Executive Summary for MEC - Highland Hospital · Patients with >28 weeks estimated gestational age should have Category I fetal heart rate tracing or a reactive NST medically indicated

1

Executive Summary Policies and Procedures for Quality Professional Services Committee

From the Medical Executive Committee January 2018

Title of Policy Last

Approved Date

BOT due date

from last approval

Next review date after

BOT approval

Policy Owner/Author/

Reviewer

Purpose Summary of Changes

History of Review Committee

Type

Labor and Delivery Triage (HH Only)

New Policy N/A 3 Years Rachel Hogan (Asst Nurse Manager), Theresa Cooper (Director of Nursing –MCH), Sophie Shabel, MD (Chair, MCH), Kinzi Richholt (CNE)

Establish parameters for obstetric triage, including admission, transport and discharge criteria, acuity assignment and standardization of nursing documentation for all patients who present to Labor and Delivery.

Changes: This policy was originally presented to MEC in March 2017 and not approved. Document Owner/ Writer was asked to revise policy and re-submit to MEC for approval.

• Clinical Practice Council (3/2017), Patient Care Leadership (3/2017)

• Medical Executive Committee (11/2017)

Clinical

Medical Record Delinquency and Medical Staff Suspension:

New Policy N/A 3 Years Bernice Zander (Dir., HIM), Steve Kilgore (DON-Ambulatory), Palav

To describe the process for suspension of provider privileges for

Changes: New Policy

• Ambulatory Operations Council (8/2017)

• Medical Records

Admin

2

Title of Policy Last Approved

Date

BOT due date

from last approval


BOT approval


Reviewer



Type

Ambulatory Babaria, MD (CAO-Ambulatory), Dave Cox (CFO)

delinquent medical records. Timely completion of ambulatory medical records is essential for ensuring patient safety, continuity of care and appropriate clinical care, especially when outpatients are seen in other locations subsequent to their outpatient visits.

Committee (8/2017)

• Medical Executive Committee (10/2017)

Medication Kit/ Transport Boxes for Specific Departments and Divisions (HH Only)

New Policy N/A 3 Years Doug Del Paggio (Director, Pharmacy), Diana Thamrin (System Director, Pharmacy), John Chapman (CAO)

Different departments/divisions store boxes or kits to get access to mediations in their specific areas, where Automated Dispensing Machines (ADM, e.g. Pyxis) are not accessible and/or certain specific drugs are not included in crash cart. These departments/ divisions include Allergy Clinic, Anesthesiology, Cardiology, Diagnostics, Oral Surgery, Operating Room and Radiology.

Changes: New Policy

• Pharmacy and Therapeutics (10/2017)

Dept

Medications: Look-Alike, Sound-Alike

New Policy N/A 3 Years Priya Patel (Medication Safety

To ensure Alameda Health System (AHS)

Changes:

• Pharmacy and Therapeutics (AHS

Clinical

3


Date

BOT due date

from last approval


BOT approval


Reviewer



Type

(System) Officer), Diana Thamrin (System Director, Pharmacy), John Chapman (CAO)

has a system in place to eliminate medication errors caused by the procurement, storage, dispensing and administration of look alike, sound alike medications.

New System-Wide Policy

Core, 2/2017, AH 4/2017, SLH 3/2017)

• Clinical Practice Council (6/2017)

• PCLT (7/2017)

Medications: Prescribing and Ordering (AHS Core)

2/2011 2/2017 3 Years Doug Del Paggio (Director, Pharmacy), Priya Patel (Medication Safety Officer), Diana Thamrin (System Director, Pharmacy), John Chapman (CAO)

The formulary system improves patient care by promoting rational and discriminate drug therapy, providing medications in a timely manner and generally at a lower cost to the patient because of the contractual prices.

