care units to assist with the basic information Pre and Post test Counseling Should include medical indications for the test, the possibility of positive of false negative results, the potential need for confirmatory testing, the consequences of a positive test, and the need to eliminate behavior to minimize the risk of disease to others. Florida law requires face-to-face post testing counseling of the test results that include the possibility of additional testing, the consequences of positive results, and the need to eliminate behavior, which might cause disease to others. Informed Consent No one may order a test designed to identify the HIV or its antigen or antibody, without first obtaining the informed consent of the person on whom the test is being performed. Right to Know Confidentiality The identity of the test subject and test results shall be confidential. The test results can only be disclosed to the test subject, unless written authorization has been obtained Reporting of HIV results Positive test results are reported to the local county health department Noncompliant carriers tmm 4

56 HIV/AIDS infected individuals may not have sex or share needles with others without informing them of their HIV status Blood Banks All donated blood and human tissues are to be tested Education Professionals licensed in Florida are required to have HIV/AIDS education. Individuals who work in licensed facilities are required to have HIV/AIDS education Insurance Cannot cancel an existing policy or refuse to renew a policy due to HIV/AIDS. Cannot exclude or limit coverage for HIV/AIDS differently than what is common practice for other health conditions Hospital Cannot require an HIV test as a condition for admission Florida law allows for testing a source patient under the following circumstances: A Health Care Worker (HCW) had a documented exposure that meets the CDC definition of a significant exposure The HCW was seen by their Employee Health Provider And agreed to be tested themselves The source patient was given informed consent and agreed to be tested OR The source patient refuses to be tested, but blood was available that had been drawn PRIOR to the exposure The source patient can not be charged for the HIV test, nor can any documentation regarding the testing or the results be on the patient s medical record Infection Control or Employee Health Services can answer any questions on source patient testing The Florida AIDS Health Fraud Task Force is an organization that helps protect Floridians against: AIDS health fraud Deceptive fund raising practice Unethical people Items sold at exorbitant prices Unapproved drugs and therapies marketed as guaranteed preventive or cure for HIV/AIDS Maintaining confidentiality, the department of health may interview all persons infected or suspected of being infected with a sexually transmissible disease for the purpose of investigating the source and spread of disease HIV positive status is part of the patient s medical history and can be relayed to other hands-on health care workers. Be sure to maintain confidentiality at all times. HIV/AIDS continues to affect the more vulnerable people in developing countries where there is limited access to effective therapy. In developing and transitional countries, 9.5 million people are in immediate need of life saving AIDS drugs. Of these only 4 million are receiving the drugs. Treatment of infected pregnant women remains uncommon. Women are at increasing risk of infection. Women are at increasing risk of infection. At the end of 2008, women accounted for nearly 50% of all adults living with HIV worldwide. Young people ages account for nearly half of all new HIV infections worldwide. They are the largest youth generation in history and need regular schooling, and access to health and support services to combat the epidemic. Those most at risk to HIV do not always know how to protect themselves. They also lace access to the means to protect themselves. Levels of knowledge remain low in many countries. Lastly, some people think they are not at risk tmm 5

57 Tackling stigma and discrimination that hamper the effectiveness of AIDS responses and stop people from being tested for HIV and using preventative measures. In just the past year, the AIDS epidemic in Africa has claimed the lives of an estimated 1.5 million people in this region. More than eleven million children have been orphaned by AIDS. Around 2 million children in sub-saharan Africa were living with HIV at the end of They represent more than 85% of all children living with HIV worldwide. If Mom is HIV + without treatment there is a 100% chance that baby will be HIV + at birth; after the first year, 2 out of 3 HIV + babies are now negative for HIV. If Mom takes antiretroviral drugs during pregnancy, the odds of uninfected baby increase to 4 out of 5. When an HIV+ Mom has access to medical care and is compliant taking their meds, prenatal transmission of HIV is now approximately 9% Reduce viral load as much as possible for as long as possible Restore or preserve the immune system Improve the patient s quality of life Reduce sickness and death due to HIV Increase longevity Keep virus from replicating Raise CD4 count are tested before starting or changing medications to provide a reference value helps doctors choose the most effective drug * Efavirend (Sustive) * Laminivudine (Epivir) * Emtricitabine (Emtriva) * Zidovudine (AZT) * Tenofovir (Viread) * Lopinavir/ritonavir (Kaletra) * Abacavir (Ziagen) * Didanosine (Videx) Nucleoside reverse transcriptase inhibitors (NRTI) like AZT, ddl, and ddc Protease Inhibitors (PI) like Saquinavir and Ritonavir Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI) like Efavirinz and Nevirapine Nucleotide Reverse Transcriptase Inhibitors (NTRTI) like Tenofovir tmm 6

