Welcome to Provena!

Agency Orientation

Sisters of Mercy of the Americas, Regional Community of Chicago (Aurora Ministries), Chicago, Illinois

Servants of the Holy Heart of Mary, Holy Family Province, USA, Kankakee, Illinois

Franciscan Sisters of the Sacred Heart, Frankfort, Illinois

Building a Culture of Excellence through our Mission, Vision, Values:

Provena Health Sponsoring Congregations

184318761889

Varied Pasts, Common Present, Shared Future

Mission Statement

Provena Health, A Catholic health system, builds communities of

healing and hope by compassionately responding to

human need in the spirit of Jesus Christ.

Our Values• Respect – We affirm the individuality of each person

through fairness, dignity, and compassion.• Integrity – We demonstrate the courage to speak and

act honestly to build trust.• Stewardship – We use our human and economic

resources responsibly with special concern for the poor and vulnerable.

• Excellence – We achieve exceptional performance through continuous growth and development.

Gospel Emphasis

• Defend Human Dignity• Whole Person – Body-Mind-Spirit• Care for the Poor and Marginalized• Promote the Common Good• Agents for Justice• Stewardship of Resources

Ethical & Religious Directives• Pastoral & Spiritual Responsibility of

Catholic Health Care Services• Professional-Patient Relationship• Issues in Care of the Beginning of Life• Issues in Care for the Dying• Forming New Partnerships with Health

Care Organizations & Providers

The Role of Pastoral Care• We attend to the medical, emotional and spiritual

needs of all patients, families, and you – the staff.• We do daily rounding to all floors and electronic

charting of all visits. • We respond to all codes, traumas, clinical alerts,

and pastoral care pages. • We educate, initiate and complete advance

directive planning.• We provide Catholic sacraments and services.• We advocate for patient rights and ethical concerns

Pastoral Care Documents• Power of Attorney for Healthcare• Living Will• Healthcare Surrogate Act• DNR Form

Provena Mercy Medical CenterSERVICE:

Measures of Excellent Service

1. Patient Satisfaction2. Employee Satisfaction3. Physician Satisfaction

Excellent Service is:Living our Mission every day

Excellent ServiceCreates a Great Place for:

Patients to receive care Physicians to practice

Employees to work

We serve patients/families, physicians, and the community

How do we Serve?

By Consistently Practicing the Standards of Behavior

Standard of Respect

• Definition: Affirms the individuality of each person through fairness, dignity and compassion.– Professionalism: Speaking and acting with

appropriate body language and tone.– Teamwork: Building trust by providing

support, encouragement and gratitude to fellow co-workers.

– Communication: Objectively presenting views, suspending judgment when listening.

Key Words at Key Times When do you use Key Words?

• To address survey questions/key drivers

• Tough Questions• To help the patient or family understand

his/her care – when we need to be consistent

• Five Fundamentals of Service

Key Words/Key Actions at Key Times

What do our patients need to hear to feel safe… “Your doctor is excellent; the radiology teamhas over __ years of experience.”

To feel cared for…“I am here for you…I have time for you…whatcan I do to make you feel better?…”

5 Fundamentals of Service

Acknowledge – Key Words and Key Actions

– Walk a visitor/patient to his/her destination

– Knock, touch curtain– Speak before entering room– Make eye contact– Smile– Stop whatever you are doing so the

customer knows he/she is important

Introduction

• Welcome (standing up when meeting someone shows respect)

• Say your name• Give your department• Tell your role in patient care• Manage up your skills, experience and

training – why is this important?

Duration

• How long before the test begins• How long the test will take once begun• How long before results of the test are

available• What happens with results

Explanation• Test or procedure• Who is involved• If there will be pain or discomfort and

what will be done to ease either• Offer to answer questions, address

concerns• “Is there anything else I can do for you?

I have the time.”

Thank You Key Words and Key Actions

“Thank you for choosing Provena Mercy Medical Center for your healthcare needs.”

“Thank you for your patience, while I ___.”

“Do you have any questions that I can answer for you now?”

Managing the Moment/ Service Recovery

All employees are responsible for identifyingservice recovery opportunities when a

patient/family identifies a “less than bestservice” experience or an employee is aware

of an unhappy patient/family member as adirect result of our service.

On the Road to Excellence…Service Recovery Decision & Gift Guideline

Start with an Apology Determine the

Level of Severity Apologize & Acknowledge

AmendIt is very important to us to provide very good care. I’m so

sorry we did not meet your expectations

Thank you for bringing this situation to our attention. What can

we do to help the situation?

Please accept this gift to further express our

apology. Is there anything else I can do

for you? I have the time.

Again, it is very important to us to provide very good

care.

Level 1-Minor•Food Late•Noise Level•Cleanliness of Room•Utility Problems•Cold Food

Level 2-Moderate•Wait time for schedule services•Roommate issues•Time delay•Communication Problems

Level 3-Serious•Failure to communicate Increased LOS

Level 4-Severe•Fall with Injuries•Medication Errors•Poor Pain Control•Loss of Personal Property•Major Lack of communication•Issues resulting in Litigation

Explain that the problem will be addressed

immediately and ask for any necessary information.

Notify appropriate persons) as necessary to correct

situation

Provide Service Recovery Gift as Appropriate

Level 1-MinorCafé coupons Dining In

$5 or less

Level 2-ModerateCafé Coupons /Gift Shoppe

Coupons

Level 3-SeriousCafé Coupons or Gift Shoppe

Notify Patient Advocate

Level 4-SevereSenior Management Notification

Notify Patient Advocate

Performance Improvement/Follow Up

When an Incident Occurs!

*Providing “AAA” Service*

At Serious Level, notify your manager or director. If they are not available

contact the patient advocate.

Corporate Responsibility:Regulatory Compliance

“Systems that ensure all employees are aware of laws and regulations and act

in accordance of those regulations”

Corporate ResponsibilityWhy is this important to me?

Regulatory compliance programs are put into place to reign in those organizations

that operate outside established laws and guidelines to turn a profit. It has

become vital that healthcare organizations implement compliance

program to prevent compliance violations and reduce the potential for liability

should violations occur.

Compliance GoalProvena Health is committed to compliance with all

federal and state laws and regulations.

The goal of Provena Health’s compliance efforts is to ensure all business is conducted ethically,

honestly and in accordance with all rules, regulations and standards

Office of the Inspector General

• Office of the Inspector General (OIG)• The enforcement arm of the Department of

Health and Human Services.• Primary goal is to investigate suspected

health care fraud and abuse, specifically:Medicare

&Medicaid

RiskA large portion of the OIG regulations focus on

Risk Assessment

At Provena Health our highest risk areas are:• Coding• Billing• Documentation/Charting• Chain of Command issues• Quality of care-Substandard Care• Patient/Resident Privacy (HIPAA)

OIG - RecommendationsDue Diligence Recommendations

• Standards of Business conduct education for all employees

• Senior Oversight of Compliance Programs• Background checks on all employees, vendors, and

volunteers before hire and biannually• Create a culture of awareness and establish reporting

mechanisms• Compliance monitors and audits performed on a regular

basis• Standards and Compliance procedures for all employees

The Provena Health Corporate Responsibility Plan

Provena Health’s Standards of Behavior are based on the Provena Health Values of:

RespectIntegrityStewardshipExcellence

It is the expectation of all Provena Health employees that they act with integrity, honesty, and they approach all customer interactions

ethically and confidentially

The Provena Health Corporate Responsibility Plan

Due Diligence in Hiring:Criminal background checks are performed on all new employees. We additionally check the Excluded Provider list to assure that our employees, medical staff and vendors have not been excluded from participating in any federally funded health care programs.

Employee Awareness and Training:All Provena Health employees are required to participate in annual Corporate Compliance training. All employees are required to receive Corporate Compliance in Orientation.

The Provena Health Corporate Responsibility Plan

Monitors and Audits:At Provena Health, systems are in place to continuously monitor the accuracy of our coding, billing, and documentation. These systems are designed to reasonably detect errors and problems.(CHAN -Catholic Health Audit Network is Provena Health’s internal auditor.)

Discipline:Any violations of corporate compliance is taken seriously and appropriate and consistent disciplinary action is taken for all violations, regardless of title, position, or affiliation.

The Provena Health Corporate Responsibility Plan

Alert-Line:• A confidential and anonymous vehicle to report

compliance issues.• Outsourced to Global Compliance and reporting is free

of retaliation.• Our preference is that you initially follow the standard

chain of command when faced with a compliance issue.Supervisor-->Local Compliance Liaison-->

System Compliance Officer, then to the Alert-Line

1-800-93-ALERT

The Provena Health Corporate Responsibility Plan

• When errors are detected, we take reasonable steps to respond appropriately:– Stop the process, protocol or billing if necessary– Determine the cause of the error– Develop a protocol to prevent future errors– Communicate and implement protocol– Continuously monitor the protocol

False Claim Act

This Act provides a legal tool to counteract fraudulent billing turned into

the Federal Government

Claims under the Act are filed by persons with inside knowledge of the false claim

(“whistle blowing”)

False Claim Act

False claims can occur with documentation issues that turn a legitimate claim into a false claim.

Problem Areas:– No documentation– Incomplete or incorrect documentation– Documenting on delivery of care that you did not

deliver personally or witness being delivered.– Missing signatures– Missing or backdated dates

False Claim ActBilling High Risk Areas:

• Supplies or services not delivered

• Services not medically necessary

• Billing for a non-covered service, as if covered

• Outpatient services that should have

been included as part of an inpatient stay

•Up-coding •Misrepresenting a diagnosis to justify services•Unbundling•Duplicate billing

Your ResponsibilityConflict of Interest:• Arises when anyone has 2 duties that conflict. Staff must not use

their positions for profit or share confidential information for gain.• Staff must disclose personal or family interests if that business:

– Buys/sells goods or services to/from Provena Health– Competes with Provena Health– Is in a position to benefit from patient referrals

Gifts, Honoraria and Gratuities:Staff is not allowed to except tips, money, gifts, or other items of value from patients, vendors, or any private party. Generally, you can only accept gifts of appreciation that can be shared or used for the common good of the ministry.

Your Responsibility

It is the expectation of Provena Health that all employees exhibit the Standards of

Behavior, know what is right, and do what is right.

If you see something that does not look or feel right, contact your supervisor or the Corporate Responsibility Liaison or call

the Alert-Line.

Your Resources• Provena Health Corporate Compliance and

HIPAA Policies can be found on DOVEnet

http://dovenet.provena.org/

• Local ComplianceLiaison

• Alert-Line

Web page photo

HIPAA Standards at Provena Health

• Protect patient rights by giving access to their confidential Health information and control over how this information is used.

• Protect the physical security of resident and patient, confidential health information.

Privacy and Security Standards

Privacy Standards:– ensure that patients have access and control over

how their health information is utilized.– these standards deal with patient expectations of

how we use that information.Security Standards:

Ensure that we keep patient health information, safe and secure. This includes all health information that is stored physically and electronically.

What HIPAA is Not

HIPAA is not a reason to withhold or discuss a patient’s condition with a family member.

“I cannot tell you what is going on with your loved one due to HIPAA”

What should be done is to verify the identity of the caller or visitor and ask verbal permission to share

information with the family member.

HIPAA Privacy

Breeches in Confidentiality• 1 out of every 5 Americans believe that

their health information has been used inappropriately.

• 1 in 6 Americans report that they have provided inaccurate information to a health provider because they feel it would not be kept confidential.

What happens when patients don’t trust us?

Protected Health Information (PHI)

Name, address, city, county, zip code, fingerprints, names of relatives, name of employer, date of birth, telephone number, social security number, fax number, photos, medical record or account numbers, and license number.

Any information that can be used to identify and individual.

Shared in any form, verbal, written, or electronic.

Vital Behaviors to Protect PHI

• Only share information on a need to know basis and accessing and disclosing information as specifically required by your duties.

• When engaging in verbal conversation, keep your voice down, close doors or curtains.

• Never discuss patient information in elevators or other public places (ex. Cafeteria)

• Patient’s charts are stored out of public view.• Reduce all patient information that could be visible to

the general public.

Vital Behaviors to Protect PHI• When announcing a patient overhead, use of

name is OK, however the patient/resident or family member should be referred to a reception desk or other non-specific location.

• When leaving information on answering machines limit information to:– Name of the facility or physician– Time of appointment– If necessary to discuss treatment or procedures,

leave a call back number

PHI – Access & ControlNotice of Privacy Practices:

– It is not the intent of HIPAA to stand in the way of the using information for normal operation: Treatment, Payment or other Health Care Related Operation.

– This document informs our patients how we use and disclose their protected health information.

Authorization Form:– HIPAA Standards state that Patients have a right to view

or obtain a copy of their medical record. This is done through the Authorization form.

Employees/Families as Patients

Sharing is

not caring

Provena Health has a HIPAA Corrective Action Policy. Willful or intentional violations will result in immediate

dismissal.

HIPAA Security Standards

Not only are we responsible for access, control and confidential handling of patient information, we are also responsible for the physical security of that information.

Provena Health Security Measures

• Provena Health takes a 3-pronged approach to protect confidential health information:– Administrative Safeguards – specific policies

and procedures that ensure HIPAA Security is a priority.

– Physical Safeguards – protective software, firewalls and controls.

– Technical Safeguards – encryption, password protection.

Workstation Management

Workstation = any electronic computing device

Not only are you responsible for the content you send and receive, but also

the physical care of that equipment

It is your professional responsibility to maintain and care for these devices.

Workstation ManagementAll devices have password protection:

– You are professionally responsible for your password and must never share it with anyone – for any reason.

Password development:• Make your password at least 6 characters

long.• Include numbers and special characters.• Use upper and lower case characters.

Electronic Applications

Sending PHI Electronically:Before you send PHI, you must get your immediate supervisors approval, approval from the patient and password protect all documents.

Electronic ApplicationsFaxes:• Fax from a machine in a secured area.• Include a cover sheet with the confidentiality

statement.• Double check the phone number:

– Before entering on the key pad– After entering on the key pad

• Pick up documents after sending.• Retrieve confirmation sheet after sending.• Call and make sure another qualified person is there

to retrieve the fax.

Quality Management:Regulatory Bodies

What is the Joint Commission?www.jointcommission.org

Who is CMS?www.medicare.govwww.hospitalcompare.hhs.gov

Who is IDPH?www.idph.il.state.us

Survey Process• Surveyors can present at any time-usually

unannounced• Can come based on complaint• Patients, families, employees can report

concerns to any regulatory body• Code 777 is announced overhead• Tidy up and continue your normal routine• Surveyors will be escorted by Administration• Answer honestly, politely

Public Reporting and whatthat means to me…

• Soon, almost everything we do will be accessible to the public-the good, bad and ugly

• Check out Minnesota Patient Adverse Events• Check out www.FloridaHealthfinder.gov• Public may not know how to

interpret the results on the internet• There is no perfect hospital

Info Available on the Web

• Patient Satisfaction scores• Mortality rates• Adverse events such as suicide, falls, abductions• Core Measures

– Heart failure– Heart attack– Pneumonia– Surgical Care

• Nursing Hours

Performance Improvement (PI)& Measurement

• What is PI?• PI is ongoing, continuous improvement ALL the

time• Can be

– Improving outcomes (no infection, no harm, live birth, no readmission)

– Improving process (wait times, accuracy, efficiency, documentation)

When something goes wrong• We investigate so that we can learn and prevent

reoccurrence-gather the people involved• Identify the ‘root cause’ of the event and analyze it

(Root Cause Analysis-RCA)• RCAs are non-punitive and confidential• What is the goal? TO LEARN• How do RCA’s come about?

– Variance Reporting(Incident Reports): one of the most valuable tools a hospital has for identifying areas where adverse events are occurring or have the potential to occur; DO NOT chart that you have filled out a variance in the patient’s record

Click here to begin Variance Reporting

On the main desktop click on the Internet Explorer

icon

Select the type of variance•Fall Variances and Medication Variances are

patient related.•Other Variances are visitor related or patient related such as delayed testing, left AMA, etc.

Each screen includes the • Main information screen

• The Legend• Help

Follow the onscreen instructions for completing the report.

Patient Safety & Risk Management: Overview

• 1999 IOM Report – Up to 100,000 preventable deaths in U.S. Hospitals per year

• 1.3 million Americans are injured and more die each year from medication errors

• Hidden epidemic of life threatening infections killing tens of thousands of patients each year

Who we are• Hospitals are high hazard organizations (along

with aviation, nuclear power production, chemical manufacturing, military). Why?– Errors that we make lead to death or injury– We deal with ethical, legal, moral issues unlike any

other business or enterprise– Intense scrutiny by the public and regulators

How Do We Ensure Safety?• With proper organization of people,

technology and processes, hospitals can handle complex and hazardous activities at acceptable levels of performance

• Support those who are Caring for the Patient– Decision making migrates to the

person best capable of making it, even if not the highest in rank

What we must doCreate a Culture of Safety

– Encourage error reporting (Variance Reports)• Non-punitive system• No tolerance for avoidance or cover-up• Support any employee involved in a serious error

– A culture of safety is about changing the environment from one of blame, to one where we ask, why did this happen, and what can we do to prevent it from happening again?

Systems Issues as Opposed to People Issues

• Understand that humans make errors, especially when tired, stressed, and they feel unsupported.

• Ask “why” an error occurred, rather than “who” made the error

• Moving past “blame and shame” mentality• Every “incident” or error would be viewed as a

System Problem, not an Individual Problem.

