B-6634-001 Reviewed: June 2019 Page 1 of 3 Santa Clara

B-6634-001

Reviewed: June 2019

Page 1 of 3

Santa Clara Valley Medical Center

Emergency Department

Standards Manual

Standardized Procedure

Point of Care Laboratory Testing

I. POLICY 1. Functions Registered Nurses (RN) may perform:

a. Point of care (POC) laboratory testing for glucose and urine pregnancy in the Emergency Department

2. Circumstances under which RNs may perform these functions: a. Setting ED

b. Supervision Attending emergency physicians are always available for in-person consultation to RNs

c. Required patient conditions are listed in Table 1 3. Level: Independent Protocol, RN will order as physician co-sign required. II. PROTOCOL 1. Assessment

a. RNs should perform the subjective and objective assessments listed in Table 1

2. Diagnosis a. RNs should determine presence of a required patient condition

3. Plan a. RNs may obtain appropriate specimens and perform POC testing as listed in Table 1

b. Patient conditions requiring consultation: RNs should consult physicians under the following circumstances:

Emergent condition requiring prompt medical intervention after initial stabilizing care has been started

Acute decompensation of patient Problem which is not resolving as anticipated Clinical findings not consistent with clinical picture Upon request of patient, nurse, or supervising physician

RNs should notify supervising physician regarding the result of POC testing per the criteria in Table 1

c. Record keeping RNs should document in the electronic medical record: Assessment Patient condition POC test performed and result Supervising physician consultation and notification Date and time Signature and title

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Standards Manual



III. Requirements for RN:

1. Education and training a. Orientation/inservice to this standardized procedure b. Completion of POC testing class 2. Method of initial evaluation of competence

a. Completion of orientation/inservice competency validation for this standardized procedure 3. Method of ongoing evaluation of competence

a. Completion of annual competency review for standardized procedures. b. Any RN having successfully completed initial ED orientation and subsequent annual

competency trainings will be authorized to perform this standardized procedure, unless otherwise noted.

IV. Development and approval of standardized procedure

1. Method a. Developed and approved by authorized representatives of Nursing, the Medical Staff and Administration, according to standards set forth by CLIA

History: Original 04/12 Reviewed: 10/13, 12/14, 08/15, 07/16, 06/19 Revised: 12/17

Nurse Manager, Emergency Department Date

Chair, Department of Emergency Medicine Date

Director, Nurse-CC/OR Services Date

Chief Nursing Officer Date

Chair, Interdisciplinary Practice Committee Date

6/11/2019

6/10/2019

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Standards Manual



President, Medical Staff Date Table 1: POC laboratory testing

Required Patient Condition

Subjective Assessment

Objective Assessment POC Test Supervising Physician

Notification Criteria

Vaginal bleeding Onset, amount of bleeding; date of last normal menstrual period.

Vital signs; skin signs; level of consciousness

Urine HCG Positive urine HCG

Altered mental status

Onset, duration of altered mental status


POC Glucose

Glucose < 70 mg/dL or > 300 mg/dL

Seizure or syncope within 24 hours

Onset, duration of loss of consciousness or seizure


POC Glucose


Dizziness or lightheadedness

Onset, duration of dizziness; precipitating factors


POC Glucose


Dysuria or urinary frequency in female patient of child-bearing age

Onset, location amount of abdominal or flank pain on 1-10 scale; vomiting; hematuria; date of last normal menstrual period

Vital signs Urine HCG

Positive urine HCG

Abdominal pain in female patient of child-bearing age

Onset, location, amount of pain on 1-10 scale; vomiting; fever; date of last normal menstrual period.