Changes: Minor revisions

• Pharmacy and Therapeutics (3/2017)

Dept

Scope of Service – Health Information Management (System)

7/2014 7/2017 3 Years Bernice Zander (Director, HIM), Dave Cox (CFO)

To ensure adequate information is available to the members of the healthcare team and other health care providers and when necessary to provide effective patient treatment. To process and maintain patient care information for the continuity of patient care research, legal


• Health Information Management (

4


Date

BOT due date

from last approval


BOT approval


Reviewer



Type

purposes, and justification for reimbursement, service utilization and other administrative purposes.

Vancomycin Pharmacy Dosing Protocol (HH Only)

9/2014 9/2017 3 Years Matt Labreche (Clinical Pharmacy Specialist) (Doug Del Paggio (Director, Pharmacy), Diana Thamrin (System Director, Pharmacy), John Chapman (CAO)

To enhance the safe and effective use of vancomycin and to increase antibiotic stewardship for this medication with a pharmacist dosing and monitoring protocol.


• Pharmacy and Therapeutics Committee (11/2017)

Dept

PLANS Infection Prevention and Control Annual Plan: 2016 Assessment 2017 Plan (AHS Core)

9/2016 9/2017 Annually Deborah Ellis (Interim System Director, Infection Prevention and Control), Adrian Smith (Interim VP, Quality)

This document is a comprehensive evaluation, risk assessment, prevention and control plan completed annually. This document may be revised at any time based on significant changes in the healthcare setting and infection control field.

Changes: Annual Plan

• Infection Control Committee (8/2017)

• Quality and Safety Committee (11/2017)

Admin

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Alameda Health System LABOR AND DELIVERY TRIAGE Department Maternal Child Heath Effective Date New Policy Campus Highland Date Revised 2/2017 Unit Labor and Delivery Next Scheduled Review 2/2020 Manual Maternal Child Health Author Director of Nursing – MCH Replaces the following Policies: Responsible Person Chief Nurse Executive

Chair, Maternal Child Health Printed copies are for reference only. Please refer to electronic copy for the latest version.

Purpose

Establish parameters for obstetric triage, including admission, transport and discharge criteria, acuity assignment and standardization of nursing documentation for all patients who present to Labor and Delivery.

Policy

Alameda Health System Family Birthing Center will provide comprehensive professional nursing care to all patients presenting to Labor and Delivery under the guidelines of the Emergency Medical Treatment and Active Labor Act (EMTALA) and the AHS EMTALA policy. Use of a maternal fetal triage index and standardized criteria for ongoing assessment and dispensation will facilitate the highest quality care delivery.

Admission to Labor and Delivery Triage

1. Labor and Delivery (L & D) triage services will be available 24 hours per day, seven days per week.

2. Patients less than 20 weeks gestation or with a non-obstetric emergency will be triaged in the Emergency Department. If patient’s condition warrants, fetal monitoring or obstetric clearance may be provided in the Emergency Department by Labor and Delivery RN and/or OB physician.

3. Obstetric patients at 20 weeks of gestation or greater will be evaluated on the labor and

delivery unit. Patients may present to L & D Triage in the following ways: self present, brought in by ambulance, referred or brought in from an outpatient setting, brought from the Emergency Department, transported from another medical facility or from an out-of-hospital birth attendant.

4. Patient with the following conditions will bypass L & D Triage and be either directly

admitted or placed in observation status: a. Patients scheduled for cesarean delivery, induction of labor, cerclage placement,

external cephalic version, or other conditions as determined by provider. b. Patients directly admitted to the postpartum or antepartum unit.

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c. Patients who present as born out of asepsis. d. Patients with imminent delivery.

5. All patients will be interviewed in a private location by an RN to determine evaluation

priority. Patient acuity will be categorized according to the Maternal Fetal Triage Index (Appendix A).

6. Initial and ongoing assessment and documentation will occur per Labor and Delivery RN Triage Protocol (Appendix B).

7. An in-house OB provider will be notified of each patient’s chief complaint and acuity index

on patient arrival depending on assigned acuity level.