Good Documentation is Key

• Patient charts document the quality of patient care

• Communicate the care of the patient to all caregivers

• Is used by attorneys to determine whether they will file a lawsuit

• Juries rely on the chart as the authoritative account of what transpired

What Are We Doing at PMMC to Create This Culture?

• Blame and shame behaviors are not tolerated• Errors and unanticipated events are viewed

with an eye toward systems issues, not human ones

• Teamwork and communication is emphasized• We encourage the reporting of all adverse

events and near misses

PMMC Safety Initiatives

• Fall prevention program• Education and training of all staff (patient

identification, suicide assessment, communication of critical lab values, etc.)

• Patient and Staff Safety surveys• Restraint Reduction

Patient Rights & Responsibilities

Every patient upon registration, receives a brochure detailing their RIGHTS:– Be free from abuse, neglect, inappropriate

behavior– Be treated with courtesy and respect– Have personal privacy respected– Know the identity and professional status

of individuals providing care

Staff with Concerns about Patient Safety

• Any employee who has concerns about the safety or quality of care provided at PMMC may report these concerns to The Joint Commission.

• There will be NO retaliation or discipline on the part of PMMC for any report made by an employee.

• The Joint Commission may be reached at 630-792-5000.

Safety & Security • 24/7 operation - E.D. & BHS offices• ID Badges• Access control• Suspicious persons/circumstances• Valuables, lost & found, patient meds• Escort employees to vehicles• Vehicle assistance – lock outs, jump starts

Who is Responsible for Safety?

All of us. Be aware of your surroundings, notify Security of

suspicious or dangerous persons or circumstances.

Dial 1111.

Id Badges• Worn at all times while on duty• Worn above waist • Unobstructed w/name & photo clearly visible• No pins, stickers, etc. on badge• Used for Kronos time clock & door access • Wear your Agency badge and we will give

you a PMMC contractor badge when you sign in

Code Red = Fire• R.A.C.E. = Rescue Alarm Contain Evacuate • P.A.S.S. = Pull Aim Squeeze Sweep

describes the proper use of a fire extinguisher. – Use for small fires– 15 – 25 seconds operation time– Meant to slow the fire’s spread

Code Green• Dial 1111• Utilities Failure• Red outlets/plugs are for required

patient support equipment• Await instructions from supervisor

Code Orange• Hazardous Material Spill• Dial 1111 and have Environmental

Services notified• Take necessary precautions, i.e.

evacuate, keep others away• Contact supervisor

Code Gray

• Bomb Threat• Dial 1111 to report a bomb threat or

suspicious package• Prepare for evacuation• Assist response team with search

Code Black• Tornado warning - within 20 miles• Do not use elevators• Close all doors and window coverings• Move patients away from windows• Move ambulatory patients into hallway

Code Purple

• Prepare to evacuate patients and visitors

• Wait for instructions for evacuation

Code Adam• Infant or Child abduction• Newborn to 1 year: Use “Code Adam.” • 1 year and up: State the age and gender

as, for example: “Code Adam, male, 8• Do not allow anyone in or out of your area• Watch elevators, stairs and exits• Immediately contact security to report

suspicious persons

Mr. Speed – Dial 1111

• Aggressive/Disruptive Person• CPI trained staff respond• Show of force is important• If in doubt, call it out

Code Silver• An aggressive or agitated person armed

with a firearm (handgun, rifle, shotgun) Call 1111

• Report location to operator• Close all doors and remain with most

critical patients• Non-clinical staff evacuate from public

areas of the hospital to a safe location

Code Blue/Code Blue Pediatric

• Cardiac and/or Respiratory Arrest• Dial 1111• Remain with the patient and start BLS• Code Blue team will respond

Code Blue Team• Patient’s RN: responsible for

providing history• ED or other physician: runs

the code• ED RN: documents and runs

the crash cart• ICU RN: starts lines and

administers medications• Anesthesia• Respiratory• Pharmacy• Pastoral Care

• Security• Director/Coordinator/

Nursing Supervisor– Directs &/or dismisses

team as needed– Assures Physician & family

notified– Arranges for transfer– Completes Code Quality

Review Form in non-patient areas or directs others

Expectation of Staff• Assess ABCs• Initiate CPR• Call a Code• Bring Code cart• Remove

roommate/visitors • Clear space• Staff off floor: return• Start documentation• Set up suction• Assist as directed

Primary Nurse• Give report to Code

Team• Assist with

documentation on Cardiopulmonary Resuscitation Record

• Ensures Code cart is exchanged

Rapid Response

• If there is concern for patient condition or signs of deterioration

• Responders: ER RN, ICU RN, Respiratory Therapist, the Nursing Administration Supervisor, Clinical Nurse Manager if available and Clinical Nurse Specialist/APN if available.

• Any person can call a Rapid Response including patients, family, or visitors

Brain Alert

• Suspected Stroke• 1st call a Rapid Response for further

evaluation• Inpatients sent to ED for further

assessment and/or treatment• Stroke patients are then

transferred/admitted to 4th floor or ICU

Equipment Management

A Medical Device is any item that is used for the diagnosis, treatment, or prevention of a disease, injury or other condition and is NOT a drug or biologic.

Inspecting Medical Equipment• Inspecting Medical Equipment for safety and correct

operation before its use, is the responsibility and requirement of each of us as end users of a device.

• ALL new medical equipment must be inspected by Clinical Engineering prior to use.

• It is critical to the safe use of medical equipment that before it is used, that it be inspected for safety and correct operation.

• This needs to be done each and every time it is used. – Are the cords frayed – Is the device functioning the way it is supposed to

function?

Reporting Equipment Failure• To report a failure or to submit a work request for a

piece of medical equipment call extension 3100. This will open a work order for the Biomedical Engineering. Please no not use the on-line work order system as this is for non-medical equipment failures.

• Have the CEID number (Clinical Equipment ID Number) ready, as this will help us locate the correct device.

The 3100 extension goes to a live operator at TriMedX. These operators will then dispatch a service engineer. This includes normal and after hours needs.

Hazardous Communication Plan

The Materials Safety Data Sheets (MSDS):

Is a vehicle that is used to allow employers to provide employees with information about hazardous chemicals and materials that the employee may be exposed to in the workplace.

Hazardous Communication PlanWhere to Find the MSDS at PMMC:

• On PMMC’s Intranet-materials used in each department is available on line via 3E’s Healthcare MSDS Database. A guideline on how to access 3E by intranet or phone will be kept in all departments (a burgundy colored binder)

• The Emergency Department houses the master file of the MSDS, excluding those pertaining to Pharmacy and Laboratory chemicals, which will be housed in the respective department manuals.

The Hazardous Communication Plan can be found in our on-line policies. The policy number is II-03-3.5

Emergency ManagementWhat is Emergency Management?

An overall strategy developed in order to successfully handle large numbers of casualties and/or disruption to normal

hospital operations.

Goals of Emergency Management• To provide safe, effective patient care during an

emergency• Staff roles are defined, and they are trained in their

responsibilities• Priority emergencies for the organization are

assessed, prioritized and planned for • It allows staff to easily adjust to changes in volume,

acuity, work procedures • It outlines who our work partners are within the

community at times of emergency

What is the EmergencyOperations Plan (EOP)

• An all-hazards response that outlines what to do in an emergency situation or event

• Fundamentals: receive direction from supervisor– “1111”– Code Triage Levels– Departmental Roles & Responsibilities– Surge Capacity– Other related policies

EOP Fundamental: Code Triage Levels

• Divides emergency into 3 levels based on number of patients anticipated– Code Triage Level 1 (1-10 patients)– Code Triage Level 2 (11-20)– Code Triage Level 3 (21 or more)

• A red Disaster/Surge manual is kept in every department outlining roles at every level

EOP Fundamental: Surge Capacity Policy

• Plan where to place overflow patients • Takes what we already do & places it in a written

format; Drawn on experience of our senior staff• IDPH mandate is to prepare for 20% over our

licensed operating capacity• Activated after we reach Peak Census

Diversity:Diversity Definitions

• Diversity – Recognizing and respecting similarities and differences

• Cultural Diversity – A dimension of diversity within society which includes country of origin, ethnicity, race

• Workplace Diversity – A dimension of differences within the work environment including job level, occupation, department, FTE status, exempt vs. non-exempt, benefited vs. non-benefited, etc.

What is Diversity?

Diversity is about inclusion of differences and the respectful

involvement of all people, calling forth the gifts from each person’s

cultures, perspective and background.

What is Inclusion?Inclusion is:• Welcoming the uniqueness of the talents,

beliefs, backgrounds, capabilities and ways of living of individuals and groups when joined in a common endeavor

• Welcoming differences to create a culture of belonging

• Practicing behaviors that leverage and honor the uniqueness of people’s different talents, beliefs, and ways of living

Diversity in the WorkplaceValuing diversity means creating a

workplace that respects and includes differences, recognizing the unique

contributions that individuals with many types of differences can make, and creating a work environment that

maximizes the potential of all employees.

Our Commitment

Provena Health is committed to diversity. We believe that respecting, leveraging, and celebrating the diversity of our workforce, our patients and their families, and our communities create value. We practice inclusion because it’s central to our mission and values and enables us to respond to the diverse needs of those we serve.

Accessing Policies

Harassment

Harassment

Visual Verbal Physical/Sexual

We are committed to providing a professional, respectful and safe working environment that is free from

discrimination or harassment.

Harassment = Unwelcome conduct, based upon…

Gender Color Race

Ancestry Religion National Origin

Age Disability Marital Status

Veteran Status

Citizenship Sexual Orientation

What Do You Do?

• Discuss with your Immediate Supervisor if appropriate, or your Manager or Director.

• If your Immediate Supervisor is not available you may contact the Nursing Administrative Supervisor (5549), Human Resources or call the Alert-Line at 1-800-93-ALERT.

Smoke Free Campus• To establish and maintain the safest possible

environment in which to deliver quality health care.

• Includes all tobacco products.• Includes PMMC campus building/structures,

property, parking lots, and vehicles.• Applies to all Employees, Medical Staff,

Patients, Visitors, Students, Vendors, Contracted Personnel, Volunteers, Tenants and other invitees of PMMC.

Meal Periods & Rest Breaks• Meal Periods: Non-exempt, (hourly), employees scheduled to

work a shift of 7½ continuous hours or more are provided a 30 minute unpaid uninterrupted meal period.

• Time keeping system automatically deducts an unpaid 30 minute meal period for those non-exempt employees who work 5 hours or more.

• Non-exempt employees must be paid for all time worked. In those rare situations when an employee is not able to take or complete an unpaid meal period without interruption, he/she must notify their leader before completion of the shift and complete a “Missed Unpaid Meal Period” form and enter “no lunch” in Kronos.

• IF YOU DO NOT THINK YOU WILL RECEIVE A LUNCH, NOTIFY THE CHARGE NURSE AND THE NURSING SUPERVISOR OR YOU WILL NOT BE PAID FOR IT

Workplace SafetyWork-Related Injury

• An injury during the course of doing your job • All injuries are investigated and evaluated• Not all injuries that happen in the work place are

work-related• If you are injured while working:

– Notify Charge RN and RN supervisor– Fill out the paper Injury Report– Notify your Agency

What Governing Body Regulates Safety within Our Institution

Occupational Safety and HealthAdministration (OSHA):

OSHA was created in 1971 under the OccupationalSafety and Health Act. It’s mission is to “preventwork-related injuries, illnesses, and deaths.Since the agency was created in 1971, occupationaldeaths have been cut by 62% and injuries havedeclined by 42%.”

Back Safety

• Get close to the object • Face the object squarely. • Make sure you are balanced • Squat, bending your knees, Keep your back straight • Tighten your stomach muscles • Bring the object close to you • Grip the object firmly • Look straight ahead or up • Use your legs to stand • Keep the movement smooth and controlled

Back Safety• Prepare: Is your footing solid? • Clear the movable objects out of the way • Know where the unmovable objects are and how to get around them• Do not lift objects over your head • Do not twist • Do not reach over an obstacle to lift • Follow the safety guidelines of the workplace • Wear supportive shoes that are not slippery• When lowering an object follow the same steps • Lifting guidelines apply to all job tasks-shoveling, pushing, pulling,

sweeping, etc. • These guidelines also apply to patient transfers

Minimal Lift Program

WHY USE LIFT EQUIPMENT?

• Prevent care giver injury

• Prevent patient injury • Prevent patient fall • Corporate policy

WHO USES LIFT EQUIPMENT?

• All care givers who transfer or reposition patients

• Nursing staff • Transporters • Therapists • Radiology • Surgery

What Equipment Do We Have and Where Is It?

EQUIPMENT TYPESEquipment is available to

move most patients. • Minimal assist-Stedy • Extensive assist-Encore • Total assist-Tempo • Bariatric-Tenor • Lateral transfers-

maxislides or Patrans or Hover Matt

LOCATIONS • 3rd floor • 4th floor • 5th floor • Hope Unit • Radiology • Emergency

Department • Surgery

2 ways to Wash your hands1.Soap and Water Method2.Waterless Method (Alcohol-based hand rub)

Infection Control

HAND HYGIENE:the biggest piece of the puzzle

Hand Washing• Before and after work shift• After using washroom, before eating, drinking,

or handling food• After your skin comes in contact with blood,

body fluids, mucous membranes, non-intact skin, secretions, excretions, and contaminated items

• Whenever hands become visibly soiled

Effective Hand Washing1. Wet hands first with water (avoid HOT water)

2. Apply 3 to 5 ml of soap to hands

3. Rub hands together for at least 15 seconds

4. Cover all surfaces of the hands and fingers

5. Rinse hands with water and dry thoroughly

6. Use paper towel to turn off water faucet

Hand SanitizingWhen?• Entering and Exiting a patient room• Before putting on and after removing gloves and other PPE• After blowing your nose, covering a sneeze/coughHow?• apply 1.5 to 3 ml of an alcohol gel or rinse to the palm of one

hand, and rub hands together• cover all surfaces of your hands, including fingernails• continue rubbing hands together until alcohol dries

It should take at least 10 -15 seconds of rubbing before your hands feel dry

Advantages of Alcohol-Based Hand Rub:

– take less time to use– can be made more accessible than sinks– cause less skin irritation and dryness– are more effective in reducing the number

of bacteria on hands– making alcohol-based hand rubs readily

available to personnel has led to improved hand hygiene practices

Artificial Nails• These are not permitted for direct patient caregivers and outpatient care settings• Not permitted for individuals whose responsibilities include the handling of patient care supplies/ equipment or food• Glitter, appliqués, and cracked nail polish also harbors organisms and contributes to the spread of infection in the health care setting

Infection ChainTHREE ELEMENTS

1. Organism

2. Susceptible

Host

3.

Organism• Bacteria• Viruses• Fungi

Susceptible Host

– Very old or young– Unvaccinated– Weakened immune system– Malnourished– Chronically ill

Modes of Transmission

Contact• Direct• Indirect

Many DRUG RESISTANT ORGANISMS

Airborne•Tuberculosis•Chickenpox•Smallpox•Measles

Droplet• Flu• Some types

of Meningitis

Vector / Vehicle– VECTOR BORNE

• West Nile Virus• Malaria• Plague

– VEHICLE BORNE• Food Poisoning

Breaking the Chain

– Good hand hygiene is the single most effective means of breaking the chain

– Receive immunizations– Adhere to isolation precautions and utilize

appropriate PPE– Don’t come to work if you are ill

Isolation Precautions

• AIRBORNE• DROPLET• CONTACT• CONTACT WITH MASK• NEUTROPENIC• SPECIAL = AIRBORNE + CONTACT

AIRBORNE PrecautionsRequirements: • Negative Pressure Room• N95 Respirator Mask on family and care providers• No children visitorsOrganisms:

– Tuberculosis– Measles

Tb Risk Factors:• Foreign Born• High Risk Occupations• Suppressed Immune System

• HIV Infection • Substance Abuse

• Resident of • Correctional Facility• Nursing Home • Homeless Shelter

Signs & Symptoms Tb Disease• PERSISTENT, PRODUCTIVE COUGH (more than 3

weeks)• Hemoptysis (bloody sputum)• Chest pain• Fever, chills and night sweats• Loss of appetite and weight loss• Easy fatigability• Upper lobe infiltrate• History of having TB in past or being exposed

Susceptible Host: EVERYONE

Tb Infection vs. Disease

INFECTIONOrganism is

INACTIVEPatient is NOT SICK

but could become sick later

NOT INFECTIOUSPositive PPD skin test

DISEASEPatient is SICKINFECTIOUS

Needs to be Isolated

BREAK THE CHAIN

PATIENT CONTROL–Use tissue when coughing–Transport only when necessary–Place mask on patient when leaving

room

DROPLET PrecautionsRequirements:

• Surgical Mask Organisms:

• Bordetella pertussis• Neisseria meningitidis• Mumps• INFLUENZA

CONTACT PrecautionsRequirements: Wear gowns and gloves for all

interactions that may involve contact with the patient or the patient's environment

Organisms:– MRSA– VRE – ESBL– RSV

CONTACT PrecautionsWith MASK

• Adds DROPLETPrecautions

• Use if Drug Resistant Organism is in the SPUTUM or Patient has a Respiratory Infection

MASK not Required• Use for Infections :

WOUNDSURINESTOOL

• Use for COLONIZATIONS

Special Precautions

Requirements:– Gown– Gloves– Soap and Water Handwashing

Organisms:– C. Difficile– Norovirus– Acute Viral Gastroenteritis– MDR Acinetobacter

Clostridium difficile

Protocol:– Use SOAP and WATER – Manual removal of spore– Place Sign outside door and laminated sign

in room over hand gel pump.