Vital signs; level of consciousness

Urine HCG

Positive urine HCG

Patient with diabetes Current medications Vital signs; level of consciousness

POC Glucose


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Standards Manual


Intravenous Access I. POLICY 1. Functions Registered Nurses (RN) may perform:

a. Establishment of intravenous (IV) access and administration of IV fluids for patients in the Emergency Department (ED)

2. Circumstances under which RNs may perform these functions: a. Setting ED proper


c. Required patient conditions: Historical features Severe dyspnea Chest pain Syncope within past 12 hours

Upper gastrointestinal bleeding – vomiting blood or coffee grounds, melena

Severe vaginal bleeding Severe abdominal pain Physical examination features Heart rate > 120 in absence of fever Systolic blood pressure (SBP) < 100 mm Hg Oxygen saturation < 90% Altered mental status (including active seizure) Laboratory features POC Glucose < 70 or “high” mg/dL d. Level: Independent Protocol II. PROTOCOL 1. Assessment a. RNs should perform the following subjective assessment:

Description of severity of shortness of breath Description of location, type and amount of bleeding Description and timing of any loss of consciousness Description of location and amount of pain on a scale of 1-10 (7-10 = severe)

b. RNs should perform the following objective assessment: Estimation of visible blood loss

Vital signs – respiratory rate, heart rate, blood pressure, temperature, oxygen saturation

Respiratory – use of accessory muscles

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Standards Manual


Intravenous Access Circulatory – skin color, temperature Neurologic – mental status POC glucose result when performed

2. Diagnosis a. RNs should determine presence of a required patient condition as above

3. Plan a. Treatment

RNs may initiate an IV line with a saline lock or normal saline 0.9% and administer an IV fluid rate to keep the SBP ≥ 100 mm Hg when a required patient condition is present RNs may only access vascular access ports with right angle non-coring needle

RNs may only access renal dialysis shunts when patient is in extremis b. Patient conditions requiring consultation: RNs should consult physicians under the following circumstances:


Acute decompensation of patient Problem which is not resolving as anticipated Clinical findings not consistent with clinical picture Upon request of patient, nurse or supervising physician

c. Record keeping RNs should document the following in the ED nursing notes: Assessment Patient condition IV location, catheter size, fluid, flow rate Supervising physician consultation Date and time Signature and title III. Requirements for RN:

1. Method of initial evaluation of competence a. Completion of orientation/in-service competency validation for this standardized procedure

2. Method of ongoing evaluation of competence a. Completion of annual competency review for standardized procedures b. Any RN having successfully completed initial ED orientation and subsequent annual



1. Method

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Standards Manual


Intravenous Access a. Developed and approved by authorized representatives of Nursing, the Medical Staff and Administration

Approval: 5/94 History: Original 05/94, Revised 11/02, 11/04, 10/13, 12/17 Reviewed 01/09, 03/12, 05/14, 08/15, 07/16, 06/19






President, Medical Staff Date

6/11/2019

6/10/2019

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Reviewed: June 2019

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Standards Manual


Laboratory Testing

I. POLICY 1. Functions that Registered Nurses (RN) may perform:

a. Order selected blood and urine laboratory testing in the Emergency Department 2. Circumstances under which RNs may perform these functions: a. Setting ED


c. Required patient conditions are listed in Table 1 3. Level: Independent Protocol, RN will order as physician co-sign required. II. PROTOCOL

1. Definition a. Systemic inflammatory response syndrome (SIRS) (see Table 1): Any two of the following: Temperature > 38°C or < 36°C Respiratory rate > 20 bpm Heart rate > 90 bpm WBC > 12K or < 4K; or > 10% bands

2. Assessment a. RNs should perform the subjective and objective assessments listed in Table 1

3. Diagnosis a. RNs should determine the presence of a required patient condition as listed in Table 1

4. Plan a. RNs may obtain appropriate specimens and order blood and urine laboratory tests as listed in Table 1. b. Patient conditions requiring consultation: RNs should consult physicians under the following circumstances:


Acute decompensation of patient Problem which is not resolving as anticipated Clinical findings not consistent with clinical picture Upon request of patient, nurse, or supervising physician

RNs should notify supervising physician regarding the result of laboratory tests per the criteria listed in Table 1

c. Record keeping RNs should document in the electronic medical record: Assessment

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Standards Manual


Laboratory Testing

Patient condition Lab test performed and result Supervising physician consultation and notification Date and time Signature and title III. Requirements for RN:

1. Method of initial evaluation of competence a. Completion of orientation/in-service competency validation for this standardized procedure

2. Method of ongoing evaluation of competence a. Completion of annual competency review for standardized procedures b. Any RN having successfully completed initial ED orientation and subsequent annual