Ongoing Evaluation

Following Medical Screening Exam by Qualified Medical Personnel (QMP):

1. Orient patient to nurse call light, restroom and fetal surveillance. 2. Re-assess vital signs per protocol or as ordered. 3. Document all interventions including start and stop times of infusions and injections. 4. Complete triage re-evaluation within 2 hours to determine if patient will be discharged,

admitted or placed on observation status. 5. When it is determined that the pregnant patient is not in labor and does not have an

emergency medical condition, the woman may be transferred to another health care facility, be referred for outpatient services, be discharged, or be seen in the Emergency Department as determined clinically appropriate by a physician or Certified Nurse Midwife (CNM) or other Qualified Medical Personnel (QMP). The medical record will reflect the basis of the determination.

Acceptance of Maternal Transports to Labor & Delivery

1. Requests for maternal transport should be from the attending physician at the referring hospital to the triage attending and/or perinatologist at the transport hospital to assess medical need.

2. Request for maternal transport from an out of hospital birth site may be made directly from

out of hospital birth attendant to on- duty Certified Nurse Midwife or OB Attending. 3. Triage attending physician, CNM, or their designees should notify the charge nurse or unit

manager that they have accepted the transport.

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4. Referring hospital should call with a nurse-to-nurse report. The nurse receiving the referral call will complete the Obstetric Evaluation database form, including patient information, referring physician’s name and relevant contact numbers.

5. The patient being transported should go directly to the triage area, unless previously accepted

for direct admission. Patient acuity level will be assigned and she will be cared for accordingly.

Transfer out of Labor & Delivery

1. Requests for maternal transport to another facility should be from the AHS attending physician to the OB attending or perinatologist at the receiving hospital to assess medical need.

2. Triage attending physician or their designees should notify the AHS L&D charge nurse or

unit manager that they are planning to transport the patient to another facility. 3. The OB Attending will order the type of transport and level of support required (BLS,

ACLS) during transport as well as the destination facility and indication for transfer. 4. The charge nurse will contact the House Supervisor and arrange for transfer via ambulance. 5. The Triage/designated nurse will contact the receiving hospital via telephone to complete a

nurse-to-nurse report. 6. The charge nurse or delegate will ensure that copies of all medical records have been

completed and prepared for ambulance pick up.

Discharge From Labor & Delivery Triage

All patients will undergo fetal monitoring per MCH Fetal Monitoring policy before discharge . Patients with >28 weeks estimated gestational age should have Category I fetal heart rate tracing or a reactive NST medically indicated and ordered prior to discharge or other check for fetal wellbeing per provider discretion.

1. For patients who are to be sent home

a. If the nurse has done the vaginal exam and reassessment, notify the obstetrician /CNM to evaluate the patient and discharge, if appropriate.

b. Complete discharge vital signs for any patient without vital signs for more than 2 hours, or any patient who presented with abnormal vital signs.

c. Provide the patient with information needed for self-care at home, including labor precautions, kick count instruction, medication teaching and other discharge instructions.

d. Document all care and assessments provided in triage, including patient’s verbal understanding of instructions.

e. Patients discharged home may walk unaccompanied by hospital personnel.

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2. For patients who are to be admitted or place in observation status a. Notify the primary nurse who will be accepting the patient, arrange for warm transfer

of patient to the assigned room and provide report to the assigned RN. b. Transfer the patient in the central fetal monitoring system to the appropriate labor

room. c. Obtain and implement diet orders. d. Observation beds may be provided for patients who do not yet meet criteria for

inpatient admission and who require a period of ongoing evaluation for further treatment and to determine dispensation. Reassess Observation patients in accordance with the RN Triage Protocol and patient acuity. Record start and stop times for all infusions and injections.

3. For patients leaving against medical advice (AMA):

a. Notify provider immediately of any patient expressing intention to leave the unit AMA.

b. Staff will take all reasonable steps to ensure patient (or legal representative) is informed by the OB Provider of the examination, stabilizing treatment and/or transfer to another facility that patient is refusing. Document patient status and attempts of OB Provider to counsel patient regarding care recommendations.