Documentation and Communication

1. Patient Face Sheet2. Status Board3. Ticket to Ride

Bloodborne Pathogens

–Human Immunodeficiency Virus

–Hepatitis B Virus–Hepatitis C Virus

OSHA Standard• Effective since 1992• Requires that hospitals minimize or

eliminate occupational exposures to blood borne pathogens– EXPOSURE CONTROL PLAN

Exposure Control Plan

EXPOSURE DETERMINATION– Category I job- everyone who has the job is

at risk for exposure– Category II- only some people who have the

job have duties that put them at risk for exposure

– Category III - no one who has the job is at risk for exposure

What Can You Do? Engineering Controls

• SHARPS CONTAINTERS• NEEDLELESS SYSTEMS• SAFETY DEVICES ON SHARPS• BIOHAZARD SIGNAGE

Work Practice Controls• Proper Hand Hygiene• Standard Precautions• Use appropriate PPE & Isolation

Precautions• Restrict eating, drinking, applying

cosmetics, handling contact lenses in areas where exposure might exist

• Not recapping needles, scalpels

Standard Precautions• Assume that everyone is infectious• Includes:

– Blood– Body fluids– Secretions– Excretions– Non-intact skin– Mucous membranes

– Sweat only body fluid excluded (unless visibly contaminated with blood)

– If it is wet, use barrier precautions– PPE

• Gloves• Gowns • Masks• Eyewear

Standard Precautions

What else can YOU do to minimize EXPOSURE risks?

• GET YOUR VACCINATIONS• INFLUENZA• HEPATITIS B • CHICKENPOX

• GOOD HOUSEKEEPING

POST EXPOSURE

• WASH / FLUSH• REPORT IMMEDIATELY to Supervisor• Evaluation & Testing done through

OCCUPATIONAL HEALTH ED on off-shifts

• CONFIDENTIAL evaluation & follow-up

Needs of a Dying Patient

• Physiological: good symptom control• Safety: a feeling of security• Love: expression of affection/human contact

(touch)• Understanding: explanation about symptoms

of disease and the opportunity to discuss the process of dying

Needs of a Dying Patient

• Acceptance: regardless of mood and sociability

• Self-Esteem: involvement in decision making, particularly as physical dependency on others increases

• The opportunity to give as well as to receive

Disruptive and Impaired Licensed Independent Practitioners

Provena Health’s CommitmentConsistent with its Mission, Vision, Values and Ethical

and Religious Directives for Catholic Health Care, Provena Health is committed to providing a safe environment of care for patients and an optimum practice environment for physicians and all other

clinicians.

What is disruptive behavior?

Disruptive behavior is defined as a “chronic” pattern of contentious, threatening, litigious behavior that deviates significantly from the cultural norm of the

peer group, creating an atmosphere that interferes with the efficient function of the health

care staff and the institution.

This behavior may be, but is not necessarily, related to substance abuse/dependency.

Disruptive Physician Defined

The disruptive physician often lacks the ability of self observation.

The disruptive physician views:– Themselves as Clinically superior– Other members of the health care

team as less competent or incompetent, weak and/or vulnerable

– Themselves as champions for their patients

Disruptive actions cause:

• A distraction from the goal of providing optimum patient care

• A decrease in morale• Increase level of workplace stress• Inordinate time spent by staff appeasing or

avoiding the physician• Increased potential for malpractice litigation

Recognizing ImpairmentDrug and/or alcohol impairment should be ruled out

prior to addressing the issue as purely negative behavior

• Physical appearance• Personality or behavior changes• Deterioration of hygiene or appearance• Frequent or unusual accidents• Multiple prescriptions

What Can You Do?

Organizational staff, including hospital employees, who observe

or are subjected to, inappropriate behavior by a physician are responsible for communication with their supervisor about the incident

Abuse & NeglectAbuse

• Physical: An act that results in bodily harm, injury, impairment or disease

• Hitting, slapping, striking, sexual coercion/assault, incorrect positioning of the elder, forced feeding/ medicating, improper use of restraints

• Psychological: Inflicts emotional pain or distress• Verbal scolding, harassment, intimidation, threatening

punishment or deprivation, isolation• Financial

– Taking control of resources of another through misrepresentation, coercion or outright theft for personal gain

Child Abuse/Neglect• Abuse

– Unexplained or questionable scars, burns, welts, bruises or fractures

– Unnecessary confinement– Witnessed beatings– Sexual abuse– Emotional abuse– Withdrawn, angry or

unusual behavior exhibited by the child.

• Neglect– Malnourishment, failure to

thrive and grown– Lack of medical care– Filthy or unsafe

environment– Poor hygiene and personal

care– Absence of

parents/appropriate supervision

– Irregular school attendance

Adult Abuse/Neglect• Abuse

– Witnessed beatings– Emotional abuse– Sexual abuse– Unexplained or

questionable scars, welts, bruises or fractures

– Unexplained or questionable burns

– Signs of unnecessary confinement

– Financial exploitation

• Neglect– Hazardous housing– Failure to administer

prescribed medications or seek medical care for the adult

– Any situation where there is failure to provide for the needs of the adult that result in physical harm to that person

Neglect• Physical: Failure to provide goods/services necessary

for the health and well being • Withholding adequate meals/hydration, therapy,

hygiene, failure to provide physical aids or safety precautions

• Psychological: Failure to provide social stimulation• Leaving someone alone for long periods of time, failing

to provide companionship or links to the outside world• Financial: Failure to use available resources to sustain

or restore health and security• Improper level of care when resources available to

provide the proper level of care, sudden transfer of assets

Mandated Reporter• Mandated reporters are professionals who, in the

ordinary course of their work and because they have regular contact with children, disabled persons, senior citizens, or other identified vulnerable populations, are required to report (or cause a report to be made) whenever financial, physical, sexual or other types of abuse has been observed or is suspected, or when there is evidence of neglect knowledge of an incident, or an imminent risk of serious harm

• These professionals can be held liable by both the civil and criminal legal systems for intentionally failing to make a report but their name can also be said unidentified.

• The Illinois Abused and Neglected Children's Reporting Act ("ANCRA")

Resources Available

• PMMC/PHS Policies• Internal Resources

– Social Work• Diane Feltes x 5695

– Nursing Supervisors, Managers, Directors– Case Management Department

• Colleen Morley-Wines, Mgr. X2620

• Community Resources

Community Resources• DCFS (age birth to about 18

years)– 800-252-2837

• Office of Inspector General (disabled, 18-59)– 800-368-1463

• Senior Services (if from home or independent living)– Hotline: 800-252-8966

• IDPH (if from nursing home)– Hotline: 800-252-4343

• Self-Neglect– >60, Senior Services 630-897-

4035– <60, OIG 800-368-1463 (may

not take report)

• Mutual Ground (Domestic Violence, Rape 18-59)– No mandated reporting for this

population• Hotline: 630-897-0080• Sexual Assault: 630-897-8383• Advocacy: 630-897-8009

Provena Health’s Mission, Values & Vision 1 Catholic Directives/Medical Ethics 2 Patient Rights 3 Advance Directives 4-5 Standards of Business Conduct 6-7 Patient Safety 8-10 Code Blue/Facilities Alert/Weather Alerts 11 Pain Management 12 Employee Incident, Safety Concerns Reporting 13 Interpreting Services 14 HIPAA 15 Patient Confidentiality 16 Policy & Procedures 17 Information Services 18 Quality Improvement Process 19 Approved Forms of Identification 20 Disaster Alerts/Codes 21-23 Responding fire Drill/Fire Extinguishers 24-25 Code Pink (Infant/Child Abduction) 26 Code White (Aggressive/Disruptive Crisis) 27 Operation Alert (Bomb Threat) 28-29 Infection Control 30-31 Restraints 32 Code Orange /Code T 33 Customer Service RISE 34 Severe Weather 35 Service Excellence 36 Color Codes 37 Proper Body Mechanics/Patient Handling Lift Equipment 38 Equipment Management 39-40 Utilities Management 41 Hazardous Materials/ Handling Spills 42-43

* Bolded items reflect changes/corrections in 2008 Emergency contact numbers:

Dial 333 for any hospital code emergency. Security x5220 Engineering x5251 Infection Control x5689 Occupational Health x5555 Risk Management x5682 PSJH AlertLine (confidential) 1 800 93 ALERT

PROVENA HEALTH’S MISSION, VALUES AND VISION

OOuurr MMiissssiioonn Provena Health, a Catholic health System, builds communities of healing and hope by

compassionately responding to human need in the spirit of Jesus Christ.

OOuurr VVaalluueess Respect Integrity Stewardship Excellence

OOuurr VViissiioonn Provena Health, an integrated delivery system, is a leader in redefining Catholic health care. In partnership with our communities, we are committed to improving health status by providing consistent outcomes and creating value.

1

CCAATTHHOOLLIICC DDIIRREECCTTIIVVEESS

The Ethical and Religious Directives for Catholic Health Care Services are as follows:

The primary purpose of the relationship between medical science and Christian faith is for the common good of all human persons. Health care professionals share in carrying forth God’s life-giving and healing work by:

Defending human dignity Respecting the sacredness of every human life from the moment of conception until death Protecting and respecting the person’s health problem or social status

The Catholic health care institution is a community of healing and compassion, embracing the physical, physiological, social and spiritual dimensions of the human person.

MMeeddiiccaall EEtthhiiccss

Ethics is a process of choosing the best way of acting in a situation. Provena Saint Joseph Hospital’s Medical Ethics Committee meets on a regular basis to discuss ethical dilemmas, and to develop policy. Access to appropriate resources are available to manage ethical conflicts in your healthcare decision-making by calling the Chaplain-On-Call or the Pastoral Care Department at Ext. 5767.

2

PPAATTIIEENNTT RRIIGGHHTTSS//RREESSPPOONNSSIIBBIILLIITTIIEESS

Each patient receives a written statement of his or her rights. These statements can be found in the “Patient Handbook” or “Flyer.”

Admission to the hospital can be a frightening and confusing experience for patients, making it difficult for them to understand and/or exercise their rights. It is our duty to assure patients of their rights. This may mean you will read them their rights, or ask an interpreter to inform them of their rights in their primary language. The on-call chaplain is available for assistance by calling the operator and having the chaplain paged.

All Patients Have the Right to: Privacy, Confidentiality, Security Receive an Explanation of Billing Disclosure of Hospital and Business Relationships The Resolution of Complaints Pastoral Care and Other Spiritual Services Communicate Be Involved in all Aspects and Decisions Regarding their Care Informed Consent Make Advance Directives Know their Caregivers’ Names Refuse Treatment or Request Treatment Elsewhere Informed about the outcomes of care treatment and services File a complaint with the state authority

3

ADVANCE DIRECTIVES

A Time for Decisions… Everyone has the right to make decisions about their healthcare, including the right to receive information about his/her condition, treatments and the expected outcome, the right to discontinue medical treatment when the treatment extends living without offering reasonable benefits or quality of life. It is each individual’s right to express in writing his/her wishes about health care. How can a person pre-determine how they wish to be medically treated in case they become unable to make decisions regarding care and treatment? They may initiate two legal documents, which will provide for their care. These two documents are called the Living Will and the Durable Power of Attorney for Health Care. What is a Living Will? A Living Will is a written directive in which you state your choices for medical treatment if you should become terminally ill. Through this document, you are saying to your physician that if you develop an incurable and irreversible condition (“terminal condition”), and there is no reasonable chance of recovery, you want those procedures withheld or withdrawn that serve only to prolong the dying process. A Living Will does not take effect until you have a terminal condition, documented by your physician.

4

ADVANCE DIRECTIVES (Con’t)

What is the Power of Attorney for Health Care? The Power of Attorney for Health Care is a written directive, which designates another person to make health care decisions on your behalf if you become unable to make such decisions. This person is known as your “agent”.

Any competent adult at least 18 years old may act as an agent. You should discuss your wishes with your agent personally and make sure he/she understands your wishes. The Power of Attorney for Health Care is broader than the Living Will because it allows your agent to make health care decisions for you in any situation where you are unable to do so and is not limited to situations where you have a terminal illness. What if I have not signed any Advance Directive of any kind? The Illinois Healthcare Surrogate Act applies to this situation. If your attending physician determines that you do not have the ability to understand and appreciate the nature of, or consequences of a decision regarding your medical treatment, then the attending physician will pick someone to make medical decisions for you. The person/surrogate picked shall make decisions based on what they feel you would have done under the circumstances. The hospital Chaplains are available to answer questions or provide further information to assist with these very important decisions. Call Pastoral Care at ext 5767 or dial “0” to have the on call Chaplain paged.

5

SSTTAANNDDAARRDDSS OOFF BBUUSSIINNEESSSS CCOONNDDUUCCTT

Standards of Business Conduct is a program designed to support our employees in making workplace decisions which reflect the Mission of Provena Health in all of our words and actions. These standards apply to: All employees of Provena Saint Joseph Hospital All outside individuals, agencies, organizations and vendors who act on our behalf in any way.

The Provena Health AlertLine is a simple, risk-free way for you to report activities that may involve ethical violations or safety risks. AlertLine (1 800 93 ALERT)

In our Standards of Business Conduct training, employees are encouraged to follow the supervisory chain of command for advice and assistance, or to contact the Provena Saint Joseph Hospital Corporate Compliance Liaison. AAnnyy aanndd aallll qquueessttiioonnss aanndd ccoonncceerrnnss rreellaatteedd ttoo bbuussiinneessss ccoonndduucctt aarree ccoonnssiiddeerreedd vvaalliidd aanndd eemmppllooyyeeeess aarree eennccoouurraaggeedd ttoo ffrreeeellyy ddiissccuussss tthheemm wwiitthh tthhee aapppprroopprriiaattee ssuuppeerrvviissoorryy oorr mmaannaaggeemmeenntt ssttaaffff ppeerrssoonn..

6

STANDARDS OF BUSINESS CONDUCT (Con’t)

Our training includes the following directives to employees:

You are responsible for the decisions and the results of the decisions you make. When you have questions regarding the right thing to say or do in any situation, it is your responsibility to ask for help. Your words and actions should be guided by our Business Conduct Standards and your own personal standards and values. Should a conflict arise between the two, it is your responsibility to seek help in making an appropriate decision. Before you make a decision that involves your conduct in the workplace, you should ask yourself the following questions: Is safety at risk?

Provena Saint Joseph Hospital’s first priority must be the safety of our patients and employees. Does it comply with Provena Saint Joseph Hospital and/or Provena Health policies?

We are expected to follow the intent, letter and spirit of the law. Employees are responsible for knowing and following all policies and procedures.

Is it consistent with Provena Health Mission and Values? Our behavior is expected to reflect the Mission and Values of the organization we represent.

If my decision were made public, how would I feel? We are expected to know and do what is right. If we follow our Standard guidelines, we will be proud of the decisions we make.

IF YOU DON'T KNOW, ASK! 7

Patient Safety Program – The “ABCs” A. Your Patient Safety Officer is Julie Lyons. Julie can be reached by calling Extension 5682. B. Provena Saint Joseph Hospital recognizes that compliance with the Joint Commission’s National Patient Safety Goals is

essential for its goal in building a culture of safety. The new requirements for 2008 are in bold print below: (Please note: The numbers and letters of the Goals and Requirements are not consecutive because the Joint Commission makes annual changes but generally retains the original designations.) Goal 1 – Improve accuracy of patient identification.

1A PSJH uses patient name and date of birth as the two patient identifiers. Goal 2- Improve the effectiveness of communication among caregivers.

2A Write down then read back verbal & telephone orders and critical test results. 2B Use only approved abbreviations 2C Improve the timeliness of reporting results from critical tests and critical values/results. 2E Implement a standard approach to “hand off communications, including an opportunity to ask and respond to

questions”.

Goal 3 – Improve the safety of using medications 3C Prevent errors with look-alike/sound alike drugs. 3D Label all medications, medication containers (e.g., syringes, medicine cups, basins), or other solutions on and

off the sterile field in perioperative and other procedural settings. 3E Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.

8

Patient Safety Program (Con’t) Goal 7 – Reduce the risk of health-care associated infections.

7A Follow the CDC guidelines for hand hygiene. 7B Deaths/disabilities from health-care associated infections are considered sentinel events.

Goal 8 – Accurately and completely reconcile medications across the continuum of care.

8A This process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization

8B Communicate to the next provider the list of patient’s medications when patient transfers. Also provide a complete list to the patient.

Goal 9– Reduce the risk of patient harm resulting from falls.

9B Implement a fall reduction program and evaluate the effectiveness of the program. Goal 13 – Encourage patient’s active involvement in their own care as a patient safety strategy. 13A Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so. Goal 15 – The organization identifies safety risks inherent in its patient population. 15A The organization identifies patients at risk for suicide. [Applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.]

9

Patient Safety Program (Con’t) Goal 16 – Improve recognition and response to changes in the patient’s condition.

16A The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening.

C. Variance Reports are used to document unexpected events, which may occur. Unexpected events are “any

situation that is not consistent with routine operation of the facility or routine care of the particular patient.” Variance reports are also used to document incidents involving visitors. Variances should be entered into the MIDAS module found on the Home Page of our Intranet site. All variance reports must be completed before the end of your shift, and preferably at the time of the detection of the incident. Information from variance reports is tracked, trended and used in improvement activities related to patient care and safety. A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury includes loss of limb or function. Such events are called “sentinel” because they signal the need for immediate investigation and response. We conduct a root cause analysis-a process for identifying the basic or causal factor(s) that underlie variation in performance-following a sentinel event in order to prevent similar occurrences in the future.