58 The use of 3 or more drugs in combination; some antiretroviral drugs are used in combination to minimize viral resistance to any 1 drug T-cell counts should be done every 3 to 6 months to monitor the strength of the immune system. Treatment should involve a multidisciplinary approach: * Social Workers * Nurses * Infection Control Practitioners * Clergy * Physicians * Case Managers The department may establish AIDS patient care networks in each region of the state where the number of cases of AIDS and HIV infections justifies the network. The AIDS epidemic remains extremely dynamic, growing and changing character as the virus has more opportunities for transmission. Efforts must continue to increase funding for treatment and more importantly education and prevention. Centers for Disease Control, 8/1/2008. Florida Department of Health, World Health Organization, HIV and AIDS in Africa. 09/01/2008. Trends in HIV/AIDS Diagnosis States, /30/2005. AIDS: Still Growing, 24 Years Later. Health Politics, Dr.Mike Magee. 12/20/ Report on the global AIDS epidemic: Executive Summary. 12/20/ Antiretroviral Therapy Guidelines. Stopping the Spread of HIV. 12/15/ Florida Statutes. Surveillance report from CDC, Vol and Florida Department of Health, Bureau of HIV/AIDS. 12/31/2004. Worldwide AIDS and HIV statistics including deaths. 12/8/2006. MMWR. Missed opportunities for earlier diagnosis of HIV infections, South Carolina Vol. 55, NoMM 47: tmm 7

59 Test Questions 1. In what year was the first case of AIDS reported in the U.S.? a b c d What was the original purpose of the HIV antibody test? a. To screen the nation s blood supply b. So individuals could check HIV status c. So doctors could diagnose individuals d. For research purposes only 3. HIV is transmitted from human to human by: a. Sexual contact b. Blood to blood contact c. Insect bites d. Both A and B above 4. An infected woman can transmit HIV to her unborn or newborn baby: a. Through breastfeeding b. During the birth process c. During pregnancy d. All of the above 5. The average time from infection with HIV until major opportunistic infections and conditions begin is: a. Two years b. Six months c. Seven years d. Ten years 6. Which of the following is not considered a body fluid that transmits HIV? a. Blood b. Semen c. Saliva d. Vaginal 7. The single best means of prevention from becoming infected with HIV is: a. To only have sex with someone you know b. Wash your hands before and after any sexual contact c. Abstaining from any sexual contact or drug use d. To use a condom always 8. In general, when a person wants to be tested for HIV antibodies, what must be obtained from them by the agency doing the testing? a. Ten dollars b. Informed consent c. Demographics information d. Proof of age 9. Components of Florida Law include: a. Confidentiality b. Informed Consent c. Insurance d. All of the above 10. AIDS is curable. a. True b. False 11. Treatment Goals include: a. Raising CD4 count b. Eliminating the virus c. Increasing viral load d. Eliminate death due to HIV 12. The cornerstone of treatment is therapy. a. Antibiotics b. Antifungal c. Antiemetics d. Antiretroviral 13. Common antiretroviral drugs include: a. Ethambutol b. AZT c. Tenormin d. Effudex 14. Highly Actice Antiretriviral Therapy uses: a. 3 or more drugs in combination b. 1 drug for maximum resistance c. 3 of the newest drugs on the market d. none of the above Feb 2014 tmm