References

1. American College of Obstetricians and Gynecologists. (2016) Hospital-based triage of obstetric patients. Committee Opinion No. 667. Obstet Gynecol;128:e16–9.

2. Angelini A. and LaFontaine, D. (2013). Obstetric Triage and Emergency Care Protocols. New York, NY. Springer Publishing Company.

3. Caliendo, C et al. (2004). Obstetric Triage and EMTALA Regulations: Practice strategies for labor and delivery nursing units. AWHONN Lifelines, Volume 8, Issue 5, 442-448.

4. Ruhl, Catherine et al. (2015) Content Validity Testing of the Maternal Fetal Triage Index. Journal of Obstetric, Gynecologic & Neonatal Nursing, Volume 44, Issue 6, 701 – 709.

Approvals

Departmental Date: 2/2017 Clinical Practice Council Date: 2/2017 Patient Care Leadership Date: 3/2017 Medical Executive Committee Date: 11/2017 Board of Trustees Date:

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Appendix B—Labor and Delivery RN Triage Protocol

RN will assess each patient presenting to Triage according to the following parameters. RN will initiate care under the Labor and Delivery Triage Standing Orders and will document intake times, medications and fluids administered, interventions, ongoing vital signs and re-evaluation on the OB Triage Evaluation Form.

EMTALA requirements 1. Record time of patient entry, method of arrival, time of RN triage initiation, and time OB

provider notified. 2. Assign and document priority level according to Maternal Fetal Triage Index (MFTI)—

1-Stat, 2-Urgent, 3-Prompt, 4-Non-urgent, 5- Scheduled 3. Notify OB provider of patient’s arrival in triage, chief complaint, and MFTI priority level

within time frame indicated by acuity.

Maternal and Fetal Assessment Maternal— obtain and record initial vital signs (BP, HR, T, RR, O2 sat, pain score), height and weight, including calculation of BMI; obtain urine sample (see below). 1. If SBP ≥ 135 or DBP ≥ 85, repeat BP q 30 min x 3.

2. If SBP ≥ 140 or DBP ≥ 90, repeat BP q 15 min x 3, then q 30 min and notify provider (see

Preeclampsia Evaluation in Triage). 3. If SBP ≥ 160 or DBP ≥ 100 check BP & HR q 5 min x 3, then q 15 min x 3, then q 30 min,

notify provider at first elevation. Draw and send preeclampsia panel. 4. If BP recurs above parameters restart monitoring at q 5 min and follow timing as above. 5. If BMI ≥ 40, pulse ox with vitals q 4 hours, notify provider if pulse ox <95% . 6. Temperature Q1 hour if febrile ≥ 100.0 or after rupture of membranes. 7. Ongoing VS assessment if patient is laboring:

a. Q4 hours latent phase b. Q2 hours active phase

8. Urinalysis

a. Obtain and send UA STAT, clean catch. b. If patient has signs or symptoms of preeclampsia or hypertension AND suspected

ruptured membranes or vaginal bleeding then obtain instead: UA STAT, catheter.

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Fetal/Tocometry Monitoring-- Ensure patient entered into central monitoring system. 1. For estimated gestational age (EGA) less than 23 weeks, fetal heart rate by Doppler once.

Assess for uterine contractions. 2. For EGA greater than or equal to 23 weeks, obtain an initial 20 minute fetal monitor tracing

to evaluate for baseline rate and periodic patterns. Assess uterine contractions. If evaluation extends more than 40 minutes without appropriate fetal reassurance then treatment plan is per attending provider.