10

Code Blue

A code blue is announced from any hospital care provider to communicate an actual or potential medical emergency. As a response, trained responders from the code blue team will report to the area and administer associated medical attention.

Facilities Alert A code facilities alert is announced to report any situation requiring general hospital staff assistance. Example conditions include emergency campus surveillance, monitoring of any potential risk to the campus or grounds, security assistance or notification of a large-scale condition potentially impacting the operations of Provena Saint Joseph Hospital. Upon alert, hospital staff should be prepared to send any available staff to the scene of the called alert. The security department will provide all responders with appropriate instruction.

Weather Alerts

Code Gray: Severe weather watch. Severe weather conditions which could possibly produce tornadoes. Code Black: Severe weather alert. Very severe weather which have produced a funnel cloud within area counties.

11

PPAAIINN MMAANNAAGGEEMMEENNTT

Interdisciplinary pain assessment criteria: On admission: Pain is assessed using the appropriate pain scale (Numeric Pain Intensity Scale [0-10], Visual Pain

Analogue [Faces]. The patient’s acceptable level of pain is assessed and documented. If patient is unable to report pain, non-verbal assessment can be used (i.e., vital signs, behavior

changes). If the pain score or greater than the acceptable level of pain, then pain intervention must be

initiated and documented. If intervention through medication, the sedation score is assessed and documented (S-1-2-3-4). Reassessment is mandatory, and follows any intervention and must be documented. If pain score is less than the patient’s acceptable pain goal, pain assessment is done every shift or

as indicated. Pain score will be documented on discharge.

12

EMPLOYEE INCIDENT REPORTING Employee incident reporting is an important part of PSJH’s goal to provide a safe working environment for employees.

Employee incident reporting and investigation does not place blame, punish or find fault. It is a process that focuses on the collection of information for the maintenance of a safe working environment for all employees.

When an accident occurs, complete the Occupational Injury/Illness Incident Report. Injured employees should be seen by Occupational Health or ED. Reporting an injury promptly may lessen the severity of the injury. Also, prompt reporting will initiate a thorough investigation of the circumstances and define corrective action to be taken to prevent future accidents.

When the accident involves a needle puncture or exposure to blood or body fluids one of the following forms is to be completed immediately: Fill out Form #462-570-7601 report of Work Injury and Form #463-570-7615 Needle Stick/Body Fluid Exposure. *NOTE: If you observe someone doing something that will put someone at risk, contact a member of the Environment of Care Committee or your manager. Reporting Safety Concerns

All employees of Provena Saint Joseph Hospital are required to consistently monitor their specific work area for any safety related issues or concerns.

Any identified safety concern is to be directed to the specific department manager for review of the proper routing, and or action plan.

To report unresolved safety issues, employees may utilize the following: PSJH AlertLine 1-800-93 ALERT (confidential) JCAHO Safety Hot Line #630-792-5000

13

IINNTTEERRPPRREETTIINNGG SSEERRVVIICCEESS

Interpretation services available through hospital staff can be accessed by calling the Interpreter at 5192 or Pastoral Care at extension 5767 or Human Resources at ext 5505 or the House Supervisor when Pastoral Care or Human Resources are closed. Phone interpretation is available 24 hours a day, 7 days a week for all languages via the AT&T Language Line. The staff person needing interpretation would dial 1-800-874-9426, follow the prompts using our 6-digit organization ID #206069, and your personal code number which will be your 4 digit telephone extension. The interpreter then comes on the line. Hearing Impaired Patients who are hearing impaired will be provided qualified sign language interpreters Call Human Resources or Nursing Supervisor. TDD (Telephone Device for the Deaf) units are available from the switchboard. The television sets can be modified to provide close caption viewing. There is no charge for this service.

14

Health Insurance Portability and Accountability Act

HIPAA stands for the “Health Insurance Portability and Accountability Act”. Originally called the Kennedy Kesslebaum Act, the Department of Health & Human Services (DHHS) issued the final Privacy Regulation requires compliance by: April 14, 2003 Protect patient’s rights by giving them access to their health information and control over how it will be

used. Improve the quality of care by restoring trust in the health care system Protect the security & privacy of all medical records that is used or shared in any form Privacy Standards-deal with patient’s expectations of providers in terms of the way health information is

used. (Information released on need to know basis only) Example-limiting who has access to their records

Security Standards-deal with measures that covered entities can take to keep their information safe Example-Encrypting information before it is sent over the internet

15

“THE END”

CCOONNFFIIDDEENNTTIIAALLIITTYY

PATIENT CONFIDENTIALITY means that every employee must keep private all personal information disclosed by the patient while receiving care. This includes the patient’s: Identity Physical or psychological condition Emotional status Financial situation

All employees and volunteers in the healthcare facility are responsible for patient confidentiality.

Guidelines: All requests for patient records should be referred to Health Information Management (Medical Records). If

Medical Records is closed refer requests to the Nursing Supervisor. Medical information should only be accessed by those who need to know in order to care for the patient.

Prior written consent from the patient is required for information to be shared with insurance companies, attorneys, police, and sometimes, even the patient’s family members.

All media representatives should be referred to the Marketing Department, or evening or night Nursing Supervisor.

16

POLICIES AND PROCEDURES

Policies and procedures that direct hospital operations are developed, approved, and stored online through the Provena Saint Joseph Hospital Intranet. Policies are available to Provena Saint Joseph Hospital staff at all times for reference.

In addition to our Provena Saint Joseph Hospital Institutional Policies and Departmental Policies, we have Corporate Policies that govern our entire system. These system-wide policies can be found on our Provena Health Intranet.

17

IINNFFOORRMMAATTIIOONN SSEERRVVIICCEESS

In accordance with Corporate Compliance, HIPAA regulation, the Joint Commission and auditing, policies regarding network standards and usage have been developed and are available on DOVEnet: Access and Disclosure of Electronic Mail Information Security Policy Statement Internet/Intranet Policy Statement Software Usage Policy Statement Standard Software Policy Statement

Beyond the Information Services Institutional policies, the following are a few I.S. safety rules to follow: Do not share your network login/password with anyone.

Always log off the network and application sessions before leaving your workstation.

NEVER leave patient specific information displayed on a workstation or in view of non-authorized personnel.

1188

CONTINUOUS QUALITY IMPROVEMENT PROCESS

Problem or process change identified Recognize Excellence/Best Practice Organize a team Validate knowledge Evaluate causes Negotiate improvements Act/Accountability

19

Rapid Cycle PDSA

Plan Process

changes Data

Collection

Do Process

changes Data collection Data analysis

Act To hold gains To abandon change To determine next steps

Study Were changes

implemented as planned?

Outcomes/results Lessons learned

What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement?

AAPPPPRROOVVEEDD FFOORRMMSS OOFF IIDDEENNTTIIFFIICCAATTIIOONN

Approved forms of identification are always to be worn above the waist and must be visible at all times while on duty.

The approved form of employee identification is a Matrix Badge. Badges provide picture identification and verify the right to access job-related information. The strip on the matrix badge gives authorization for employees/persons to be at Provena Saint Joseph Hospital.

The color strip on Matrix Badges indicates: Blue-employees of PSJH. Green-Out Source employees. Pink-Volunteers of PSJH. Red-Physicians/Contracted persons working for an extended period of time who are not employees. They

are authorized to use computers and access patient information as needed. Yellow-Students/Interns of PSJH. Purple-Family Birth Place employees

Other approved forms of identification:

Patients must wear ID bracelets at all times. At least two identifiers must be used (neither to be a patient’s room number) whenever taking blood samples or administering medications or blood products. All Vendors must sign in at the Security office and receive a temporary identification badge. All construction contractors must sign-in at the Facilities Management office and receive a temporary I.D. badge.

20

DDIISSAASSTTEERR AALLEERRTTSS//CCOODDEESS EEMMEERRGGEENNCCYY TTEELLEEPPHHOONNEE NNUUMMBBEERR

Just like calling 911 for an emergency in the community, at PSJH we have one emergency number.

DIAL 333 FOR ALL EMERGENCIES ANYWHERE IN OR ON PSJH’S CAMPUS.

Emergency Announcement Procedures The 333 emergency telephone number rings at PSJH’s switchboard. Tell the operator the location and code description (in case of a fire, state the severity of the fire). Do not hang up until you are told to do so. The operator will announce the code name and the location of the emergency and notify the appropriate emergency response team.

21

CCooddee RReedd CCooddee BBlluuee

OOppeerraattiioonnss AAlleerrtt

CCooddee PPiinnkk

CCooddee WWhhiittee

RRaappiidd RReessppoonnssee RRoooomm ## oorr LLooccaattiioonn

DISASTER ALERTS/CODES (Con’t)

TTYYPPEESS OOFF EEMMEERRGGEENNCCYY RREEPPOONNSSEESS

EXTERNAL/INTERNAL DISASTER (Operation Alert) An internal disaster occurs when conditions are such that the ability of the ED to process and care for patients are compromised by conditions such as hospital explosions or gas-emission events, utility interruption or fires. The ability to handle such situations utilizing on-duty personnel is determined by the emergency physician on duty, the ED charge nurse, and the ED director/inpatient administrative director/nursing supervisor. An external disaster requires a health care facility to admit and treat many casualties, but there is no damage to the facility itself. All Provena Saint Joseph Hospital employees are required to learn the Departmental Emergency Response Plan associated within their work area(s).

PHASE I

0-9 patients admitted through the ED. Request assistance from support areas as necessary. Notify Administration

PHASE II

10-19 patients admitted through ED. ED call list activated to support internal departments

PHASE III 20 or more patients admitted through ED. Ed treatment/triage areas established as required.

22

DISASTER ALERTS/CODES (Con’t) EEXXTTEERRNNAALL//IINNTTEERRNNAALL DDIISSAASSTTEERR AANNNNOOUUNNCCEEMMEENNTT CCOODDEESS

The operator will announce: “Attention please! We have an external disaster phase ____.”

Operations Alert Phase I On-duty personnel will most likely handle such a situation.

Operations Alert Phase II Such a situation might require calling additional help. If additional help is required, the call plan would be implemented.

Operations Alert Phase II

All department disaster plans in effect. Call in off duty staff. If on-duty when the announcement is made: Remain in your work area unless pre-assigned to a Disaster Center. (Refer to your department’s specific Emergency Preparedness Plan.)

If reached through the Department Call List: Report to the hospital via the north entrance and proceed to the Volunteer’s Lounge.

Medical Equipment: Wheelchairs and carts should be sent to the Emergency Department immediately.

All Provena Saint Joseph Hospital employees are required to learn the Departmental Emergency Response Plan associated within their work area(s).

23

RREESSPPOONNDDIINNGG TTOO AA FFIIRREE OORR DDRRIILLLL

Know where fire alarms, extinguishers and exits are located in your work area before a fire or drill.

If you discover a fire follow the R.A.C.E. method: Rescue those in immediate danger. Activate the closest alarm and dial 333. Contain the fire by closing all the doors. Extinguish a fire only if it is safe to do so. Fire Announcements: CODE RED Code Red exists when Fire, smoke or evidence of burning materials. DIAL 333, State “CODE RED” and give location. CODE RED: Staff Response at the scene of the fire In addition to R.A.C.E. and P.A.S.S. procedures, all employees of Provena Saint Joseph Hospital are required to learn their specific rolls during a code red event. These procedures are reviewed during departmental orientation and reflected in the zone specific “red frame”. HORIZONTAL EVACUATION (contained within immediate working area) All staff must review their work areas to determine the appropriate direction of horizontal (smoke compartment) movement in the event of a fire. Smoke compartments within patient care areas are identified with the letter “S” above doorways. Staff are reminded to relocate into contiguous horizontal smoke compartments identified with the “S” indicator whenever moving away from the scene of a fire. VERTICAL EVACUATION (fire stairwells) All staff must review their work areas to determine the appropriate direction of vertical (fire compartment) movement in the event of a fire. Fire compartments serving patient care areas are identified with the letter “F” above doorways. Staff are reminded these exits are to be used for the evacuation of patients/staff/visitors during a full evacuation. Elevators are not to be used unless approved by the fire department. ROLES OF STUDENTS/MEDICAL STAFF DURING CODE REDS Students and medical staff are reminded to participate in concert with area specific staff during code red announcements and as directed by hospital Leadership. Further instructions will be provided as details of advanced evacuations are developed.

24

FFIIRREE EEXXTTIINNGGUUIISSHHEERRSS

Read the operating instructions on the fire extinguishers located in your work area(s) before a fire happens. Extinguishers have different contents to put out different types of fires. Extinguishers are labeled according to the class of fire they are designed to extinguish. Most extinguishers in the hospital are multipurpose and can be used on any fire.

Learn to P.A.S.S.

REMEMBER: Horizontal Evacuation: The relocation of patients and staff from a compromised smoke compartment to the next adjacent compartment (behind smoke doors) on the same floor. Vertical Evacuation: The relocation of patients and staff from a compromised smoke compartment using vertical fire exit stairwells.

25

Pull the pin. Provena Saint Joseph Hospital’s extinguishers use a plastic cord to hold the pin in place. Before you are able to remove the pin, the plastic cord needs to be broken. To break the cord, simply twist the pin. Aim the extinguisher nozzle at the base of the fire. Squeeze or press the handle. Sweep from side to side at the base of the fire until it goes out. Shut off the extinguisher. Watch for reflash and reactivate the extinguisher if necessary. Foam and water extinguishers require slightly different action.

Pull

Aim

Squeeze

Sweep

CCOODDEE PPIINNKK

Calling a Code Pink Immediately report an attempted infant or child abduction or any unusual or suspicious behaviors to Security.

Dial 333, you will be connected to the operator.

Tell the operator Code Pink, location and any identifying traits of the suspected abductor or abductor’s vehicle.

The operator will contact Security and announce overhead Code Pink and location.

Responding to a Code Pink Announcement When a Code Pink is announced, all employees have the responsibility to monitor their areas for visitors, patients or staff who may be, without permission, transporting a child or infant. Such an individual may also be transporting a large package, which may contain a child or infant patient. Staff members should never attempt to use physical force to detain a suspected abductor. Staff members should report the person to Security and follow the person (if safe to do so) until Security arrives. Most Code Pink situations are crimes of stealth and deception, and drawing attention loudly to the suspected abductor is a good way to not only alert your co-workers, but possibly change the plans of the abductor as well (leaving the child and fleeing, etc.).

Know unit/department specific Code Pink procedures and where to respond during a code Pink.

Know Provena Saint Joseph Hospital’s Code Pink policy.

26

CODE WHITE

Learning to recognize early warning signs of potentially aggressive, disturbed behavior and knowing how to de-escalate a potentially violent situation helps to ensure safety of the staff, the person acting out and the other people in the area. Be observant of behaviors that have the potential to escalate into violence.

One of the most important ways to avoid violence is to know how to respond if you are faced with someone whose words or actions frighten you. Take all threats seriously and report all threats immediately. Verbal intervention and control of the environment are the first interventions utilized to control the situation. Other patients and visitors are to be removed or restricted from coming into the area of confrontation.

During an aggressive or disruptive crisis your professionalism is on display for all visitors, patients, volunteers and employees to see. You need to respond to the crisis in an appropriate way. To learn de-escalation techniques, attend the Nonviolent Crisis Intervention class sponsored by CPI and offered throughout the year by certified instructors on staff at the hospital. Staff members who plan to become physically involved in any code white situation should take this training. Other staff members may respond to a code white situation to assist with access and crowd control, etc but only CPI certified staff should interact with an action out person.

27

OOPPEERRAATTIIOONN SSEEAARRCCHH ((BBoommbb TThhrreeaatt))

If a threat is received by telephone:

Be calm, listen and attempt to prolong the conversation as long as possible.

If possible, have someone else call 5220 while the conversation is still in progress.

Be alert for distinguishing background noises, e.g., music, aircraft, and other noises.

Note voice characteristics such as accents, etc.

Try to determine exactly where the device is located and any timeliness for activity.

Note if the caller appears to have knowledge of the hospital's floor plans or is familiar with staff.

Complete the Variance Report and/or Threatening/Obscene Call Sheet (refer to PSJH policy “Bomb Threat/Potential Concealed Weapons of Destruction” under the Management of the Environment of Care chapter).

Prepare for a possible evacuation of the area.

28

OOPPEERRAATTIIOONN SSEEAARRCCHH ((BBoommbb TThhrreeaatt)) ((CCoonn’’tt))

If you hear a Operation Search announcement: You will know that a bomb threat has been received by the hospital.

You may be required to send a representative from your department/unit to the designated meeting place.

All staff will prepare to search their units for unusual or out-of-place packages in the department.

Follow the directions of individuals leading the search activity.

If a suspicious item is discovered: Isolate the area and notify Security

Close all doors and open windows, if possible.

Evacuate patients, visitors and all other personnel if ordered by Administration.

29

INFECTION CONTROL

Sharps Containers DDIISSPPOOSSEE SSHHAARRPPSS IINN PPUUNNCCTTUURREE PPRROOOOFF ““SSHHAARRPPSS CCOONNTTAAIINNEERRSS””:: This includes sharps, syringes, scalpels, needles, lancets, blood tubes, slides and cover slips. Do not leave sharps for others to dispose. Do not overfill sharps containers. Activate sharps safety device before placing in puncture proof container.

Biohazard Waste Use red bag to dispose biohazard waste. Biohazard waste includes: Any material saturated with blood or blood components. Body tissue, organs or body parts including body fluids that are removed during medical procedures like

surgery and autopsy. Cultures and stocks from laboratories. Add Red Z to all potentially infectious liquids before disposing in the red bins.