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61 We are committed to a standard form of communication to help reduce anxiety, build trust and instill clinical compliance with our patients and guests AIDET is an acronym that stands for cknowledge, ntroduce, uration, xplain and hank. This simple communication technique allows anyone to connect with a patient or customer to let him or her know they are in very good hands Using helps decrease anxiety, increase compliance and engage the patient in their care process to improve quality and safety outcomes. helps us understand the importance of communicating effectively with patients. When we work in an environment, we sometimes take for granted both language and the situations that occur and forget how unfamiliar and frightening they may be to patients and families. A patient s anxiety rises when they do not know what s happening or who you are. AIDET is our framework to apply the five fundamentals of patient communication. If done effectively, AIDET will help make our jobs easier since it is easier to take care of a calm patient rather than one who is nervous and tense. ALL employees / students are required to perform which should be practiced daily with ALL patients, guests, and customers. This is the first opportunity to make a connection with your patient. Make eye contact, smile when greeting them. In the hallways say good morning, afternoon, evening Tell the patient your name, title and credentials, so they know who will be caring for them. This is how you manage up yourself by talking about your title and credentials, experience and certifications, as well as coworkers and other departments. Manage up co-workers, physicians etc. How long will the wait /test/ procedure/visit take? How long until the results are available? How long before the doctor comes in? How long before you will come in again? The explanation is the quality piece the important part, because it connects back to clinical quality and patient safety. Procedure; Next steps, etc. The point of a thank you is to show care and compassion for patients and their families who may be dealing with difficult situations when the patient goes home. Thank the patient /guest for choosing our facility.

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68 (Revised February 2014) Culture is the behaviors and beliefs characteristic of a particular social, ethnic, or age group. There are three attributes that contribute to a good safety culture: 1. Personal attitudes. 2. Work habits. 3. The style of organization. A good safety culture requires that the hospital ensures safety issue identification, resolution and safe work habits. This is the overriding priority of everything that takes place within our healthcare system. Munroe promotes both effective communication and collaboration among associates. Effective communication can reduce errors, mistakes, and miscommunications. Three elements to effective team member communication Willingness to talk and share information and effectively presenting your point of view Active Listening Confirmation of message Collaboration in health care is defined as health care professionals assuming complementary roles and cooperatively working together, sharing responsibility for problem-solving and making decisions to formulate and carry out plans for the provision of direct patient care or plans that support this process. Creating opportunities for different groups to get together is a highly effective strategy for enhancing collaboration and communication. Munroe fosters collaboration in many different ways: * Open dialogue * Collaborative rounds * Pre-op and post-op team briefings * Interdisciplinary committees The hospital expects that the attitudes and actions of all individuals from top management to the newest hired associate will ensure that safety issues receive attention warranted by their significance. In other words,

69 A safety committee is in place at Munroe Regional and its purpose is to identify and resolve safety and health dangers. The majority of the members on this committee are associates who work in many different areas of the hospital. Membership is open yearly and all associates are encouraged to be involved. Everyone has different job duties and safety concerns related to their area of work. It is important to be aware of risks that may include the potential for: Chemical Exposure Heat Exposure Harmful Vapors Moving Machinery Electrical Danger Repetitive Motion Radiation Exposure Excessive Noise Biohazard exposure Falls Eye injury Back injury Review your job-specific guidelines when choosing the personal protective equipment that will help keep you!!! All hallways and entrances at Munroe Regional require that an egress be maintained. At no time should stretchers, beds, computers, or containers be stored in the hallways or near doorways. These items can cause tripping hazards for staff, patients, and visitors; and may hinder evacuation procedures during an emergency. Dressing for success is part of maintaining fall safety. This includes wearing proper shoes that have good traction. Non-slip soles are recommended and should follow your department s dress code guidelines. Be alert for un-buffed wax in hallways. Secure and report spills or other tripping hazards immediately to environmental services (ext. 6363) or a supervisor. There are 3 elements in every fire: If one element is missing or taken away, there can be no fire. Building codes require that be placed to separate buildings into. Each stairwell is a separate smoke compartment. Patient rooms are stationed within smoke compartments. The door to a patient room,when closed, protects from smoke and fire for about 20 minutes. Area shutoff valves for oxygen lines are provided in patient areas. Do not use elevators during a situation. No objects may be stored within 18 inches of ceilings with overhead sprinklers.