3. Continue monitoring, if indicated, as specified in Fetal Monitoring Policy. Patients with >28

weeks EGA should have a reactive nonstress test (NST) prior to discharge. Rupture of Membranes Assessment Assess for amniotic fluid leakage, including patient report and objective findings. If spontaneous rupture of membranes suspected, collect specimen of fluid and assess per protocol. Defer SVE unless signs of imminent delivery are present. Labor Assessment Vaginal exam to assess cervix and fetal presentation. 1. Defer if ruling out SROM, vaginal bleeding, known placenta previa, or GA < 35 weeks

(unless requested by provider). 2. If suspected preterm labor, gestational age 23-34 weeks, obtain FFN specimen prior to

vaginal exam. 3. Assess cervical dilation, effacement, station, presenting part, cervical consistency, position

and membrane status. Document in the medical record and inform provider of exam results. Notify provider as necessary to repeat exam if unable to perform complete assessment.

Preeclampsia evaluation in Triage 1. If triage SBP confirmed ≥ 140 or DBP ≥ 90, draw and send Preeclampsia Panel STAT.

2. If BP ≥ 160/100, place IV & saline lock and order Type & Screen STAT. Ensure ABO re-

check done.

Assess obstetrical hemorrhage risk. 1. Low Risk : Singleton pregnancy, no previous uterine incision, fewer than 4 previous vaginal

deliveries, no known bleeding disorder, no hx postpartum hemorrhage a. Action: Verify prenatal blood type and antibody screen done.

2. Medium Risk: Prior C/S or uterine surgery, multiple gestation, greater than 4 vaginal

deliveries, hx previous PPH, chorioamnionitis, large uterine fibroids, EFW > 4 kg, BMI > 35

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a. Action: Assess need for ABO recheck.

3. High Risk : Placenta previa or low-lying placenta, suspected placenta accreta or percreta, hematocrit < 30 AND other risk factors, platelets < 100,000, active bleeding on admit, known coagulopathy

a. Action: If admitted for anticipated delivery, notify OB provider and anesthesia. Order type and cross match 2 units PRBCs.

Insert and Maintain peripheral IV with saline lock if clinically indicated. Obtain prenatal care records, including prior obstetric triage and emergency room visits. Diabetes Care in Triage: for patients with established diagnosis of DM or GDM. 1. Point of Care: Finger Stick Blood Glucose (FSBG) ONCE upon arrival2. Record current home diabetes medications in the medical record.

.

3. POC 4. POC FSBS: Fasting and 1hr after meals if has diet.

FSBG: q4 hrs if NPO or Clears.

5. Call provider for BS≥ 160 or ≤ 65 or with symptoms of hypoglycemia Limited or no prenatal care or Transfer of care: 1. If ≥ 36 weeks gestational age or with risk factors,

a. collect and send new OB panel and GBS culture if not done this pregnancy. b. send urine toxicology screen after verbal consent obtained and documented

2. If < 36 weeks without risk factors with no presenting complaint

a. obtain 1 set of vital signs ,

b. obtain medical and obstetric records, if available. c. establish and document fetal well-being and absence of uterine contractions, vaginal

bleeding or rupture of membranes d. refer to clinic triage intake to establish ongoing prenatal care

Does the woman or fetus have URGENT/PRIORITY 2 vital signs?

OR

Is the woman in severe pain without complaint of contractions?

OR

Is this a high-risk situation?

OR

Will this woman and/or new-born require a higher level of care than institution provides?

Maternal Fetal Triage Index (MFTI)Is the woman presenting for a scheduled procedure and has no complaint?

Does the woman or fetus have STAT/PRIORITY 1 vital signs?

OR

Does the woman or fetus require immediate lifesaving intervention?

OR

Is birth imminent?

Does the woman or fetus have PROMPT/PRIORITY 3 vital signs?

OR

Does the woman require prompt attention?

Does the woman have a complaint that is non-urgent?

Is the woman requesting a service and she has no complaint?

OR

Does the woman have a scheduled procedure with no complaint?