Respiratory Masks An N-95 is a special mask worn by all staff who enter a negative pressure room for airborne isolation. Fit testing is required before using this mask.

Latex Allergy Prevention Points

Minimize exposure. Continued exposure to latex allergens increases sensitization and worsens allergic reactions.

Recognize symptoms. Dermatitis, hives and nasal congestion, to asthma, food cross reactions and anaphylactic shock. (Currently there are policies for the latex allergic patient and the latex allergic HCW. To access these policies go to the PSJH policy section on the Intranet under “Management/Environment of Care”.)

Know the high-risk groups. Healthcare workers, persons with spina bifida, persons with histories of multiple surgeries or allergies.

Medic alert bracelets and emergency medical supplies should be available for persons with allergy. If you are latex allergic be your own advocate.

30

Act Study Plan Do

INFECTION CONTROL (Con’t)

Hand washing before and after patient contact and after contact with potentially infectious items or surfaces is the single most effective infection control practice in the hospital.

Alcohol hand gel can be used instead of soap and water except when the infection is clostridium difficle diarrhea, then soap and water is required.

Consider all human blood, body fluids, mucus membrane, non-intact skin and moist body surfaces to be potentially infectious. Therefore: Use standard precautions regardless of the diagnosis.

Wash hands before and after patient contact.

Use personal protective equipment (PPE): GGLLOOVVEESS--FFOORR HHAANNDD PPRROOTTEECCTTIIOONN Goggles & face shield-for face and eye protection Gowns-for protection from soiling Masks-for respiratory protection

Use transmission based precautions: Airborne Precautions for pulmonary TB, Chicken Pox, disseminated shingles or measles. With SARS, monkey pox, smallpox, Avian flu, N-95 mask and goggles are required also airborne and contact precautions. (Mode of spread-droplet nuclei from respiratory secretions) Negative pressure rooms are 212,214,312,314,412,414,ICU 8. Droplet Precautions for influenza and other communicable respiratory infections where the mode of spread is droplets from respiratory passages. Contact Precautions for communicable diseases spread by direct contact with blood or body fluids and multi drug resistant pathogens such as MRSA, VRE,ESBL and C-Difficile diarrhea. Multiple signs when a patient has a resistant organism in the respiratory tract ie MRSA. Contact and Droplet will be used in combination.

V.I.P. status: For patients with resistant organisms such as MRSA,VRE and ESBL. The V.I.P. status is not removed so the patient can be placed in isolation on readmission and rescreened. If a patient, is MRSA positive by history they can be rescreened and if negative removed from isolation. However, they will be rescreened with every subsequent admission. If they are on Mupirocin intranasally they cannot be rescreened and need Contact isolation. For VRE and ESBL, the patient must be off antibiotic treatment for the organism and 3 negative screens done 1 week apart are necessary to remove a patient from isolation. For C.Difficile diarrhea, the patient is placed in Contact and treatment started. To remove the patient from isolation, the treatment must be completed and no s/s of diarrhea for 48 hrs after treatment. No negative specimens are needed.

* Food/beverages in the workplace: When transporting food or beverages from the cafeteria to be consumed in an established break room it MUST be covered. No food or beverages are allowed in the nurses station, med carts in the hallway, etc.

31

RREESSTTRRAAIINNTTSS

Philosophy of Restraints: Provena Saint Joseph Hospital respects the rights and dignity of its patients and employs preventive and alternative strategies to reduce restraint episodes. PSJH staff delivering care to the patient will use alternative means whenever possible to protect the patient’s health, well being and safety prior to the use of restraint and/or seclusion while complying with agency standards and statutory regulations. Seclusion/restraint is only used in those situations when its use is essential to protect the patient from harming himself/herself and/or others.

Restraint is defined as any method of applying involuntary restrictions on a patient’s bodily movement (or access to his or her body areas) in order to protect the patient or others from harm.

Seclusion is involuntary confinement of a person alone in a room where the person is physically prevented from leaving.

Note: You need to know the frequency of care for behavioral vs. medical use of restraints.

32

Code Orange

A code orange is announced from the emergency room or other specified department to communicate a potential risk of exposure to chemicals/weapons of mass destruction. As a response, staff should contact the alerting department to identify risk measures and general conditions prior to responding. In situations of actual conditions, only trained staff members should respond following directions from Emergency Services leaders.

Code T

A code T is announced to communicate the imminent arrival of one or more multiple trauma patients. Only designated staff members should respond and follow directions from Emergency Services leaders.

3333

RR..II..SS..EE

As employees of Provena Saint Joseph Hospital, we are required to incorporate the RISE concept in all facets of patient contact:

Respect – We affirm the individuality of each person through fairness, dignity, and compassion.

Integrity – We demonstrate the courage to speak and act honestly to build trust.

Stewardship – We use our human and economic resources responsibility with a special concern for the poor and vulnerable.

Excellence – We achieve exceptional performance through continuous growth and development. All employees of Provena Saint Joseph Hospital are required to sign an agreement stating they will reflect the RISE standards at all times as a provision of employment.

34

Integrity Respect

Stewardship

Excellence

Customer Service

SEVERE WEATHER WARNING

A severe weather alert is announced from the switchboard to communicate pending or current weather conditions requiring response from the general staff. A severe weather watch (Code Gray) is announced when severe weather conditions could present strong winds, tornado, severe lightening or hail within our area. A severe weather Alert (Code Black) is announced when service weather conditions are sighted presenting strong winds, tornado severe lightening or hail within our area. In actual conditions staff members are encouraged to monitor each working area for specific risks and possibly relocate from window areas to hallways or common corridors. Patients are to be relocated to areas of safe refuge including hallways, common corridors or other identified areas.

35

SERVICE EXCELLENCE All employees of Provena Saint Joseph Hospital are required to reinforce the five fundamentals of customer Service. These are defined as follows: THE FIVE FUNDAMENTALS OF SERVICE (AIDET)

ACKNOWLEDGEMENT Eye Contact Smile Stop whatever you are doing so your customer knows they are important INTRODUCTION Welcome State your name State your department State your role in the customers care DURATION (TIME EXPECTATION) Explains how long before the test starts Explain how long the test itself will take Explain after the test – report process EXPLANATION Explain test or procedure Explain who is involved in providing your customers care Explain if the test will cause pain or discomfort, or if any post procedure instructions are necessary Offer to answer any concerns, questions, or resolve any complaints THANK YOU Say “Thank you for choosing Provena Health for your healthcare needs.”

36

Provena Saint Joseph Hospital Emergency Color Codes

Code Green Utilities Failure Code Red Fire Emergency Code Pink Infant abduction/alert Code Blue Medical Emergency Code White Patient restraint/assistance Code Orange Weapons/chemicals mass

destruction response plan Code T Mass causality response Facilities Alert Response/assistance needed Code Gray Severe weather watch Code Black Severe weather alert Operations Alert External/internal disaster Operation Search Bomb threat plan

37

Proper Body Mechanics for Employees Body mechanics refers to the correct use of the body as a tool for locomotion and manipulation. Proper positioning, movement techniques, maintaining balance and use of gravity are the key components for implementation of proper body mechanics. Using the proper body mechanics is essential to maintain safety and to avoid acute injury when lifting or moving objects. It can also be important over time to prevent and reduce postural dysfunction, chronic strain and degenerative changes in yourself. 1. Plan every move or lift in advance to ensure safety. Remember to anticipate obstacles-maintain clear pathway. Make use of available

equipment and assistive devices. 2. Try to maintain a proper “neutral” alignment of the head and spinal curves throughout the lift. Your shoulders, hips, knees, ankles

should be flexed and ready to lift. 3. Attain a proper base of support by keeping your feet apart and aligned with your hips and shoulders. This posture ensures balance and

prevents falling forward or backward. 4. Avoid bending over at the waist, and avoid twisting motion of the spine. This is especially true if you are sitting. Use extra care when

lowering something to the floor or when reaching with even light loads. 5. Position objects being moved as close to your body as possible. This process helps you maintain your balance and reduces strain on

your back and arms. 6. When you begin the lift or move, keep your knees bent and back straight. Tighten your abdominal muscles to stabilize the low back,

but do not hold your breath. 7. Demonstrate competency with the use of equipment that facilitates movement of objects. 8. Remember, most back injuries can be prevented through good habits and common sense. Serious injuries can occur suddenly, even

when lifting small objects if you are in the wrong position.

Patient Handling Lift Equipment

Provena Health requires that any employee whose duties include lifting, transferring and repositioning of patients be properly trained in the use of patient handling equipment and then requires the use of this equipment in patient lifts, transfers, and repositions.

38

EEQQUUIIPPMMEENNTT MMAANNAAGGEEMMEENNTT ((SSaaffee MMeeddiiccaall DDeevviiccee RReeppoorrttiinngg))

A Medical Device is an item that is used for the diagnosis, treatment, or prevention of a disease, injury or other condition and is NOT a drug or biologic. All medical device-related patient/employee incidents are reported as soon as possible by any individual, who witnesses, discovers or otherwise becomes aware of the occurrence. This individual does not need to make the judgment if the incident is reportable to FDA or manufacturer. Safe Medical Device Act (SMDA) Steps for Reporting: Attend to the medical needs of the patient. Maintain the medical device in the condition it was in at the time of the incident, including the control settings. Remove and sequester the device and any associated accessories (tubing, patient circuit etc.) from service. If available, save all materials including any disposable items and packaging that contains manufacturer name, lot numbers and serial numbers etc. Notify Biomedical Department (Ext. 5108) immediately to perform an equipment inspection on the malfunctioning equipment. During hours when Bio-Med is not staffed, notify the Nursing Supervisor. If a patient has been seriously injured, notify the Risk Management Department at Ext. 5682 soon as possible. Complete a Variance Report form and forward it to Risk Management as soon as possible. Remember, anyone can report a device incident.

Hours of Operation: The normal working hours for Clinical Engineering are Monday through Friday, 7:00am till 4:00pm.

39

EEQQUUIIPPMMEENNTT MMAANNAAGGEEMMEENNTT ((CCoonn’’tt)) Reporting Malfunctioning Medical Equipment and equipment labels: Any patient care medical device found not operating as normally intended must be removed from the area of service immediately. The item is to be affixed with a note documenting the reported problem, your name and extension. All medical equipment repairs must be communicated to the Biomedical Engineering Department at extension 5108 immediately, this includes normal and after hours calls. To expedite service please record the CEID number for the device before calling X5108. All medical devices owned by the hospital should have a CEID number affixed to it. The following is an example of a CEID tag:

For devices that are included in a regularly scheduled performance assurance (PA) program an additional inspection tag will also be affixed to the device. The date on the inspection tag should not be greater then 12-months. The following is an example of the TriMedx safety inspection tag:

For medical devices not included in the PA program, in addition to the CEID tag they will have a grey “approved for use” tag. The grey tags may or may not have a date and rep indicated. The date on these tags can be greater then 12 months. The following is an example of a grey approved for use tag with the date and rep. field:

40

UUTTIILLIITTIIEESS MMAANNAAGGEEMMEENNTT Utility Systems Utility systems provide support to life, infection control, environment, equipment and communication support systems which include: Electrical Distribution Gas Utilities Water/Steam Communication Systems Vertical Transport (Elevators) Clinical Vacuum and Medical Oxygen Systems

PSJH has colored outlets for various functions:

Ivory Outlets-provide normal power.

Ivory Outlets/Green Dots-approved for use on medical equipment in clinical areas. Green dot electrical cords should be plugged into red outlets.

Red Outlets-backed up by the emergency generators. In an emergency, red outlets should be used for critical patient care equipment only. Make sure that you can Locate the red outlets in your department. Any utility related concerns must be directed to Engineering at Ext. 5251 (24 hours a day).

41

HHAAZZAARRDDOOUUSS MMAATTEERRIIAALLSS

Hazardous materials are substances that are potentially dangerous to your health and safety. They range from flammable liquids to disease causing organisms.

Location of Material Safety Data Sheets (MSDS) The hospital inventory of Material Safety Data Sheets (MSDS) is located online from the PSJH Intranet page (MSDS Online). In the event of any hazardous material incident, PSJH staff must contact the Security Department (EXT. 5220) for further directions. Every work area at Provena Saint Joseph Hospital is responsible for maintaining MSDS on any toxic substances used in that particular work area. MSDS should be located in an area that is accessible to the employees. There is also a master copy of all MSDS in the Emergency Department. It is important that you know what hazardous materials exist in your department and where Material Safety Data Sheets are located in your work area, in case of an emergency.

Spill Handling Guidelines In the event of a hazardous chemical spill: Be careful not to touch it or walk through it. Immediately place signs to prevent other people from entering the area.

42

HHAANNDDLLIINNGG SSPPIILLLLSS Minor Spills When the volume of the spill (blood, chemo or OPIM) is small, clean up is to be initiated by trained staff wearing protective equipment in the department where the spill occurs. The appropriate spill kit must be used. Never dispose of hazardous materials in the trash or chutes. Contact Security at (Ext. 5220) for assistance immediately. For assistance in the clean up, and complete a written report of the clean-up operations.

Major Spills Major spills, because of the proportions and type of spill, may need the intervention of an off-site professionally trained team to clean up the spill. Contact Security at (Ext. 5220) for assistance immediately. A trained employee will be sent who will decide if clean up can be managed by Environmental Services or our medical waste hauler.

Large Chemical Spill For a large chemical spill such as a flammable liquid, Contact Security at (Ext. 5220) for assistance immediately for containment of the spill security will contact the medical waste hauler for cleanup.

Mercury Spill For a mercury spill, Contact Security at (Ext. 5220) for assistance immediately. Who will make arrangements for the cleanup and disposal of waste mercury? DO NOT dispose of “waste mercury” in regular trash or down drains.

43

I attended the 2008-2009 Provena Saint Joseph Hospital Safety Fair via Net Learning.

Name:_____________________________ Dept.______________________________ Date:______________________________ Completion Score:_______________________

Ambulance Technician Study

You Are Here> Home :: Content :: Cardiac :: ECG Rhythms

<< Cardiac<< ECG Basics ECG Rhythms ECG Rules >>

ECG RHYTHMS

This section will cover some of the most common ECG patterns that you'll come across on an

ambulance.

Normal Sinus Rhythm

Looking at the ECG you'll see that:

Rhythm - Regular

Rate - (60-100 bpm)

QRS Duration - Normal

P Wave - Visible before each QRS complex

P-R Interval - Normal (<5 small Squares. Anything above and this would be 1st degree

block)

Indicates that the electrical signal is generated by the sinus node and travelling in a normal

fashion in the heart.

Sinus Bradycardia

A heart rate less than 60 beats per minute (BPM). This in a healthy athletic person may be

'normal', but other causes may be due to increased vagal tone from drug abuse,

hypoglycaemia and brain injury with increase intracranial pressure (ICP) as examples

Looking at the ECG you'll see that:

Rhythm - Regular

Rate - less than 60 beats per minute

QRS Duration - Normal

P Wave - Visible before each QRS complex

P-R Interval - Normal

Usually benign and often caused by patients on beta blockers

Sinus Tachycardia

An excessive heart rate above 100 beats per minute (BPM) which originates from the SA

node. Causes include stress, fright, illness and exercise. Not usually a surprise if it is

triggered in response to regulatory changes e.g. shock. But if their is no apparent trigger

then medications may be required to suppress the rhythm

Looking at the ECG you'll see that:

Rhythm - Regular

Rate - More than 100 beats per minute

QRS Duration - Normal

P Wave - Visible before each QRS complex

P-R Interval - Normal

The impulse generating the heart beats are normal, but they are occurring at a faster pace

than normal. Seen during exercise

Supraventricular Tachycardia (SVT) Abnormal

A narrow complex tachycardia or atrial tachycardia which originates in the 'atria' but is not

under direct control from the SA node. SVT can occur in all age groups

Looking at the ECG you'll see that:

Rhythm - Regular

Rate - 140-220 beats per minute

QRS Duration - Usually normal

P Wave - Often buried in preceding T wave

P-R Interval - Depends on site of supraventricular pacemaker

Impulses stimulating the heart are not being generated by the sinus node, but instead are

coming from a collection of tissue around and involving the atrioventricular (AV) node

Atrial Fibrillation

Many sites within the atria are generating their own electrical impulses, leading to irregular

conduction of impulses to the ventricles that generate the heartbeat. This irregular rhythm

can be felt when palpating a pulse

Looking at the ECG you'll see that:

Rhythm - Irregularly irregular

Rate - usually 100-160 beats per minute but slower if on medication

QRS Duration - Usually normal

P Wave - Not distinguishable as the atria are firing off all over

P-R Interval - Not measurable

The atria fire electrical impulses in an irregular fashion causing irregular heart rhythm

Atrial Flutter

Looking at the ECG you'll see that:

Rhythm - Regular

Rate - Around 110 beats per minute

QRS Duration - Usually normal

P Wave - Replaced with multiple F (flutter) waves, usually at a ratio of 2:1 (2F - 1QRS) but

sometimes 3:1

P Wave rate - 300 beats per minute

P-R Interval - Not measurable

As with SVT the abnormal tissue generating the rapid heart rate is also in the atria,

however, the atrioventricular node is not involved in this case.

1st Degree AV Block

1st Degree AV block is caused by a conduction delay through the AV node but all electrical

signals reach the ventricles. This rarely causes any problems by itself and often trained

athletes can be seen to have it. The normal P-R interval is between 0.12s to 0.20s in

length, or 3-5 small squares on the ECG.