70 Fire drills are conducted regularly at this facility, as part of the fire response plan. Drills occur on all shifts in all buildings so that all employees know their duties if there is a fire. Sometimes a fire drill is planned at a specific time. Other times, a fire drill is unannounced. During fire drills, make sure you know the role you have been assigned by your department. Never ignore a fire alarm or warning signal. After a fire drill or an evacuation drill, everyone s response to the fire drill is reviewed and evaluated so improvements can be made in future drills or in the case of an actual fire. In the event of a fire, remember to escue Rescue persons from immediate danger larm- Pull Fire alarm box or call ontain Fire Close doors and windows in fire area xtinguish /vacuate - Use ABC extinguishers, while maintaining a route of escape Fires are classified by the type of fuel that causes the fire: Class fires involve normal combustibles, such as wood and paper. Class fires are related to flammable liquids and gases that easily catch on fire, such as gasoline, grease, or oil. Class fires are caused by electrical energy overload or breakdown of some kind. Such fires can occur in electrical wiring outlets, or cords. They can also occur with the malfunction of medical equipment, computers, or appliances. Class fires involve combustible metals (such as magnesium); these fires tend to occur in laboratories or chemical plants. Operation of Extinguishers Remember ull the pin. im at the base of the flame. queeze the handle. weep from side to side. When working with electrical equipment, it is necessary to be aware of: How the the equipment operates. Problems noted while using the machine. Proper reporting to Bio-med or facilities when equipment is broken. What tagging out procedures mean. How to prevent damage to electrical machines. Improper use of electrical equipment is dangerous and can be fatal to you or a co-worker!

71 Read your manual. Attend in-services on new or unfamiliar equipment. Request new in-services about rarely used equipment. ASK QUESTIONS if you are unsure. NEVER remove safety parts to make the operation of the machine easier. Look for broken cords or missing outlet prongs. Be aware of strange or burning odors coming from equipment. Do not make repairs on equipment unless you are qualified to do so! Remove all sources of liquids from nearby, water and electricity don t mix. For broken equipment/machines complete the medical center s work order form immediately. Notify your supervisor and the facility department (ext. 2111) of the equipment s location. Facility engineers must safely work on equipment with its energy turned off. To prevent others from turning the energy source on, or procedures are used. An engineer will apply a tag, warning others not to operate or turn on the equipment. The tag is signed by the engineer who is working on the device. It may only be removed by that engineer. In the event of a power outage: Backup generator power will be supplied via red electrical outlets and emergency lighting. Patient care personnel should immediately inspect life supporting machines (ventilators) to insure their continued operation. Assure patients and keep them informed of available information. Patients that require additional measures to maintain comfort (fans) should be addressed with your supervisor. X-rays, particles emitted by atoms cause ionization.. Ionization can cause molecular changes in human tissue. Ionizing radiation is found everywhere (cosmic sources). Everyone has some level of exposure to radiation. Individuals working around a radiation source receive added radiation called an occupational dose. The upper limit for radiation exposure to an embryo or fetus is 500 for the entire pregnancy or 50 mrems per month during pregnancy. A is one who has informed her supervisor that she is pregnant and has provided an estimated date of conception or delivery. Check with your supervisor for radiation safety procedures for patients or staff who may be pregnant. The major goal of the radiation protection program is to keep doses: s ow s easonably chievable.

72 Sources of ionizing radiation at Munroe Regional Medical Center include: X-ray units when turned on. Radioactive drugs. Radioactive implants. Working with ionizing radiation in healthcare is not a health hazard if. General safety measures in radiation protection involve: Time Distance Shielding Munroe Regional Medical Center is committed to keeping radiation exposure. Health care employees who work in close proximity to radiation (e.g., x-ray technologists) wear personal radiation-monitoring devices known as dosimeters. Dosimeters normally work for 1 month. When the used radiation-monitoring device is exchanged for a new one, the old one is processed. The occupational dose measured for that time period becomes part of the employee s personal health record. For additional guidelines on radiation protection, contact your supervisor. Magnetic resonance imaging () equipment is an important diagnostic tool. The MRI is not a source of radiation but can be hazardous to staff or patients. The following special precautions should be followed: Do not take anything into the room that is ; Because the equipment uses a highly magnetic field to work, anything attracted to a magnet will be pulled into the unit, which could cause life-threatening effects to anyone in the room. The MRI magnet is, whether or not the equipment is in use. Use a hand magnet to test any metal objects that may be magnetic. Do not go into the room if you have a Always check with the MRI technician before entering the room if there is a possibility of any metallic object in your body. In case of an accident, only the MRI technicians or facility engineers can the equipment., our MRI machine is located on-site in our mobile unit by the Emergency Department. If you have a patient that requires an MRI, please remember the following: Fill out the MRI Patient Screening Questionnaire completely your patient s life could depend on it. Hold all IV continuous drips, if reasonable. Blood products and IV nitroglycerin cannot be used in MRI-compatible pumps or tubing. You must never enter the shielded MRI room, unless directed by the radiology nurse or MRI tech. Absolute Contraindications for MRI procedures include: Cardiac Pacemakers Cardiac Valve Prosthesis Cerebral Aneurysm Clips Pregnancy Middle Ear Prosthesis or Cochlear Implants Implanted neuro-stimulator or bio-stimulator