Abnormal Vital SignsMaternal HR <40 or >130, apneic, Sp0

2 <93%, SBP ≥160 or

DBP ≥110 or <60/palpable, No FHR detected by doppler (unless previously diagnosed fetal demise), FHR <110 bpm for >60 seconds

Immediate lifesaving intervention required, such as:Maternal • Cardiac compromise • Severe respiratory distress • Seizing • Hemorrhaging

• Acute mental status change or unresponsive (cannot follow verbal commands)

• Signs of placental abruption • Signs of uterine rupture

Fetal • Prolapsed cord

Imminent Birth • Fetal parts visible on the perineum • Active maternal bearing-down efforts

Abnormal Vital SignsMaternal HR >120 or <501, Temperature ≥101.0°F, 38.3°C, RR >26 or <12, Sp0

2 <95%1, SBP ≥140 or DBP ≥90 symptomatic1

or <80/40, repeated; FHR >160 bpm for >60 seconds; decelerations

Severe Pain: (unrelated to ctx) ≥7 on a 0–10 pain scale

Abnormal Vital SignsTemperature >100.4°F, 38.0°C1, SBP ≥140 or DBP ≥90, asymptomatic1

Prompt Attention, such as:• Signs of active labor ≥34 weeks• c/o early labor signs and/or c/o SROM/leaking 34–36 6/7 weeks• ≥34 weeks with regular contractions and HSV lesion• ≥34 weeks planned, elective, repeat cesarean with regular contractions• ≥34 weeks multiple gestation pregnancy with irregular contractions• Woman is not coping with labor per the Coping with Labor Algorithm V23

Non-urgent Attention, such as:• ≥37 weeks early labor signs and/or c/o SROM/leaking• Non-urgent symptoms may include: common discomforts of pregnancy,

vaginal discharge, constipation, ligament pain, nausea, anxiety.

Woman Requesting A Service, such as:• Prescription refill• Outpatient service that was missed

Scheduled ProcedureAny event or procedure scheduled formally or informally with the unit before the patient’s arrival, when the patient has no complaint.

≥34 wks with regular contractions or SROM/leaking with any of the following

• HIV+ • Multiple gestation• Planned, medically-indicated cesarean • Placenta previa (maternal or fetal indications)• Breech or other malpresentation

Transfer of Care Needed• Clinical needs of woman and/or newborn indicate transfer of care, per hospital policy

NO

NO

YES YES

YES

YES YES

YES YES

YES YES

YES YES

NO

NO

NO

5

4

3

2

1

PR

IOR

ITY

PR

IOR

ITY

PR

IOR

ITY

PR

IOR

ITY

PR

IOR

ITY

Scheduled OR RequeSTIng

nOn-uRgenT

PROmPT

uRgenT

STaT

STAT/ PRIORITY 1

URGENT/ PRIORITY 2

PROMPT/ PRIORITY 3

NON- URGENT/

PRIORITY 4

SCHEDULED/REQUESTING PRIORITY 5

1High Risk and Critical Care Obstetrics, 20132Trauma may or may not include a direct assault on the abdomen. Examples are trauma from motor vehicle accidents, falls, and intimate partner violence.3Coping with Labor Algorithm V2 used with permission

The MFTI is exemplary and does not include all possible patient complaints or conditions. The MFTI is designed to guide clinical decision-making but does not replace clinical judgement. Vital signs in the MFTI are suggested values. Values appropriate for the population and geographic region should be determined by each clinical team, taking into account variables such as altitude.

©2015 Association of Women’s Health, Obstetric and Neonatal Nurses. For permission to use MFTI or integrate the MFTI into the Electronic Medical Record contact [email protected].

Examples of High-Risk Situations• Unstable, high risk medical conditions

• Difficulty breathing

• Altered mental status

• Suicidal or homicidal

• <34 wks c/o of, or detectable, uterine ctx

• <34 wks c/o of SROM/leaking or spotting

• Active vaginal bleeding (not spotting or show)

• c/o of decreased fetal movement

• Recent trauma2

DR A

F TImplement appropriate

infectious disease control processes for triage

and evaluation.