Looking at the ECG you'll see that:

Rhythm - Regular

Rate - Normal

QRS Duration - Normal

P Wave - Ratio 1:1

P Wave rate - Normal

P-R Interval - Prolonged (>5 small squares)

2nd Degree Block Type 1 (Wenckebach)

Another condition whereby a conduction block of some, but not all atrial beats getting

through to the ventricles. There is progressive lengthening of the PR interval and then

failure of conduction of an atrial beat, this is seen by a dropped QRS complex.

Looking at the ECG you'll see that:

Rhythm - Regularly irregular

Rate - Normal or Slow

QRS Duration - Normal

P Wave - Ratio 1:1 for 2,3 or 4 cycles then 1:0.

P Wave rate - Normal but faster than QRS rate

P-R Interval - Progressive lengthening of P-R interval until a QRS complex is dropped

2nd Degree Block Type 2

When electrical excitation sometimes fails to pass through the A-V node or bundle of His,

this intermittent occurrence is said to be called second degree heart block. Electrical

conduction usually has a constant P-R interval, in the case of type 2 block atrial

contractions are not regularly followed by ventricular contraction

Looking at the ECG you'll see that:

Rhythm - Regular

Rate - Normal or Slow

QRS Duration - Prolonged

P Wave - Ratio 2:1, 3:1

P Wave rate - Normal but faster than QRS rate

P-R Interval - Normal or prolonged but constant

3rd Degree Block

3rd degree block or complete heart block occurs when atrial contractions are 'normal' but

no electrical conduction is conveyed to the ventricles. The ventricles then generate their

own signal through an 'escape mechanism' from a focus somewhere within the ventricle.

The ventricular escape beats are usually 'slow'

Looking at the ECG you'll see that:

Rhythm - Regular

Rate - Slow

QRS Duration - Prolonged

P Wave - Unrelated

P Wave rate - Normal but faster than QRS rate

P-R Interval - Variation

Complete AV block. No atrial impulses pass through the atrioventricular node and the

ventricles generate their own rhythm

Bundle Branch Block

Abnormal conduction through the bundle branches will cause a depolarization delay through

the ventricular muscle, this delay shows as a widening of the QRS complex. Right Bundle

Branch Block (RBBB) indicates problems in the right side of the heart. Whereas Left Bundle

Branch Block (LBBB) is an indication of heart disease. If LBBB is present then further

interpretation of the ECG cannot be carried out.

Looking at the ECG you'll see that:

Rhythm - Regular

Rate - Normal

QRS Duration - Prolonged

P Wave - Ratio 1:1

P Wave rate - Normal and same as QRS rate

P-R Interval - Normal

Premature Ventricular Complexes

Due to a part of the heart depolarizing earlier than it should

Looking at the ECG you'll see that:

Rhythm - Regular

Rate - Normal

QRS Duration - Normal

P Wave - Ratio 1:1

P Wave rate - Normal and same as QRS rate

P-R Interval - Normal

Also you'll see 2 odd waveforms, these are the ventricles depolarising prematurely in

response to a signal within the ventricles.(Above - unifocal PVC's as they look alike if they

differed in appearance they would be called multifocal PVC's, as below)

Junctional Rhythms

Looking at the ECG you'll see that:

Rhythm - Regular

Rate - 40-60 Beats per minute

QRS Duration - Normal

P Wave - Ratio 1:1 if visible. Inverted in lead II

P Wave rate - Same as QRS rate

P-R Interval - Variable

Below - Accelerated Junctional Rhythm

Ventricular Tachycardia (VT) Abnormal

Looking at the ECG you'll see that:

Rhythm - Regular

Rate - 180-190 Beats per minute

QRS Duration - Prolonged

P Wave - Not seen

Results from abnormal tissues in the ventricles generating a rapid and irregular heart

rhythm. Poor cardiac output is usually associated with this rhythm thus causing the pt to go

into cardiac arrest. Shock this rhythm if the patient is unconscious and without a pulse

Ventricular Fibrillation (VF) Abnormal

Disorganised electrical signals cause the ventricles to quiver instead of contract in a

rhythmic fashion. A patient will be unconscious as blood is not pumped to the brain.

Immediate treatment by defibrillation is indicated. This condition may occur during or after

a myocardial infarct.

Looking at the ECG you'll see that:

Rhythm - Irregular

Rate - 300+, disorganised

QRS Duration - Not recognisable

P Wave - Not seen

This patient needs to be defibrillated!! QUICKLY

Asystole - Abnormal

Looking at the ECG you'll see that:

Rhythm - Flat

Rate - 0 Beats per minute

QRS Duration - None

P Wave - None

Carry out CPR!!

Myocardial Infarct (MI)

Looking at the ECG you'll see that:

Rhythm - Regular

Rate - 80 Beats per minute

QRS Duration - Normal

P Wave - Normal

S-T Element does not go isoelectric which indicates infarction

Info

ECG Component Time(sec) Small Squares

P Wave 0.10 up to 2.5

PR Interval 0.12 - 0.20 2.5-5.0

QRS 0.10 1.5-2.5

Thanks to Nixon Mcinnes for their support in producing this site

SJW 2006

1

AAnn IInnttrroodduuccttiioonn GGuuiiddee ttoo BBaassiicc EEKKGG IInntteerrpprreettaattiioonn

“Say what? “

A guide to be used in preparation for EKG Class before you attend PPrroovveennaa HHeeaalltthh MMeerrccyy MMeeddiiccaall CCeenntteerr

2

Cardiac Anatomy and Physiology The circulatory system is required to perfuse the tissues of the body to maintain cell life. It delivers oxygen and nutrients and removes waste products for elimination by the kidneys, liver and lungs. Effective circulation depends on normal electrical activation and mechanical function of the heart, normal cardiac structure and appropriate regulation. The important components of the circulatory system are the heart, great arteries (aorta and pulmonary artery), arterioles, capillaries, venules, great veins and lymphatics. The system is divided into two circuits in series, one supplying systemic requirements and the other serving the pulmonary tissues. The pulmonary artery is the only artery in the body to deliver deoxygenated blood. The pulmonary veins are the only veins in the body to deliver oxygenated blood. Poorly oxygenated blood collects in two major veins: the superior vena cava and the inferior vena cava. The superior and inferior vena cava empty into the right atrium. The coronary sinus which brings blood back from the heart itself also empties into the right atrium. The right atrium is the larger of the two atria although it recieves the same amount of blood. The blood is then pumped through the tricuspid atrioventricular valve into the right ventricle. From the right ventricle, blood is pumped through the pulmonary semi-lunar valve into the pulmonary trunk. This blood leaves the heart by the pulmonary arteries and travels through the lungs (where it is oxygenated) and into the pulmonary veins. The oxygenated blood then enters the left atrium. The blood then travels through the bicuspid valve, also called mitral valve, into the left ventricle. The left ventricle is thicker and more muscular than the right ventricle because it pumps blood at a higher pressure. From the left ventricle, blood is pumped through the semi-lunar valve into the

3

aorta. Once the blood goes through systemic circulation, peripheral tissues will extract oxygen from the blood, which will again be collected inside the vena cava and the process will continue. Peripheral tissues do not fully deoxygenate the blood, thus venous blood does have oxygen, only in a lower concentration as arterial blood. Cardiac Cycle The cardiac cycle can be divided into distinct periods determined by electrical and mechanical events.

Systole represents the time of contraction and ejection of blood from the ventricles.

Diastole represents ventricular filling and a brief period just prior to filling at which time the ventricles are relaxing.

Atrial Contraction is the first phase of the cardiac cycle. It is initiated by the p wave of the electrocardiogram (ECG), which represents electrical depolarization of the atria. Atrial depolarization then causes contraction of the atrial musculature. As the atria contract, the pressure within the atrial chambers increases so that a pressure gradient is generated across the open atrioventricular (AV) valves causing a rapid flow of blood into the ventricles. Atrial contraction normally accounts for about 10% of left ventricular filling when a person is at rest because most of the ventricular filling occurs before the atria contract and therefore is passive. However, if heart rate is very high (e.g., during exercise), the atrial contraction may account for up to 40% of ventricular filling. This is sometimes referred to as the "atrial kick." Ventricular contraction is phase of the cardiac cycle is initiated by the QRS complex of the ECG which represents ventricular depolarization. When the intraventricular

4

pressures exceed the pressures within the aorta and pulmonary artery, the aortic and pulmonic valves open and blood is ejected out of the ventricles. Approximately 150-200 msec after the QRS, ventricular repolarization occurs (T-wave). This causes ventricular active tension to decrease and the rate of ejection (ventricular emptying) to fall. How the ECG works When cell membranes in the heart depolarize, voltages change and currents flow. Because a human can be regarded as a bag of salt water, in other words, a volume conductor, changes in potential are transmitted throughout the body, and can be measured. When the heart depolarizes, it's convenient (and fairly accurate) to represent the electrical activity as a dipole --- a vector between two point charges. Remember that a vector has both a size (magnitude), and a direction. By looking at how the potential varies around the volume conductor, one can get an idea of the direction of the vector. This applies to all intra-cardiac events, so we can talk about a vector (or axis) for P waves, the QRS complex, T waves, and so on. Cardiac Conduction System

In order for normal depolarization and repolarization to occur, the electrical impulse within the cardiac cell must follow a specific pathway within the heart. This pathway is known as the conduction system.

The SA (sinoatrial) node is located in the upper part of the right atrium and is normally the primary, dominant pacemaker of the heart. When the SA node is stimulated the impulse travels to the AV node (atrioventricular) node, which is located between the atria and ventricles. The impulse then moves on to the Bundle of His and innervates the right and left bundle branches, which are located within the intraventricular septum. Finally, the Purkinje fibers located within the ventricular muscles are stimulated,

5

causing ventricular repolarization. The EKG tracing reflects these depolarization and repolarization events. Although the SA node is the primary and dominant pacemaker of the heart, another pacemaker may take control of the heart rate under certain circumstances. In general, the pacemaker with the fastest inherent rate is dominant. In adults and children, this should be the SA node, which fires a rate of 60 – 100 beats per minute (in adults). The AV node fires at a rate of 40 – 60 beats per minute and the ventricular fibers fire at a rate of 20 – 40.

Changes in the serum concentration of ions, particularly potassium, can cause changes in SA nodal firing rate. Hyperkalemia induces bradycardia or can even stop SA nodal firing. Hypokalemia causes tachycardia and ventricular ectopies. Whenever an action potential is generated, Na+ enters the cell and K+ leaves the cell.

Characteristics of the Cardiac Cell

Automaticity refers to the ability of the cardiac muscles to depolarize spontaneously, i.e without external electrical stimulization from the nervous system.

6

Contractility is the intrinsic ability of a cardiac muscle fibre to shorten in response to the electrical stimulus, causing a contraction.

If myocardial performance changes while preload, afterload and heart rate are all constant, then the change in performance must be due to the change in contractility.

Condcutivity is the ability of the cardiac muscles (cells) to receive an electrical impulse and conduct it to other cardiac cells.

Excitibility (also referred to as irritability) is the capability of the

resting polarized cardiac cell to depolarize in response to an electrical stimulus.

Rhythmicity is the ability of the heart to conduct electrical impulses in

a regular, timely fashion. Cardiac Output (CO)

The primary function of the heart is to impart energy to blood in order to generate and sustain an arterial blood pressure necessary to provide adequate perfusion of organs. The heart achieves this by contracting its muscular walls around a closed chamber to generate sufficient pressure to propel blood from the cardiac chamber (e.g., left ventricle), through the aortic valve and into the aorta.

Each time the heart beats; a volume of blood is ejected. This stroke volume (SV), times the number of beats per minute (heart rate, HR), equals the cardiac output (CO).

CO = SV · HR

Stroke volume is expressed in ml/beat and heart rate in beats/minute. Therefore, cardiac output is in ml/minute. Sometimes, cardiac output is expressed in liters/minute.

Heart Rate (HR)

Heart rate is normally determined by the pacemaker activity of the SA node located in the posterior wall of the right atrium. The SA node exhibits automaticity that is determined by spontaneous changes in Ca++, Na+, and K+ conduction. Heart rate is decreased below the intrinsic rate primarily by activation of the vagus nerve innervating the SA node. Normally, at rest, there is significant vagal tone on the SA node so that the resting heart rate is between 60 and 80 beats/min.

This vagal influence can be demonstrated by administration of atropine, which leads to a 20-40-beats/min increase in heart rate depending upon the initial level of vagal tone. The heart is innervated by vagal and sympathetic fibers. The right vagus nerve primarily innervates the SA node, whereas the left vagus innervates the AV node;

7

however, there can be significant overlap in the anatomical distribution. Atrial muscle is also innervated by vagal efferents, whereas the ventricular myocardium is only sparsely innervated by vagal efferents. Sympathetic efferent nerves are present throughout the atria (especially in the SA node) and ventricles, including the conduction system of the heart.

Stroke Volume (SV) There are three primary mechanisms that regulate SV.

1) Preload can be defined as the initial stretching of the cardiac myocytes (cells) prior to contraction.

2) Afterload is the pressure the ventricle generates during systolic ejection is very close to aortic pressure

3) Changes in contractility alter the rate of force and pressure development by the ventricle, and therefore change the rate of ejection

Autonomic Nervous System The autonomic nervous system consists of sensory neurons and motor neurons that run between the central nervous system (especially the hypothalamus and medulla oblongata) and various internal organs such as the:

Heart Lungs Viscera Glands (both exocrine and endocrine)

It is responsible for monitoring conditions in the internal environment and bringing about appropriate changes in them. The contraction of both smooth muscle and cardiac muscle is controlled by motor neurons of the autonomic system. The normal pacemaker site for the heart is located within the SA node. Cells within this pacemaker region have an intrinsic firing rate that is modulated primarily by changes in autonomic nerve activity. If there is a high level of vagal tone on the SA node, then this will cause sinus bradycardia (a sinus rate <60 beats/min). Conversely, an abnormally high level of sympathetic tone on the SA node will cause sinus tachycardia (a sinus rate >100 beats/min).

8

Sympathetic Nervous System

Stimulation of the sympathetic branch of the autonomic nervous system prepares the body for emergencies: for "fight or flight".

The release of noradrenaline:

Stimulates heartbeat Raises blood pressure Dilates the pupils Dilates the trachea and bronchi Stimulates the conversion of liver glycogen into glucose Shunts blood away from the skin and viscera to the skeletal muscles,

brain, and heart Inhibits peristalsis in the gastrointestinal (GI) tract Inhibits contraction of the bladder and rectum

Vagus Nerve

The vagus nerve (cranial nerve X) is the tenth of twelve paired cranial nerves, and is the only nerve that starts in the brainstem (within the medulla oblongata) and extends, through the jugular foramen, down below the head, to the abdomen. The vagus nerve is arguably the single most important nerve in the body.

9

ParasympatheticNervous System

Parasympathetic innervation of the heart is mediated by the vagus nerve. The right vagus innervates the Sinoatrial node. Parasympathetic hyperstimulation predisposes those affected to bradyarrhythmias. The left vagus when hyperstimulated predisposes the heart to Atrioventricular (AV) blocks.

Parasympathetic stimulation causes:

Slowing down of the heartbeat Lowering of blood pressure Constriction of the pupils Increased blood flow to the skin and viscera Peristalsis of the GI tract

Sympathetic and Parasympathetic effects on the cardiac conduction system

Paper

ECG paper is traditionally divided into 1mm squares. Vertically, ten blocks usually correspond to 1 mV, and on the horizontal axis, the paper speed is usually 25mm/s, so one block is 0.04s (or 40ms). Note that we also have "big blocks" which are 5mm on their side.

10

Always check the calibration voltage on the right of the ECG, and paper speed. The following image shows the normal 1mV calibration spike:

Damping

Note that if the calibration signal is not "squared off" then the ECG tracing is either over or under-damped, and should not be trusted.

1. P wave = depolarization of the atria. QRS = depolarization of the ventricle. T wave = repolarization of the ventricle.

Description of the waves on the ECG.

2. Cardiac muscle cells depolarize with a positive wave of depolarization, and then repolarize to a negative charge intracellularly.

3. Skin "leads" or electrodes have a positive and negative end. 4. A positive waveform (QRS mainly above the baseline) results from the wave of

depolarization moving towards the positive end of the lead. A negative waveform (QRS mainly below the baseline) is when a wave of depolarization is moving away from the positive electrode (towards the negative end of the lead).

5. ECG paper has 1millimeter small squares - so height and depth of wave is measured in millimeters. 10 mm = 1.0 mVolt

6. Horizontal axis is time. . 04 seconds for 1 mm (1 small box). . 20 seconds for 1 large box = 5 small boxes = 5 x .04 seconds.

11

Positive QRS in Lead I. Negative QRS in Lead aVR. R wave = 7-8 mm high in Lead I. QRS wave = .06 seconds long in Lead I.

Rate Rate is cycles or beats per minute. Normal rate for the SA node 60 – 100. SA node is the usual pacemaker, other potential pacemakers (if SA node fails) are atrial pacemakers with inherent rates of 60-80, AV node (rate 40-60), or ventricular pacer (rate 20-40). In certain pathologic conditions ectopic (out of place) pacemakers can go much faster at rates 150-250 cycles/minute. There are three methods of calculating rate: Most Common Method: (Most rates can be calculated this way). Find an R wave on a heavy line (large box) count off "300, 150, 100, 75, 60, 50" for each large box you land on until you reach the next R wave. Estimate the rate if the second R wave doesn't fall on a heavy black line.