73 In summary, it is an internationally developed system of classifying and labeling chemicals. Revising the standard practice of labeling chemicals, will improve worker understanding of the hazards associated with the chemicals in the workplace. Due to regulatory changes, on or before June 1, 2015: Material Safety Data Sheets (MSDS) will become Safety Data Sheets (SDS) SDS will serve the same purpose s MSDS SDS will be in a uniform format and easier to read Labels on hazardous chemicals will be standardized Hazard statements (what is the hazard?) Precautionary statements will be listed. (what should you do to protect yourself from the hazard?) New Labels The product identifier A signal word A standardized pictogram A hazard statement A precautionary statement A name, address, and phone number of the manufacturer, distributor, or importer Product identifiers are how hazardous chemicals are identified. This may be by the chemical name, special code numbers, or batch numbers. It is up to the manufacturer to choose the appropriate identifier. (it must also appear in the same name on the SDS safety date sheet) Only 2 signal words will be used to indicate the relative severity of a potential hazard to the product. The word DANGER is used for more severe hazards that could likely cause the need for medical attention. The word WARNING is used for less severe hazards. Only one signal word (most severe) will appear if multiple hazards can occur. It is up to the manufacturer to choose the appropriate identifier. (it must also appear in the same name on the SDS safety date sheet)

74 OSHA s required pictograms must be in the shape of square set at a point and include a black hazard symbol on a white background with a red frame. Multiple pictograms may appear representing any and all potential hazards of the chemical. Product identifiers are how hazardous chemicals are identified. This may be by the chemical name, special code numbers, or batch numbers. It is up to the manufacturer to choose the appropriate identifier. (it must also appear in the same name on the SDS safety date sheet) Health Hazard chemicals pose a risk to your health if used improperly. These risks include: 1. Causing cancer 2. Causing mutations 3. Reproductive health problems 4. Lung damage 5. Liver and kidney damage 6. Choking Skull and Crossbones pictograms will usually be used in combination with a health hazard pictogram to signify particularly hazardous chemicals. Chemicals with Acute Toxicity (fatal or toxic) are chemicals that will produce adverse effects following a single dose of the substance. These effects are more serious than the Acute Toxicity (harmful) listed under the Exclamation Point pictogram. The Exclamation Mark pictogram will usually be used in combinations with a Health Hazard pictogram to signify particular health risks which are less severe than the Skull and Crossbones category. The Flame pictogram indicates there is a fire risk, and you should be especially concerned about ignition sources and combustible materials.

75 Chemicals labeled with a Flame Over circle can create an increased fire risk in your work or storage environment. Oxidizers are chemicals that produce additional oxygen in an environment which may cause to contribute to the combustion of other materials. The Corrosion label should prompt you to be especially aware of PPE (personal protective equipment) and storage requirements. The Gas Cylinder pictogram alerts you to the physical hazards inherent in the use and storage of compressed gas. Hazard statements describe the nature of the hazards, including the degree of the hazard, when appropriate. Chemicals marked with an Exploding Bomb pose a significant physical risk and should be treated with extreme caution. The Environment pictogram is a nonmandatory category for safety training because it is regulated by other agencies but is included here for your information Precautionary statements describe recommendations that should be taken to minimize exposure or to prevent adverse effects resulting from an exposure to the chemical. The name of the chemical manufacturer, distributor, or importer, must be present. Also included, should be the address and phone number of the company that is named. This will allow anyone with questions regarding the chemical, to access the company directly.

76 XYZ Chemical, 234 E. 3 rd St., Murray KY,

77 maintains a current, online inventory and keeps (. Y ou may access these records at any time, through the Munroe Bulletin Board - under Quick Links. Staff is responsible to be familiar with hazardous chemicals used in their work area and proper protective measures for use. OLD NEW New format of SDS MSDS ( Material Safety Data Sheets SDS (Safety Data Sheets) The Safety Data Sheet provides staff with the most complete information about the substance you may potentially have exposure to. Safety Data Sheets (SDS) Safety Data Sheets may be found on the Munroe Bulletin Board for review. Always refer any additional questions to your supervisor prior to working with any chemical.