1. Method a. Developed and approved by authorized representatives of Nursing, the Medical Staff and Administration, according to standards set forth by CLIA

HISTORY: Original 05/94, REVISED: 11/02, 11/04, 05/06, 03/09, 05/12, 06/12, 07/12, 12/17 Reviewed: 10/13, 12/14, 08/15, 07/16, 06/19 Approval




6/11/2019

6/10/2019

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Standards Manual


Laboratory Testing



President, Medical Staff Date

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Standards Manual


Laboratory Testing

Table 1: Laboratory testing

Required Patient Condition

Subjective Assessment

Objective Assessment

Lab Test Supervising Physician

Notification Criteria

Vomiting blood or coffee grounds; melena

Onset, estimated amount of bleeding


Complete blood count (CBC)

Hct < 30%

Platelets < 150K

Syncope within 24 hours Onset, duration of loss of consciousness


Complete blood count (CBC)

Hct < 30%

Platelets < 150K

Glucose < 70 mg/dL or high on POC Glucose result

Current medications


Panel 7 Glucose < 70 mg/dL or > 300 mg/dL

Patient with chronic kidney disease on hemodialysis

Most recent hemodialysis


Panel 7 K ≥ 5.5 mEq/dL

Any positive anion gap

Patient with first serum troponin test resulted

Onset, location, amount of chest pain on scale 1-10; dyspnea


Repeat serum troponin at six hours after first test sent

Any repeat troponin result

Patient with SIRS criteria and: 1) altered mental status; 2) SBP < 100 mm Hg; 3) WBC ≥ 7 per hpf on UA; or 4) infiltrate on CXR per radiologist

SIRS criteria (see definition); mental status; UA result; CXR result


Serum lactate Lactate ≥ 4.0 mg/dL

Patient with bleeding or with painful condition currently taking warfarin

Onset, estimated amount of bleeding; onset, location, amount of pain on scale 1-10

Vital signs, skin signs, level of consciousness

PT INR PT INR ≥ 2.0

Dysuria, frequency or hematuria; flank pain; or lower abdominal pain

Onset, location, amount of pain on scale 1-10; vomiting; fever


Urinalysis

WBC ≥ 5 per hpf

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Standards Manual


Oxygen Therapy

I. Policy 1. Functions Registered Nurses (RN) may perform:

a. Establish oxygen therapy for patients in the Emergency Department (ED)

2. Circumstances under which RNs may perform this function: a. Setting

ED proper b. Supervision

Attending emergency physicians are always available for in person consultation to RNs

c. Required patient conditions Complaint of chest pain Complaint of shortness of breath Severe vaginal bleeding Vomiting blood or melena Actively seizing History of syncopal episode

3. Level: Independent Protocol

II. Protocol 1. Assessment

a. RN’s should perform the following subjective assessment: Description of chest pain and pain scale rating from 1-10 (7-10 being severe) Description of shortness of breath Description of location, type and amount of bleeding Description of timing of any loss of consciousness

b. RNs should perform the following objective assessment: Neurologic-mental state Vital signs-respiratory rate, blood pressure, heart rate, temperature and oxygen saturation Difficulty breathing

1. Rapid respiratory rate 2. Use of accessory muscles 3. Adventitious breath sounds

Circulatory-skin color temperature Urinary output

2. Diagnosis

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Standards Manual


Oxygen Therapy

a. RNs should determine presence of a required patient condition as above 3. Considerations

a. Patients with history of: chronic obstructive pulmonary disease, C02 retention, or unknown pulmonary disease should be placed on 2 liter of oxygen per cannula only and advise the attending emergency physician

4. Plan

a. Treatment RNs may initiate oxygen therapy to maintain oxygen saturation >92%

b. Patient conditions requiring consultations: i. RNs should consult physicians under the following circumstances:

Emergent condition requiring prompt medical intervention after initial stabilizing care has been started Acute decompensation of the patient Problem which is not resolved as expected Clinical findings not consistent with clinical picture Upon request of patient, nurse or supervising physician

c. Record Keeping i. RN should document the following in the ED nursing notes:

Assessment Patient condition Delivery Device and flow rate Physician notification

Initial pulse oximetry reading, repeated as necessary after initiation of therapy Date and time Signature and title

III. Requirements for RN: Method of initial evaluation of competence

a. Completion of orientation/in-service competency validation for this standardized procedure Method of ongoing evaluation of competence a. Completion of annual competency review for standardized procedures b. Any RN having successfully completed initial ED orientation and subsequent annual competency

trainings will be authorized to perform this standardized procedure, unless otherwise noted. IV. Development and approval of standardized procedure

1. Method a. Development and approved by authorized representatives of Nursing, the Medical Staff and

Administration

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Standards Manual


Oxygen Therapy

References: Sheey’s Manual of Emergency Care, (2013), ENA, Chicago, IL.

Emergency Nurses Association. (2018). ENA: Core Curriculum. Chicago, IL. History: Original 5/94, Reviewed: 11/02, 11/04, 01/09, 10/13, 08/15, 07/16, 06/19 Revised 02/11, 7/12, 05/14, 12/17


Chairman, Department of Emergency Medicine Date




Medical Staff Date

6/11/2019

6/10/2019

STP-6517-602 Page 1 of 10

S:\Nursing\Policies and Procedures\Neonatal ICU\STP\2019\STP-6517-602.doc

SANTA CLARA VALLEY MEDICAL CENTER NEONATAL INTENSIVE CARE UNIT (NICU) PROCEDURE MANUAL

RET CAMTM FOR RETINOPATHY OF PREMATURITY (ROP) SCREENING

EXAMINATIONS STANDARIZED PROCEDURE

I. PURPOSE: A. To ensure that all infants with the potential for developing ROP are screened appropriately. B. To provide a method for screening vulnerable infants for ROP, thus ensuring prompt intervention

to prevent vision loss.

II. POLICY: A. ROP screening is performed on infants at risk for retinopathy of prematurity, as defined by the

most recent joint statement of the American Academy of Pediatrics (AAP), the American Association for Pediatric Ophthalmology and Strabismus, and the American Academy of Ophthalmology.

B. Registered nurses, who have met the requirements and demonstrated competency in the use of RetCam in the Neonatal Intensive Care Unit (NICU) will obtain images using the RetCam on infants at risk for retinopathy of prematurity in the event that no pediatric ophthalmologist is available for screening. 1. Infants with a birth weight of ≤1500 g or gestational age of 30 weeks or less (as defined by

the attending neonatologist) and selected infants with a birth weight between 1500 and 2000 g or gestational age of >30 weeks with an unstable clinical course, including those requiring cardiorespiratory support and who are believed by their attending pediatrician or neonatologist to be at high risk for ROP, should have retinal screening examinations performed after pupillary dilation.

2. Timing of first eye examination will be based on gestational age at birth, shown in Table 1. 3. Images will be sent to the designated pediatric ophthalmologist for screening for ROP.

C. The procedure will be reviewed with the parents and their signatures will be obtained prior to the procedure. The attending neonatologist will be notified immediately if the infant demonstrates signs of physiologic instability and/or abnormal eye anatomy and/or physiology.

D. The ophthalmology consultation will be completed by a California Children’s Services (CCS) paneled ophthalmologist with experience in the examination of preterm infants based on the

Who May Perform This Procedure: Population: RN X Ambulatory Pediatrics* X LVN Inpatient X Adolescents HSA APS Adults MA NICU X MUC HSR Techs

STP-6517-602 Page 2 of 10


images sent from the RetCam. The Neonatal Director and his associates will be responsible for ordering the exam and/or ordering follow-up appointments. The Neonatal Director/or his associates, in the weekly multidisciplinary rounds, will review eligibility screening and recommendations will be made if required.

E. Standardized procedure to be reviewed and approved collaboratively by the Interdisciplinary Practice Committee (IDPC) whose membership consists of nurse practitioners, nurses, physicians, and administrators and must conform to all 11 steps of the standardized procedure guidelines as specified in Title 16, CCR Section 1474.