Rate calculation Memorize the number sequence:

300, 150, 100, 75, 60, 50

1.

<60 bradycardia

>100 tachycardia

12

2. Mathematical method: Use this method if there is a regular bradycardia, i.e. - rate < 50. If the distance between the two R waves is too long to use the common method, use the approach: 300/[# large boxes between two R waves].

Count number of large boxes between first and second R waves=7.5. 300/7.5 large boxes = rate 40.

3. Six-second method: Count off 30 large boxes = 6 seconds (remember 1 large box = 0.2 seconds, so 30 large boxes = 6 seconds). Then, count the number of R-R intervals in six seconds and multiply by 10. This is the number of beats per minute. This is most useful if you have an irregular rhythm (like atrial fibrillation) when you want to know an average rate.

Count 30 large boxes, starting from the first R wave. There are 8 R-R intervals within 30 boxes. Multiply 8 x 10 = Rate 80.

ECG Lead Placement

Lead Selection

Lead II is the same as standard lead two as seen in a 12 lead EKG.

13

o It is the most common monitoring lead. o It is not the optimal monitoring lead

V1 lead is the best lead to view ventricular activity and differentiate between right and left bundle branch blocks.

o The only way to view V1 is with a five lead system. o Therefore, MCL1 was designed to overcome the inconvenience

of a five lead system and provide all the advantages of V1 viewing

Tips for Preparation

Wash site with soap and water Dry briskly, try not to abrade the skin Clip hair if necessary When possible attach leads to electrodes prior to attachment to patient Make sure electrode backing is moist Change electrodes daily

Troubleshooting Tips

Change the electrodes everyday. Make sure all electrical patient care equipment is grounded. Be sure all the lead cables are intact. Some manufacturers require

changing the cables periodically. Be sure the patient's skin is clean and dry. Make sure the leads are connected tightly to the electrodes. Patient movement frequently causes interference. For example, the

action of brushing teeth may cause interference that mimics V-tach

14

ECG (EKG) Waveforms P wave, the first positive deflection is called the P wave, which represents the contraction of the atria. The P wave represents the wave of depolarization that spreads from the SA node throughout the atria, and is usually 0.08 to 0.1 seconds (80-100 ms) in duration

PR interval is a short, flat pause called the PR interval, which is the space between the P wave and the R wave. The PR interval represents the time between when the electrical signal causes the atria to contract and when that signal causes the ventricles to contract. The period of time from the onset of the P wave to the beginning of the QRS complex is termed the P-R interval, which normally ranges from 0.12 to 0.20 seconds in duration. This interval represents the time between the onset of atrial depolarization and the onset of ventricular depolarization.

QRS interval, there may be a small dip called the Q wave (it may not be present) followed by a tall spike called the R wave and another small dip called the S wave. Together, the Q, R, and S waves (called the QRS complex) represent the activation of the left and right ventricles. The pattern of the QRS complex depends on the location of the electrode recording it. The QRS complex represents ventricular depolarization. The duration of the QRS complex is normally 0.06 to 0.10 or < 0.12 seconds. This relatively short duration indicates that ventricular depolarization normally occurs very rapidly. If the QRS complex is prolonged (> 0.1 sec), conduction is impaired within the ventricles.

T wave represents the resetting, or repolarization, of the electrical cells in the ventricles. By contrast, the resetting of the cells in the atria actually occurs while the ventricles are contracting, which masks the signal so it does not appear on the waveform. When the ventricles have reset, the entire cycle repeats and is represented by a new EKG waveform. The T wave represents ventricular repolarization and is longer in duration than depolarization (i.e., conduction of the repolarization wave is slower than the wave of depolarization). Sometimes a small positive U wave may be seen following the T wave. This wave represents the last remnants of ventricular repolarization. Inverted or prominent U waves indicate underlying pathology or conditions affecting repolarization.

QT interval represents the time for both ventricular depolarization and repolarization to occur, and therefore roughly estimates the duration of an average ventricular action potential. The QT interval can range from 0.2 to 0.4 seconds depending upon heart

15

rate. At high heart rates, ventricular action potentials shorten in duration, which decreases the Q-T interval. Because prolonged Q-T intervals can be diagnostic for susceptibility to certain types of tachyarrhythmias, it is important to determine if a given Q-T interval is excessively long.

EKG Rhythms Interpretation 5 Basic Steps

1. Rhythm check: regular / irregular, patterns 2. Rate: exact / approximate; atrial / ventricular 3. P waves: regular / upright, Look similar? In front / behind the QRS? More than 1? 4. PR interval: within normal measurement? Constant? Patterns? 5. QRS complex: within normal measurement? Look similar?

16

Sinus Rhythms Sinus rhythm occurs when the sinoatrial node, the normal cardiac pacemaker, depolarizes spontaneously, and the consequent wave of depolarization follows the natural pathways through the heart. The parasympathetic system normally slows the spontaneous discharge rate of the sinoatrial node from 100bpm to about 70bpm. Sinus rhythms (SR) are a class of rhythms that originate at the SA node. It is the standard against which all dysrhythmias are measured. The criteria for a Normal Sinus Rhythm is:

P wave before each QRS PR interval 0.12 to 0.20 seconds QRS < 0.12 seconds QT interval < 0.40 seconds Heart rate between 60 to 100 beats a

minute

If the rhythm does not meet of the above criteria, then it cannot be interpreted as a normal sinus rhythm Patients in Sinus Bradycardia (SB) can be asymptomatic. If slow heart rates are accompanied by a decrease in cardiac output, symptoms like syncope, hypotension, chest pain, or shortness of breath may be present. Treatment is not indicated unless patient is symptomatic. If symptomatic, consider atropine and pacing. Drips may be considered for pressure and rate. Treatment should be aimed at treating the underlying cause. The criteria for Sinus Bradycardia is:

P wave before each QRS PR interval 0.12 to 0.20 seconds QRS < 0.12 seconds QT interval < 0.40 seconds Heart rate less than 60 beats a minute

Sinus Tachycardia (ST) is usually cause by non-cardiac factors. Fear, anxiety, fever, anemia, hypovolemia, pain, pulmonary embolism may be factors in ST. Cardiac causes can include heart failure, acute MI, myocarditis, and pericarditis. Medications such as atropine. Isuprel, dopamine, Dobutamine, epinephrine can also cause an increase in heart rate.

17

The criteria for Sinus Tachycardia is:

P wave before each QRS PR interval 0.12 to 0.20 seconds QRS < 0.12 seconds QT interval < 0.40 seconds Heart rate greater than 100 beats a

minute to about 150 beats a minute Dysrhythmias (Arrhythmias) About 14 million people in the USA have arrhythmias (5% of the population). The most common disorders are atrial fibrillation and flutter. The incidence is highly related to age and the presence of underlying heart disease; the incidence approaches 30% following open-heart surgery.

Patients may describe an arrhythmia as a palpitation or fluttering sensation in the chest. For some types of arrhythmias, a skipped beat might be sensed because the subsequent beat produces a more forceful contraction and a thumping sensation in the chest. A "racing" heart is another description.

A frequent cause of arrhythmia is coronary artery disease because this condition results in myocardial ischemia or infarction. When cardiac cells lack oxygen, they become depolarized, which lead to altered impulse formation and/or altered impulse conduction. The former concerns changes in rhythm that are caused by changes in the automaticity of pacemaker cells or by abnormal generation of action potentials at sites other than the SA node (termed ectopic foci). Altered impulse conduction is usually associated with complete or partial block of electrical conduction within the heart. Altered impulse conduction commonly results in reentry, which can lead to tachyarrhythmias. Changes in cardiac structures that accompany heart failure (e.g., dilated or hypertrophied cardiac chambers), can also precipitate arrhythmias. Finally, many different types of drugs (including antiarrhythmic drugs) as well as electrolyte disturbances (primarily K+ and Ca++) can precipitate arrhythmias.

Arrhythmias can be either benign or more serious in nature depending on the hemodynamic consequence of the arrhythmia and the possibility of evolving into a lethal arrhythmia. Occasional premature ventricular complexes (PVCs), while annoying to a patient, are generally considered benign because they have little hemodynamic effect. Consequently, PVCs if not too frequent, are generally not treated. In contrast, ventricular tachycardia is a serious condition that can lead to heart failure, or worse, to ventricular fibrillation and death.

18

Premature Atrial Contractions

If the premature impulse falls in the relative refractory period or later, an atrial contraction may occur. This is called a Premature Atrial Contraction (PAC). The rate is determined by the underlying rhythm. Isolated PACs can occur in healthy adults and can be caused by anxiety, stress, excessive caffeine, nicotine, alcohol and drug use. Frequent is measured at 6 or more. Symptoms such as palpitations and fluttering may be present. Presence of PACs may forewarn of more serious atrial dysrhythmias such as atrial fibrillation and atrial flutter.

Examine the PAC for common characteristics of atrial complexes:

Upright normal P wave Looks different from Sinus P wave Narrow QRS complex < 0.12 seconds

If the SA node or the internodal pathways fail, suffer stress or damage, the atria can frequently initiate impulses from other portions of the atrial tissue. PACs are one possible outcome. Other dysrhythmias that may occur are atrial fibrillation and atrial flutter.

Atrial Fibrillation Atrial fibrillation (A fib or AF) describes a condition in which the atrial tissue randomly generates action potentials from man different regions. Physically, the atrial muscle appears to quiver. There are no noticeable P waves, and the overall rhythm is irregularly irregular

The atrial rate is impossible to count and may be as fast as 400 plus Ventricular rate is variable Uncontrolled: over 100 beats a minute Controlled: 60 – 100 beats a minute Over controlled: less than 60 beats a minute Rapid (RVR): is > 150 beats a minute

No P waves Irregular rhythm Chaotic baseline Narrow QRSs Heart rates greater than Atrial Flutter

Atrial flutter (A flutter) is recognized by the distinct “saw tooth” pattern of the P waves. The atria are “fluttering” at a rapid rate. These atrial impulses produce a series of waves that occur at a rate of at least 250 per minute. To keep the heart rate in control, the AV

19

node blocks many of the atrial impulses but allows some to reach the ventricles. Can be seen in patients with valvular heart disease, hypoxemia, lung disease, pulmonary embolus, heart failure, cardiomyopathy, and post cardiac surgery. The QRS complexes can appear at different intervals and frequencies. Naming conventions for depend on these relations:

Saw tooth pattern waves PR not measurable

Atrial flutter 2:1 block

2 flutter waves followed by 1 QRS Atrial flutter with variable block

Common Can range between as few as 1 flutter wave to 6 flutter waves between each

QRS complex The clinical significances of both atrial fibrillation and atrial flutter are that a fast heart rate can decrease cardiac output. The atria generally don’t have time to fill completely, the preload to the ventricles is reduced and atrial kick and cardiac output suffers. The erratic and turbulent blood flow can form small blood clots. If a blood clot is release, it can cause a stroke. The primary aim of treatment is to control the heart rate then restore sinus rhythm. For various reasons, conduction through the AV node may be come impeded or impaired. This may be benign or develop into a fatal dysrhythmia. Junctional Dysrhythmias Junctional dysrhythmias originate in the AV junction. When the SA node is unable to perform as the primary pacemaker of the heart, the AV node will assume control of the heart rate. The impulse is generally conducted differently than from the SA node and retrograde conduction is seen.

20

Premature Junctional Contractions The AV node like other cardiac tissue has automaticity. The AV node is stimulated before it fires by itself. Occasionally, an extra impulse may develop in the junction, spreading to the atria and down to the ventricles. Just like in the case of PACs, the Premature Junctional Contractions (PJCs) occur periodically.

The rate is determined by the underlying rhythm and number of premature beats

The P wave of the PJC may be seen inverted before the QRS, inverted after the QRS or not at all

Etiology and treatment same as PAC A PJC may be seen in patients with respiratory difficulty. The poor gas exchange irritates myocardial tissue and causes abnormal activity. Clinically, PJCs are not usually treated.

Junctional (Junctional Escape) If no stimulus reaches the AV node, the cells assume that the SA node never fired. The AV junction will reach it automatic threshold and generate an action potential. Unlike, PJCs, the escape complexes will appear late in the rhythm (why they are call escape beats) and although you may not treat PJCs, escape rhythms may need treatment. P waves, if seen, will be retrograde conducted and be inverted before or after the QRS and may not be seen at all. The QRS complex should remain narrow because the impulses are generated above the ventricles.

Rate is between 40 to 60 beats a minute

Rhythm is regular P waves are inverted when

seen QRS should be normal

Cardiac output may be impaired or lost along with loss of the atrial kick. Patients may be asymptomatic. Symptoms might include lightheadedness and syncope and may be treated like symptomatic bradycardia.

Accelerated Junctional and Junctional Tachycardia

Accelerated Junctional Rate 60 – 100 beats a minute Junctional Tachycardia Rate 100 – 250 beats a minute

Etiologies usually include ischemia, digoxin toxicity, hypoxia and electrolyte imbalance. Treatment is usually observation and discontinuing the offending medications.

21

Supraventricular Tachycardia The term Supraventricular Tachycardia (SVT) refers to any tachycardia in which the pacemaker is located above the ventricles. With fast heart rates the P waves may not be seen. SVT is used to classify rapid, regular rates greater than 150 beats a minute in which P waves are not identifiable. Treatment of SVT is the same as for all rapids rates, control of the rate and return to normal sinus rhythm. Valsalva maneuvers like bearing down, coughing, and throwing up can cause the heart rate to decrease. Carotid massage should only be done by a licensed independent practitioner trained in the skill.

Adenosine is the medication of choice for rapid heart rates. It has a fast half-life and can either break the rapid heart rate, converting it to sinus or it can slow the conduction to allow visualization of the underlying rhythm. Adenosine (Adenocard) is given rapidly with a rapid intravenous bolus of normal saline. The initial dose is 6 mg followed by a doubling of the dose to 12 mg, which may be repeated once more if not effective. Rhythms included in SVT include but not limited to:

Atrial Tachycardia Junctional Tachycardia Atrial Fibrillation with a rapid ventricular response Atrial Flutter Rapid unidentifiable sinus tachycardia

22

Heart Blocks

AV blocks result from an impaired impulse transmission between the atria and ventricles. Atrial impulse formation is normal, however, they are delayed, intermittently blocked, or completely blocked by the AV node. The major distinguishing characteristics are either PR interval abnormalities and/or more Ps than QRSs.

1st Degree heart Block 1st Degree AV Blocks (AVB) are generally benign. They are characterized by a constant PR interval greater than 0.20 seconds. The rhythm is otherwise normal. Rates may range from bradycardias to tachycardias with a full variation in between. Normally, there are no symptoms associated with 1st Degree AVB. Excessive medications, AV node trauma, Ischemia or disease, hyperkalemia, rheumatic fever, viral myocarditis or congenital heart disease may precipitate this rhythm. It may be temporary or permanent and in some cases, may progressive to a more severe block. Treatment depends on cause. 2nd Degree Heart Block 2nd Degree AV Blocks are subdivided into 2 types: Mobitz I and Mobtiz II 2nd Degree AV Block (AVB) Type I, Wenchebach, or Mobitz Type I, is distinguished by a repeating cycle of increasing PR intervals. As the interval gets longer, a P wave is either not conducted (there is no QRS) or the P wave is simply dropped. The cycle then repeats again. Impulse generation is delayed at the AV node. The delay progressively lengthens the PR intervals until the impulse cannot be conducted. Mobitz Type I is more common than Mobitz Type II and are generally not dangerous. The patient may complain of palpitations or skipped beats. Digoxin toxicity, post-operative surgery, inferior MI and congenital heart disease may accompany this rhythm. Treat symptomatic low heart rate.

23

2nd Degree AV Block (AVB) Type II or Mobitz Type II, can be recognized by a consistent PR interval and frequently non-conductive P waves. QRS complexes may appear widened depending on the location of the block. Wide QRS complexes indicate that the ventricles are depolarizing from an action potential in the ventricular tissue, rather than from at the AV node or above. Generally, Mobitz Type II is not a good sign and may tend to worsen leading to 3rd Degree Heart Blocks. Impulse conduction is intermittently blocked at the AV node or Bundle of His. Impulse transmission time can be normal or prolonged, but always constant. Impulse can be blocked in a fixed or varying rate.

Most frequently seen after an acute anterior wall MI, severe CAD, cardiomyopathy, age-related deterioration of the conduction system. Slow ventricular rate can impair cardiac output and lead to hypotension, angina, CHF or syncope. Frequently progresses to more severe block. Atropine has little to no effect and pacing is the only treatment. Attempt Transcutaneous and then Transvenous pacing.

3rd Degree AV Block (AVB), Complete Heart Block (CHB), is the most dangerous heart block. There is absolutely no conduction through the AV node. Due to the automaticity of each region of the heart, the atria beat at their intrinsic rate of about 60 to 80 beats a minute and the ventricles, which are completely isolated from the atrial beat at their slower rate of 20 to 40 beats a minute. The QRS complexes will often be wide, but depending on the origin of the ventricular action potential, they may remain narrow. The P – P interval and R – R intervals will each be regular and consistent. The P – P will be faster than the R – R and there will be no relation between the two.

3rd Degree AVB can be caused by AV node disease, ischemia, calcium or beta- blockers, acute inferior and anterior wall MI, chronic degeneration of conduction with age. Both second and third degree heart blocks require pacemaker intervention!