78 SDS Format Identification Hazard(s) identification Composition/information on ingredients First-aid measures Fire-fighting measures Accidental release measures Handling & storage Exposure control/personal protection Physical & chemical properties Stability & reactivity Toxicological information Ecological information Disposal consideration Transport information Regulatory information Other information The Joint Commission may survey Munroe Regional Medical Center at anytime, with no prior notice. The purpose of the survey is to evaluate Munroe s compliance with nationally established Joint Commission standards. The survey results will be used to determine whether, and the conditions under which, accreditation should be awarded the organization Any associate who has concerns about the safety or quality of care provided in the hospital may report these concerns to the Joint Commission. Associates may contact the Joint Commission s Office of Quality Monitoring to report any concerns by either calling or ing In the event of a safety issue or emergency, remember: Unusual Activity / Behavior Hazardous weather conditions Things out of place Unexplained liquids Strange smells Abnormal fogs or mists Suspicious Packages The 4 Don ts Don t become a victim Don t rush in Don t assume anything Don t TEST (Taste, Eat, Smell, Touch) Keep others away from hazard area!! Immediate Supervisor Hospital Emergency Phone Number

79 The MRMC Safety Hotline can be accessed twenty-four (24) hours a day, seven (7) days a week by dialing OUCH (6824) in-house or ext 6824 (OUCH) from outside the Munroe campus. When calling the MRMC Safety Hotline, leave a message stating the safety issue, where it occurred, and what measures (if any) have been taken to correct the issue. Providing your name and phone number is not required. A response will be provided. Messages left Sunday through Thursday will be retrieved within twenty-four (24) hours. Messages left Friday or Saturday will be retrieved on Monday. When retrieved, the message will be reviewed by the MRMC Safety Officer and notification will be made of the action taken (if a name and phone number was provided). The MRMC Hotline is NOT to be used for emergency or injury reporting. In such instances, Associates should immediately notify their Manager, House Supervisor or Security, or in case of injury, follow the established policies for Incident and Associate Injury reporting. In the event of an injury or safety/ quality concern, use the Munroe Event Management System, to document the event. has policies and procedures in place for the disposal of hazardous waste. It is the associate s responsibility to be familiar with the materials that they use, and the requirements for proper disposal. Refer to MSDS documentation online or a supervisor if you have any questions about the proper procedure for discarding materials that could be considered hazardous. For example, used alkaline batteries should be separated from regular trash and stored for removal by environmental services. Munroe Regional has security officers on duty at all times. The main security office is located on the 1st floor across from the print center. For you may dial from any in-house phone. For, please dial. Functions of security staff include: Investigating and recording incidents, thefts, disturbances, vandalism, accidents, and traffic accidents. Monitor parking and traffic of associates and visitors. Protecting staff, patients, visitors, and property. (firearms, clubs, and knives with long blades) may be carried on facility property except by on-duty, licensed law-enforcement officers. Failure to follow policy is grounds for immediate termination. is brought in as a patient, notify a security officer and cooperate with the prison guard when providing treatment or other services. These individuals are considered forensic staff, and will need direction during emergency procedures. On November 19, 2009, Munroe Regional and Ocala Regional Medical Centers became Tobacco-Free campuses. Associates, patients, and visitors are not permitted to smoke or use any tobacco containing products on Munroe Regional property. This includes, but not limited to the parking garage, parking lots and sidewalks. Please remind anyone found using tobacco products that Munroe Regional is Tobacco-Free. Munroe frequently offers associates a smoking cessation program for assistance with quitting. Gum and other smoking cessation products are available for purchase in the gift shop.