Page 1 of 2

Alameda Health System MEDICAL RECORD DELINQUENCYAND MEDICAL STAFF SUSPENSION: AMBULATORY Department Health Information Management Effective Date New Policy Campus All Ambulatory Clinics Date Revised 8/2017 Unit Ambulatory/HIM Next Scheduled Review 8/2020 Manual Health Information Management Author Director, Medical Records Replaces the following Policies: Responsible Person Chief Administrative Officer,

Chief Information Officer (CIO) Printed copies are for reference only. Please refer to electronic copy for the latest version.

Purpose

To describe the process for suspension of provider privileges for delinquent medical records. Timely completion of ambulatory medical records is essential for ensuring patient safety, continuity of care and appropriate clinical care, especially when outpatients are seen in other locations subsequent to their outpatient visits.

Policy

All documentation for outpatient encounters (clinic visits and outpatient procedures) should be completed within 3 days of the clinic visit. Residents should complete documentation on the day of the encounter, and supervising attendings are expected to co-sign encounters within 3 days of the clinic visit. Documentation will begin to appear on the ‘delinquent’ list at day 7. Provider privileges shall be suspended when completion of the clinic or procedural progress note exceeds 21 days after the clinic encounter.

Procedure

1. The Medical Record Department will generate a weekly report that lists all documentation that is incomplete for more than 7 days after the clinic visit from the outpatient EHR (clinics not utilizing the EHR will be exempt from this policy until they are on the EHR). The Medical Record Department will distribute this list on a weekly basis to all individuals on the delinquent list and to Department/Clinic leaders.

2. Providers with incomplete documentation will be listed starting at day 7 on the weekly list of overdue missing documentation. The provider (s) to whom the incomplete medical record is assigned shall be notified ("D7 - first notice of impending suspension").

3. Seven days later, the missing documentation list will be e-mailed again.

a. If the record has been completed, the provider shall be removed from the suspension list.

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b. If the record remains incomplete, the provider shall be issued a second notice ("D14 - second notice of impending suspension").

4. Seven days after, the missing documentation list will be e-mailed again.

a. If the record has been completed, the provider shall be removed from the suspension list.

b. If the record remains incomplete, the provider shall be notified his/her privileges have been suspended effective immediately ("D21 - Suspension") and will not be allowed to practice at AHS clinics until privileges are re-instated

i. Shall have this suspension noted in his/her provider privileging file ii. Shall have the suspension documented on his/her Ongoing Professional

Performance Evaluation (OPPE), and iii. May trigger a Focused Professional Performance Evaluation (FPPE) for

multiple occurrences

5. The suspension process shall be temporarily halted for provider vacation or illness. a. The provider and/or Department Chair or designee is responsible for

informing HIM. b. The suspension process shall start in the next business day after the

provider's return.

6. The Department Chairs and/or designees shall be notified weekly of all providers to whom suspension notices have been issued (D7, D14, D21).

7. Suspension shall be immediately rescinded once incomplete records have been completed.

Process map: [Needs to be created from above]

Approval

Departmental Date: 8/2017 Medical Records Committee Date: 8/2017 Medical Executive Committee Date: 10/2017 Board of Trustees Date:

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Alameda Health System MEDICATION KITS/TRANSPORT BOXES FOR SPECIFIC DEPARTMENTS AND DIVISIONS Department Pharmacy Effective Date New Policy Campus Highland Date Revised 10/2017 Unit Pharmacy Next Scheduled Review 10/2020 Manual Multidisciplinary Clinical Author Director, Pharmacy Services Replaces the following Policies: Responsible Person Chief Administrative Officer Printed copies are for reference only. Please refer to electronic copy for the latest version.