III. QUALIFICATIONS/TRAINING PROGRAM:

A. Education and performance requirements: 1. Current California Registered Nurse (RN) license 2. Current Neonatal Resuscitation Program Provider (NRP) Certification 3. Minimum 3 years NICU nursing experience 4. Certification in Neonatal Nursing by a nationally recognized accrediting organization. 5. Successful completion of initial training, and skill validation with ongoing annual

competencies provided by ophthalmic imaging RN who has at least one year of experience performing procedure.

B. Initial Skill Validation and Ongoing Evaluation 1. Competency checklist will be completed. (See Attachment A). 2. Competent performance of RetCam exams under the direct supervision of the experienced

ophthalmic imaging RN. 3. Three to six months training as an ophthalmic imaging RN. 4. Final competency shall be determined by ability of the new ophthalmic imaging RN to

complete three exams, which are sent to the pediatric ophthalmologist, who will confirm if the images are acceptable and if he is able to interpret them without difficulty.

5. Competency will be validated yearly by an experienced ophthalmic imaging RN based on completion of the competency checklist and continued ability to send high quality images approved by the pediatric ophthalmologist.

IV. SCOPE OF SUPERVISION: A. Pediatric ophthalmologist will review secured images sent and evaluate quality by requesting

additional images if needed.

V. EQUIPMENT: A. RetCam 3TM (computerized ophthalmic imaging system) B. ROP tray C. Alcohol pads D. Sterile 2x2’s E. Sucrose solution F. SaniCloths G. Medications:

1. Proparacaine HCl 0.5% ophthalmic solution 2. Cyclopentolate 0.5% (Cyclogyl) ophthalmic solution 3. Phenylephrine 2.5% ophthalmic solution 4. Alternative combination product if ordered: Cyclopentolate-phenylephrine 0.2-1 %

(Cyclomydril®) ophthalmic solution

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5. Lubricating hypercellulose or equivalent ophthalmic lubricant KEY POINT: Medications may cause feeding intolerance, seizures, bradycardia, tachycardia, and arrhythmias.

VI. PROCEDURE:

A. Perform Ret Cam eye exams once per week on Tuesdays. Pediatric ophthalmologist will order if infant requires additional screenings.

B. Provider orders eye drops one day in advance. 1. Dilate infant’s eyes 60 to 90 minutes prior to photography to ensure proper dilation. 2. Proparacaine HCl 0.5% one drop both eyes, x 1. 3. Cyclopentolate 0.5% (Cyclogyl) one drop, both eyes, repeat in 5 minutes x1 4. Phenylephrine 2.5% ophthalmic solution, one drop both eyes x1, repeat in 5 minutes x1. 5. Alternative if combination product ordered: Cyclopentolate-phenylephrine 0.2-1 %

(Cyclomydril®) one drop both eyes, repeat in 5 minutes x 1 KEY POINT: Peak dilating effect is 90-120 minutes.

C. Bring RetCam 3TM to bedside. D. Verify patient ID/time out:

1. Plug machine in, turn on, and open program using password. 2. Position machine and computer screen as needed. KEY POINT: Screen needs to be easily visible to the examiner during procedure. 3. Place foot pedal within easy reach. 4. Attach lens and focus as needed. 5. Adjust light intensity as needed. KEY POINT: Darker skinned infants may require higher intensity light. 6. If this is infant’s first screen:

a. Click on create patient record. b. Do a time out to verify patient’s identity. c. Complete starred boxes:

i. Name of pediatric ophthalmologist is listed in references below. ii. Pathology is prematurity, unless otherwise indicated by

Ophthalmologist. iii. Weight is birthweight. iv. Gestation refers to gestation at birth rounded down to whole number.

d. Click okay then confirm when information is complete. 7. If this is a repeat exam:

a. Enter patient’s last name in the “patient search” box. b. Time out to verify infant’s identity. c. Click on “new exam”

E. Wash hands and don gloves. F. Assure proparicaine HCl 0.5%, ophthalmic lubricant, and eye speculum are within easy reach. G. Position infant for eye exam:

1. Top of infant’s head must be at examiner’s waist. 2. Assure infant is contained with adequate swaddling. 3. Bedside nurse may be needed to assist with containment and positioning. 4. Provide sucrose solution.