80 Always wear your ID badge at eye level, whenever working or performing clinicals at Munroe Regional. Report suspicious behavior and all individuals without badges, in restricted areas, to security. Keep valuables out of sight when they are in your car. Either lock them in the trunk or place them under the seat of your car. Always try to walk with a group, rather than alone, to your vehicle. After dark, request a security escort to your vehicle if you are alone. Be very aware of your surroundings. Look before you enter and exit your vehicle. If the scene makes you uncomfortable, drive away or leave then notify security. Some common signs seen in victims of abuse may include: Unexplained injuries Fear of leaving the facility suspicion of abuse or neglect must be reported to your supervisor Over-protective family members immediately. An abuse hotline may also be called: Witnessed verbal abuse or threats Fall risk assessment and communication to other staff Frequent monitoring Fall alert designation (yellow bracelets) Patient education on preventing falls at home A fall prevention team at Munroe Regional Medical Center, is constantly reviewing evidence-based practice guidelines that will reduce the incidence of patient falls. The Joint Commission. (2008) hospital accreditation standards. Oakbrook Terrace, IL: Author, "Guidelines for Employer Compliance to the Hazard Communication Standard." U.S. Department of Labor, Occupational Safety & Health Administration, "Hazard Communication in the 21st Century Workplace." March U.S. Department of Labor, Occupational Safety & Health Administration, "HealthCare Wide Hazards Module, Hazardous Chemicals." Last accessed December 3, The Hospital Core Competency Sub Committee Core Competencies for Disaster Preparedness. O Daniel Michele Rosenstein Alan Professional Communication and Team Collaboration Patient Safety and Quality: An

81 1. is responsible and accountable for safety a. Everyone b. Nobody c. Only the Manager d. Only the Supervisor 2. To properly operate a fire extinguisher, you should remember the initials: a. PASS b. RACE c. SQUIRT d. SWEEP 3. It is acceptable to use elevator during a code red, as long as it is just one floor a. True b. False 4. Machines that are taggedout may only have the tag removed by the engineer that place it. a. True b. False 5. Munroe Regional maintains a current online inventory of MSDS that may be accessed through the bulletin board a. True b. False 6. Used batteries should a. be thrown in the regular trash b. separated from trash for environmental services to pick up c. be placed in sharps containers d. be placed in red bags 7. The main security office is located a. on the 1 st floor of the main building b. on the 6 th floor, north side of the building c. off site, near the lifetime fitness building d. in a trailer behind the parking garage 8. All student MUST wear a their school ID badge at all times while performing clinical at MRMC a. True b. False 9. You may bring a weapon on MRMC property, as long as you have a concealed weapons permit. a. True b. False 10. Emergency generator power is supplied through a. Red Outlets b. Ivory Outlets c. Orange Outlets d. Green Outlets

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83 2014 National Patient Safety Goals The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems in health care safety and how to solve them. Identify patients correctly o Use at least two ways to identify patients. For example, use the patient s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment. Improve the effectiveness among caregivers o Utilize SBAR: Situation the problem Background brief, related, to the point Assessment- what you found, what you think Recommendation what you want Use medications safely o Label all medication containers o Pay close attention to sound alike and look alike medications o Medication Reconciliation: Record and pass along correct information about a patient s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor. Use alarms safely o Make improvements to ensure that alarms on medical equipment are heard and responded to on time. Prevent infections o Wash hands before AND after procedures o Use alcohol based hand cleaner or soap and water o Must wash hands with soap and water if hands are visibly soiled, after contact with a patient with C-diff, after going to bathroom and before handling food or eating. o Wash for a full 15 seconds: i.e., sing the ABC song, or sing Happy Birthday twice. Identify patient safety risks o The hospital identifies safety risks inherent in its patient population. Prevent mistakes in surgery o Make sure that the correct surgery is done on the correct patient and at the correct place.

84 2014 Anyone can access the Munroe Regional Medical Center Bulletin Board from any computer desktop. T A: on the the left side of the Bulletin Board Home Page under the column titled Under tab you will find the following information Emergency Code Cardex Code Blue, Code Triage, Bomb Threat etc. Interdisciplinary Referral Unsafe Abbreviations Look Alike Sound Alike Medication List of High Alert Medications Honoring Patient Preferences Select the home tab on title bar AND Scroll over to the right side under tab you will find the following information MSDS Event Management Systems (EMS) - Report an event/error

85 @ the left side of the Bulletin Board Home Page and the left side of theuntil you reach the title bar named Under site page you can locate the following information: Isolation and Barrier Precautions CDC Isolation Guidelines Instructions for Donning/Removing the left side of the Bulletin Board Home Page and the left side of the until you reach the title bar named Under title bar you will select and the following information will be listed: Clinical Pharmacology- Abbott A+ Pump Interactive (Plum Pump Machine) Mosby Nursing Skills

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