24

Ventricular Dysrhythmias Normal impulse conduction can either be interrupted by an ectopic impulse or absent due to failure of a higher pacemaker to control and initiate the heart rate. Ventricular dysrhythmias can be a very serious problem. Impulses from the ventricle follow an abnormal pathway and may lead to alteration in cardiac output, which could be lethal.

Premature Ventricular Contractions (PVC) In adults, coronary heart disease is the leading cause of PVCs. Premature Ventricular Contractions (PVC) result from an irritable focus in the ventricles and initiate an early beat. The rate is determined by the underlying rhythm and number of premature beats. The PVC will occur as an early beat and is usually followed by a compensatory pause. If no compensatory pause is present, the PVC is said to be interpolated (between the two poles) the QRS of the PVC is wide and bizarre. PVCs can be caused by a variety of conditions including respiratory problems and stress. PVC s can also be seen after an MI, with low potassium and magnesium, low PO2/hypoxia, digoxin toxicity, and improper PA catheter placement. Drugs like theophylline, Isuprel and dopamine can precipitate PVCs. Patients can experience symptoms like hypotension, syncope, and further dysrhythmias. Medications used in the treatment of PVCs include, amidodarone, Lidocaine, and other antiarrhythmics. PVCs are classified on the basis of their origin. Unifocal PVCs originate from the same focus They all have the same shape or morphology Multifocal PVCs arise from multiple foci. Each PVC has a unique morphology. PVCs are also classified by their frequency If each normal contraction is followed by a single PVC, we call this Bigeminy If two normal contractions are followed by a single PVC, this is called trigeminy If three normal contractions are followed by a single PVC, this is called quadrigeminy, etc.

25

Couplets Two PVCs in a row are called a couplet Three or more PVCs in a row is called a short run of V-tach R on T Phenomena R on T phenomena is described as an action potential, depolarization of ventricular muscle during the recovery phase of the ventricle. R on T can lead to a fatal dysrhythmia called ventricular tachycardia (v tach). R on T can occur with very fast rates, but also with prolonged QT intervals, ectopic beats like PACs, PJCs, and PVCs. It can be precipitated by electrolyte imbalance. Ventricular Tachycardia (VT, V tach) Ventricular tachycardia (VT) is a serious, life threatening, rapid dysrhythmia in which the ventricles depolarize very quickly. V tach is actually said to happen whenever three or more PVCs in a row occur. Rate for v-tach may vary between 100 to 250 beats a minute, may be intermittent or sustained and might have been preceded by signs of cardiac irritability: R on T, Bigeminy and couplets. If you have a pulse for every complex, the pulse will be weak and cardiac output low. If you have a pulse for some beats, this is ominous. If you have no pulse, you need to intervene and resuscitate the patient! Ventricular tachycardia may lead to ventricular fibrillation. Treatment includes admiodarone, Lidocaine, synchronized cardioversion and / or defibrillation. Ventricular Fibrillation (VF, V fib) Ventricular fibrillation (VF, vfib) is the most common fatal dysrhythmia in adult patients. Vfib represents a chaotic depolarization or random ventricular cells. The ventricles are said to be quivering and have been described as resembling a bowl of jello! There is no cardiac output and death will result without intervention and termination. Vfib can be fine or coarse, as tissue dies, the voltage decreases, coarse might be better than fine, all things considered.

26

Idioventricular Rhythm Idioventricular rhythm (agonal rhythm) is the heart’s last possible mechanism to maintain a heart rate. In the absence of a higher pacemaker, the ventricles initiate an impulse at their inherent rate (escape rate) of 2o to 40 beats a minute. The heart rate is usually ranges between 20 to 40, regular, no P waves, wide and bizarre QRS.

Asystole Asystole is the absence of all electrical activity in the heart. It is seen on the EKG monitor as a straight line. It is a lethal rhythm with poor prognosis. Asystole must be “conformed: in 2 leads and by turning the gain up. If the rhythm demonstrates fine fibrillatory characteristics, treat like vfib. Ensure that the patient’s leads have not fallen off or become otherwise, detached from the patient. Consider atropine, epinephrine and attempt a pacemaker. Consider stopping rescue efforts.

Brush up on Your Drug Calculation Skills

HOME

Who am I?

Interesting Articles

Helpful Hints & Links

Publication Guidelines

Advertising Info

Contacting Me

Visit me at work atLehigh Valley

Wellness Center

byLouise Diehl, RN, MSN, ND, CCRN, ACNS-BC, NP-C

Nurse Practitioner - OwnerDoctor of Naturopathy

Lehigh Valley Wellness Center

Many nurses are weak with drug calculations of all sorts. This article will help to review the major concepts related to drug calculations, help walk you through a few exercises, and provide a few exercises you can perform on your own to check your skills. There are many reference books available to review basic math skills, if you find that you have difficulty with even the basic conversion exercises.

Common Conversions:

1 Liter = 1000 Milliliters1 Gram = 1000 Milligrams1 Milligram = 1000 Micrograms1 Kilogram = 2.2 pounds

Methods of Calculation

Any of the following three methods can be used to perform drug calculations. Please review all three methods and select the one that works for you. It is important to practice the method that you prefer to become proficient in calculating drug dosages.

Remember: Before doing the calculation, convert units of measurement to one system.

I. Basic Formula: Frequently used to calculate drug dosages.

D (Desired dose) H (Dose on hand) V (Vehicle-tablet or liquid)

Page 1 of 9nursesaregreat.com - Brush up on Your Drug Calculation Skills

1/4/2012http://nursesaregreat.com/articles/drugcal.htm

D = dose ordered or desired dose H = dose on container label or dose on hand V = form and amount in which drug comes (tablet, capsule, liquid)

II. Ratio & Proportion: Oldest method used in calculating dosage.

Left side are known quantities Right side is desired dose and amount to give

Multiply the means and the extremes

D=1 gm (note: need to convert to milligrams)1 gm = 1000 mg

H=250 mg V=1 capsule

250X = 1000

DH x V = Amount to Give

Example: Order-Dilantin 50 mg p.o. TIDDrug available-Dilantin 125 mg/5ml

D=50 mg H=125 mg V=5 ml

50 125 x 5 = 250

125 = 2 ml

Known Desired

H : V :: D : X

Means

Extremes

HX = DV

X = DVH

Example: Order-Keflex 1 gm p.o. BIDDrug available-Keflex 250 mg per capsule

250 : 1 :: 1000 : X

X = 1000250

Page 2 of 9nursesaregreat.com - Brush up on Your Drug Calculation Skills

1/4/2012http://nursesaregreat.com/articles/drugcal.htm

X = 4 capsules

III. Fractional Equation

Cross multiply and solve for X.

0.125X = 0.25

X = 2 tablets

IV. Intravenous Flow Rate Calculation (two methods)

Two Step

Step 1 - Amount of fluid divided by hours to administer = ml/hr

One Step

Two Step

HV = DX

HV = DX

HX = DV

X = DVH

Example: Order - Digoxin 0.25 mg p.o. QDDrug Available - 0.125 mg per tablet

D=0.25 mg H=0.125 mg V=1 tablet

0.1251 = 0.25

X

X = 0.25 0.125

Step 2 - ml/hr x gtts/ml(IV set)60 min = gtts/min

amount of fluid x drops/milliliter (IV set)hours to administer x minutes/hour (60)

Example: 1000 ml over 8 hrsIV set = 15 gtts/ml

Page 3 of 9nursesaregreat.com - Brush up on Your Drug Calculation Skills

1/4/2012http://nursesaregreat.com/articles/drugcal.htm

One Step

V. How to Calculate Continuous Infusions

A. mg/min (For example - Lidocaine, Pronestyl)

B. mcg/min (For example - Nitroglycerin)

Step 1 - 10008 = 125

Step 2 - 125 x 1560 = 31.25 (31 gtts/min)

1000 x 158 hrs x 60 = 15,000

480 = 31.25 (31gtts/min)

Solution cc x 60 min/hr x mg/minDrug mg = cc/hr

Drug mg x cc/hr Solution cc x 60 min/hr = mg/hr

Rule of Thumb

Lidocaine, Pronestyl2 gms/250 cc D5W

1 mg = 7 cc/hr2 mg = 15 cc/hr3 mg = 22 cc/hr4 mg = 30 cc/hr

Solution cc x 60 min/hr x mcg/minDrug mcg = cc/hr

Drug mcg x cc/hr Solution cc x 60 min/hr = mcg/hr

Rule of Thumb

NTG 100 mg/250 cc

1 cc/hr = 6.6 mcg/min

NTG 50 mg/250 cc

1 cc/hr = 3.3 mcg/min

Page 4 of 9nursesaregreat.com - Brush up on Your Drug Calculation Skills

1/4/2012http://nursesaregreat.com/articles/drugcal.htm

C. mcg/kg/min (For example - Dopamine, Dobutamine, Nipride, etc.)

1. To calculate cc/hr (gtts/min)

2. To calculate mcg/kg/min

A. How to calculate mcg/kg/min if you know the rate of the infusion

For example:

26.6 is the dosage concentration for Dopamine in mcg/cc/min based on having 400 mg in 250 cc of IV fluid. You need this to calculate this dosage concentration first for all drug calculations. Once you do this step, you can do anything!

NOW DO THE REST!

If you have a 75 kg patient for example...

Solution ccDrug mcg x 60 min/hr x kg x mcg/kg/min = cc/hr

Example: Dopamine 400 mg/250 cc D5W to start at 5 mcg/kg/min.Patient’s weight is 190 lbs.

250 cc 400,000 mcg x 60 min x 86.4 x 5 mcg/kg/min = 16.2 cc/hr

Drug mcg/ x cc/hr Solution cc x 60 min/hr x kg = mcg/kg/min

Example: Nipride 100 mg/250 cc D5W was ordered to decrease your patient’s blood pressure.The patient’s weight is 143 lbs, and the IV pump is set at 25 cc/hr. How many mcg/kg/min of Nipride is the patient receiving?

100,000 mcg x 25 cc/hr250 cc x 60 min x 65 kg = 2,500,000

975,000 = 2.5 mcg/kg/min

Dosage (in mcg/cc/min) x rate on pumpPatient’s weight in kg = mcg/kg/min

400mg of Dopamine in 250 cc D5W = 1600 mcg/cc60 min/hr

= 26.6 mcg/cc/min

26.6 mcg/cc/min x 10 cc on pumpPatients’s weight in kg (75 kg) = 3.54 mcg/kg/min

= 3.5 mcg/kg/min (rounded down)

Page 5 of 9nursesaregreat.com - Brush up on Your Drug Calculation Skills

1/4/2012http://nursesaregreat.com/articles/drugcal.htm

B. How to calculate drips in cc per hour when you know the mcg/kg/min that is ordered or desired

For example:

400 mg Dopamine in 250 cc D5W = 26.6 mcg/cc/min

ALWAYS WORK THE EQUATION BACKWARDS AGAIN TO DOUBLE CHECK YOUR MATH!

For example:

For example:

400mg of Dopamine in 250 cc D5W = 1600 mcg/cc 60 min/hr = 26.6 mcg/cc/min

26.6 is the dosage concentration for Dopamine in mcg/cc/min based on having 400 mg in 250 cc of IV fluid. You need this to calculate this dosage concentration first for all drug calculations. Once you do this step, you can do anything!

NOW DO THE REST!!

If you have a 75 kg patient for example

Now do some practice exercises to check what you learned

A. Practice Problems:

1. 2.5 liters to milliliters 2. 7.5 grams to milligrams 3. 10 milligrams to micrograms 4. 500 milligrams to grams 5. 7500 micrograms to milligrams 6. 2800 milliliters to liters 7. 165 pounds to kilograms

mcg/kg/min x patient’s weight in kgdosage concentration in mcg/cc/min = rate on pump

3.5 mcg/kg/min x 75 kg26.6 mcg/cc/min = 9.86 cc

= 10 cc rounded up

10 cc x 26.6 mcg/cc/min75 Kg = 3.5 mcg/kg/min

Dosage (in mcg/cc/min) x rate on pumpPatient’s weight in kg = mcg/kg/min

26.6 mcg/cc/min x 10 cc on pumpPatients’s weight in kg (75 kg) = 3.54 mcg/kg/min

Page 6 of 9nursesaregreat.com - Brush up on Your Drug Calculation Skills

1/4/2012http://nursesaregreat.com/articles/drugcal.htm

8. 80 kilograms to pounds

B. Practice Problems: Use the method you have chosen to calculate the amount to give.

1. Order-Dexamethasone 1 mgDrug available-Dexamethasone 0.5 mg per tablet

2. Order-Tagamet 0.6 gmDrug available-Tagamet 300 mg per tablet

3. Order-Phenobarbital 60 mgDrug available-Phenobarbital 15 mg per tablet

4. Order-Ampicillin 0.5 gmDrug available-Ampicillin 250 mg per 5 ml

5. Order-Dicloxacillin 125 mgDrug Available-Dicloxacillin 62.5 mg per 5 ml

6. Order-Medrol 75 mg IMDrug Available-Medrol 125 mg per 2 ml

7. Order-Lidocaine 1 mg per kgPatient’s weight is 152 pounds

8. Order- 520 mg of a medication in a 24 hour period. The drug is ordered every 6 hours.How many milligrams will be given for each dose?

C. Practice Problems:

D. Practice Problems:

1. Dopamine 400 mg in 250 cc D5W to infuse at 5 mcg/kg/min. The patient’s weight is 200 pounds. How many cc/hour would this be on an infusion pump?

2. A Dopamine drip (400mg in 250 cc of IV fluid) is infusing on your 80 kg patient at 20 cc/hour. How many mcg/kg/min are infusing for this patient?

3. A Nitroglycerin drip is ordered for your patient to control his chest pain. The concentration is 100 mg in 250 cc D5W. The order is to begin the infusion at 20 mcg/min. What is the rate you would begin the infusion on the infusion pump?

4. A Nitroglycerin drip (100mg in 250 cc D5W) is infusing on your patient at 28 cc/hour on the infusion pump. How many mcg/min

1. Order-1000 ml over 6 hrs

2. Order-500 ml over 4 hrs

3. Order-100 ml over 20 min.

IV set 15 gtts/ml

IV set 10 gtts/ml

IV set 15 gtts/ml

Page 7 of 9nursesaregreat.com - Brush up on Your Drug Calculation Skills

1/4/2012http://nursesaregreat.com/articles/drugcal.htm

is your patient receiving?

5. A procainamide drip is ordered (2gms in 250 cc D5W) to infuse at 4 mg/min. The patient weighs 165 pounds. Calculate the drip rate in cc/hour for which the infusion pump will be set at.

6. A Lidocaine drip is infusion on your 90 kg patient at 22 cc/hour. The Lidocaine concentration is 2 grams in 250 cc of D5W. How many mg/min is your patient receiving?

Summary

Many nurses have difficulty with drug calculations. Mostly because they don’t enjoy or understand math. Practicing drug calculations will help nurses develop stronger and more confident math skills. Many drugs require some type of calculation prior to administration. The drug calculations range in complexity from requiring a simple conversion calculation to a more complex calculation for drugs administered by mcg/kg/min. Regardless of the drug to be administered, careful and accurate calculations are important to help prevent medication errors. Many nurses become overwhelmed when performing the drug calculations, when they require multiple steps or involve life-threatening drugs. The main principle is to remain focused on what you are doing and try to not let outside distractions cause you to make a error in calculations. It is always a good idea to have another nurse double check your calculations. Sometimes nurses have difficulty calculating dosages on drugs that are potentially life threatening. This is often because they become focused on the actual drug and the possible consequences of an error in calculation. The best way to prevent this is to remember that the drug calculations are performed the same way regardless of what the drug is. For example, whether the infusion is a big bag of vitamins or a life threatening vasoactive cardiac drug, the calculation is done exactly the same way.

Many facilities use monitors to calculate the infusion rates, by plugging the numbers in the computer or monitor with a keypad and getting the exact infusion titration chart specifically for that patient. If you use this method for beginning your infusions and titrating the infusion rates, be very careful that you have entered the correct data to obtain the chart. Many errors take place because erroneous data is first entered and not identified. The nurses then titrate the drugs or administer the drugs based on an incorrect chart. A method to help prevent errors with this type of system is to have another nurse double check the data and the chart, or to do a hand calculation for comparison. The use of computers for drug calculations also causes nurses to get “rusty” in their abilities to perform drug calculations. It is suggested that the nurse perform the hand calculations from time to time, to maintain her/his math skills.

Answers to Practice Problems

A. Practice Problems 1. 2500 mL 2. 7500 mg 3. 10,000 mcg 4. 0.5 gm 5. 7.5 mg 6. 2.8 L 7. 75 kg 8. 176 lbs

Page 8 of 9nursesaregreat.com - Brush up on Your Drug Calculation Skills

1/4/2012http://nursesaregreat.com/articles/drugcal.htm

Copyright © 2002-2010, nursesaregreat.comALL RIGHTS RESERVED

B. Practice Problems 1. 2 tablets 2. 2 tablets 3. 4 tablets 4. 10 mL 5. 10 mL 6. 1.2 mL 7. 69 kg = 69 mg 8. 130 mg for 4 doses

C. Practice Problems 1. 41.6 (42) 2. 20.8 (21) 3. 75

D. Practice Problems 1. 17 cc/hr 2. 6.65 mcg/kg/min 3. 3 cc 4. 186.5 mcg/min 5. 30 cc/hr 6. 3 mg/min

Reference: Dosage Calculations Made Incredibly Easy! by Springhouse Corporation, 1998

Page 9 of 9nursesaregreat.com - Brush up on Your Drug Calculation Skills

1/4/2012http://nursesaregreat.com/articles/drugcal.htm