H. Adjust camera cord as needed.

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I. Perform screening: 1. Place one drop of proparicaine HCl 0.5% into each eye. 2. Insert speculum into right eye. 3. Focus camera for iris view, using image on platform. 4. Click on “recording video”. 5. Using either foot pedal or green button on platform to start and stop the video, obtain iris

view. 6. Refocus camera for retina views. 7. Place ophthalmic lubricant into right eye. 8. Float lens on gel, moving camera to obtain all views. 9. Using either foot pedal or green button on platform to start and stop video, obtain retina

images. KEY POINT: Take 6 standard images per eye beginning with external iris examination. Image to include central, nasal, temporal, superior, and inferior views. If iris demonstrates a small pupil on attempted photography, then re-dilate and wait 60-90 minutes, then photograph.

10. When all images have been obtained: a. Click on “stop recording”. b. Remove speculum.

11. Place used speculum onto ROP tray. 12. On screen, select “left eye”. 13. Repeat steps 1-10.

J. Review video of right eye: 1. Click on first video and click back arrows to rewind (<<). 2. View video by pressing right arrow button on keyboard. 3. Select images by clicking “S’ on keyboard. 4. Review images and place an “X” on those images that are to be discarded. 5. Repeat for left eye images.

K. Clean equipment: 1. Clean lens first with 2x2, hospital approved cleaning agent, then alcohol pad. 2. Wipe down camera and platform with hospital approved cleaning agent.

L. Unplug machine and move to next patient. Plug machine into red outlet only. M. Repeat procedure for each patient.

KEY POINT: Wash hands between each patient.

VII. TRANSFER OF IMAGES: A. Move RetCam 3TM to “synch” outlet. B. Synchronize images by connection to Ethernet Connection. C. Images will be sent via secure server to pediatric ophthalmologist (see reference section) (CCS-

Paneled Ophthalmologist). D. To send images:

1. Select “view all” on computer screen. 2. Check box for each patient to by synched. 3. Look for green light that indicates connection to server at Stanford. 4. Click on synch.

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5. When all patient images have been synched: a. Click on shut down. b. Once system has shut down, toggle the on/off switch in the back, waiting for about 5

seconds to turn back on. c. Unplug and re-plug black cable next to on/off switch in the back.

VIII. SPECIAL CONCERNS:

A. If ophthalmic imaging RN has any concerns while imaging related to images seen, the nurse is to contact pediatric ophthalmologist (see reference section) by email or call him after images have been sent.

IX. FAILED SYNCHRONIZATION A. In the event of failed synchronization, re-attempt synchronization. B. If synchronization fails again, take note of the error message (or photograph the error message). C. Immediately contact local IT to see if they can correct the issue. D. Contact Natus: Direct (925) 201-1666; or Mobile (925) 548-6806 if local IT says that it is not a

problem on your hospital’s end. E. Await instructions from Natus. F. If unable to correct within 60 minutes or unable to connect with Natus, contact pediatric

ophthalmologist (see reference section) to update him on the problem. G. Simultaneous to Step C, download the images to a portable thumb drive and arrange for them to

be couriered to pediatric ophthalmologist. H. Verify with pediatric ophthalmologist that these steps have been taken and the images are being

sent via courier. I. Repeat the next examination cycle.

KEY POINT: Keep pediatric ophthalmologist in the loop in real time if there is a synchronization issue or image transfer issue or if the camera malfunctions.

X. DOCUMENTATION: A. Write procedure note for each patient in HealthLink.

1. Use code 92134 – Scanning Computerized Ophthalmic Imaging. 2. Include:

a. Date and time of procedure. b. Medications used. c. Procedure. d. How patient tolerated procedure. e. Signature.

B. Complete billing: 1. In HealthLink: choose “shift assessment”. 2. Choose “charge capture”. 3. Select RetCam 4. File charges.

C. Complete HealthLink documentation: 1. Choose flowsheets. 2. Open patient care summary. 3. Select infant screens.

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4. Insert column and enter time of exam (should match time of exam in procedure note). D. In Eye Book, place ID sticker for each baby whom was screened, onto the next week’s date.

KEY POINT: Assures infants are screened weekly.

XI. ADDITIONAL IMAGING: A. Re-screens:

1. If there is a request for a re-screen prior to the next regular screening date, that date will be added to the Eye Book with a patient sticker placed on the request date.

2. Arrangements must be made for a screener to be available to perform these additional screenings.

B. Non-routine imaging: 1. Pediatric ophthalmologist may request imaging for other than ROP diagnosis:

a. Non accidental trauma. b. Other diagnostic purposes.

2. Request to be made to NICU: a. Arrangements to be made to see that a screener is available. b. Screener will complete procedure:

i. Images will not be synched to Stanford. ii. At the request of the ophthalmologist, images will be downloaded to a

flash drive and given to him. c. Documentation and billing is the same.

XII. CLEANING OF INSTRUMENTS:

A. Speculum is to be placed in sterile processing container, then in blue transport bin. B. Contact transport to take to sterile processing.

XIII. SUNDROP REPORTS:

A. After pediatric ophthalmologist reviews the images, a report will be sent via secure email. B. Reports will be reviewed by the providers the next day. C. Reports will be scanned by medical records personnel into the media tab.

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References American Academy of Pediatrics Policy Statement (2013). Screening examination of premature infants For retinopathy of prematurity. Pediatrics, 131(1). Board of Registered Nursing Title 16, CCR Section 1474. California Board of Registered Nursing. Business and Professional Code: Section 2725. California Board of Registered Nursing. Article 7. Standardized Procedure Guidelines, 2011. California Children’s Services Manual of Procedures, Regional NICU (1999). Chapter 3.25.1-28. http://neofax.micromedexsolutions.com. Moshfeghi, D. Vitreoretinal surgery. Byers Eye Institute Stanford University School of Medicine, Associate Professor. RetCam3TM and Shuttle Ophthalmic Imaging Systems User Manual.

Resources

Pediatric Ophthalmologist for SCVMC NICU. Contact information: Darius M. Moshfeghi, MD Chief | Retina Division Byers Eye Institute Stanford University of School of Medicine 650-644-5561 (m)

[email protected]

mailto:[email protected]

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Approved by:

________________________________________________ ____________ Dr. Balaji Govindaswami, MPH, MD Medical Director, NICU Date ________________________________________________ ____________ Laura Berritto MHA, RNC Nurse Manager, NICU Date ________________________________________________ ____________ Dr. Darius Moshfeghi, MD Vitreoretinal Specialist Date ________________________________________________ ____________ Sue Kehl MSN, RN, CCRN Director, Inpatient Acute Nursing Date ________________________________________________ ____________ Pharmacy & Therapeutic Committee Date ________________________________________________ ____________ Jill Sproul, MSN Chief Nursing Officer Date ________________________________________________ ____________ Interdisciplinary Practice Committee Date ________________________________________________ ____________ Medical Leadership Counsel Date ________________________________________________ _____________ Governing Board-Health and Hospital Committee Date History: Original 11/07. Revised 11/08, 05/09, 08/13, 01/15, 07/17, 12/18, 8/19

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Appendix A

Name______________________________


Competency: Ret Cam – ROP screening

Instructions: Complete the self-assessment portion of this document using the key below. Your preceptor will observe you performing the skills and validate your competency by initialing the appropriate box.

Self-Assessment: 1=Can perform independently 2=Need practice prior to evaluation 3=Need to learn and practice prior to evaluation

Method of Evaluation: PO=Preceptor Observation

Competency Statement Self-Assessment

Method of Evaluation

Preceptor Initials

Date of Observation

Comments

Reads Ret Cam Policy States criteria for Ret Cam screening States criteria for maintaining certification Explains process to parents States medications required for exam, their function and potential side effects

Prepares infant for exam Prepares Ret Cam equipment for exam Obtains images per protocol Cleans RetCam lens and machine per protocol Synchronizes images and successfully sends them to Ophthalmologist

States procedure on what to do if synchronization fails

Documents eye exam in Health Link, completes billing, and records in Log Book

States procedure for re-screening and non-routine imaging

Has access to obtain reports through secure email

Signature_______________________________________________________________________ Preceptor Signature_______________________________________________________________________