Purpose

Different departments/divisions store boxes or kits to get access to mediations in their specific areas, where Automated Dispensing Machines (ADM, e.g. Pyxis) are not accessible and/or certain specific drugs are not included in crash cart. These departments/divisions include Allergy Clinic, Anesthesiology, Cardiology, Diagnostics, Oral Surgery, Operating Room and Radiology. Other medication kits are assembled and put in ADM by pharmacy for the ease of removal under specific situations.

Procedure

Preparation

1. Pharmacy staff fills medications listed in the boxes and kits. Non-medicinal supplies in oral surgery boxes are filled by the Oral Surgery division.

2. Pharmacy staff records expiration dates of mediations on the content list. 3. Pharmacy staff who prepares the box or kit will sign and date on the content list. 4. Pharmacist will check all medications against the content list for correct quantity and

expiration. 5. Pharmacist will sign and date the content list after checking the box or kit. 6. The signed and dated content list will be put inside the box or kit. 7. A copy of this content list can be put outside the box or kit. Or a sticker with the name of

earliest expired drug and expiration date will be put outside the box or kit. This is to identify when to replace the content of the box or kit.

8. Pharmacy will put a tamper resistance lock on the checked box or kit to ensure the box or kit

is secured before being dispensed.

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Dispensing

1. When a box or kit is needed for a procedure by a department/division, the department/division staff will come to pharmacy to pick up the specific box or kit.

2. Pharmacy staff, before dispensing the box or kit, will make sure the lock is secured and

medications are not expired. 3. Pharmacy staff fills out the dispensing log to indicate when and where the box/kit is

dispensed.

Storage

1. Each department/division is responsible to store the box/kit in an area where direct supervision of its usage is allowed until the procedure is complete.

2. Anesthesia department, oral surgery division and radiology department will store the boxes/kits in their areas until replacement.

3. Such storage area should be easily monitored by the department or division staff to prevent unauthorized usage.

Administering and Returning

1. When a medication is needed, the department staff will break the lock to open the box or kit.

2. The department/division staff will put the patient addressograph sticker on the content list for subsequent billing by pharmacy.

3. The department/division staff will return the used box or kit with the patient stamped content

list to pharmacy for replacement. 4. In the situation where the lock is found broken in the department/division but medications are

not used, the box or kit should be returned to pharmacy for checking.

Replacement

1. Pharmacy will follow the procedures under “Preparation” in this policy to replace and refill any medications used in the box or kit that is returned from the department/division.

2. When the box or kit is pending to expire, the department/division staff is responsible to inform pharmacy and bring the box or kit to pharmacy for replacement.

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Medication kits stored in Automated Dispensing Machine (ADM, e.g. Pyxis)

1. These kits are assembled in pharmacy and checked by pharmacist before putting in ADM. 2. Kits are removed from ADM according to the ADM procedure. 3. A refill or stock out report will be printed in pharmacy to prompt for replacement. 4. Used kits should be placed in the “return to pharmacy” bin for pick up and return to

pharmacy.

List of Specific-Medication Boxes or Kits (See Attachment A)

List of Medication Kits Stored in Automated Dispensing Machines (Pyxis) (See Attachment B)

Locations Name of Medication Kit ACT-7th Chemotherapy Agent Extravasation Kit floor, Infusion Center Emergency Department, Cath Lab Heart Alert (STEMI) Kit Operating Room OR Emergency Kit (Anesthesia Pyxis) Emergency Department, Floor Units, Cath Lab, GI Lab/Pulmonary

Rapid Response Intubation (RSI) Kit

Emergency Department Calcium Gluconate Kit, Tranexamic Acid (TXA) Kit-- ED

Operating Room Anesthesia Support Kit Operating Room Tranexamic Acid (TXA) Kit -- OR Highland Care Pavilion-Diagnostics Electrocardiography (EKG) Medication Kit

STEMI = ST-Elevation Myocardial Infarction; GI= Gastrointestinal; ED = Emergency Department; OR = Operating Room Approvals

Department/Divisions Name of Emergency Box/Kit Allergy Clinic Allergy Emergency Kit Anesthesiology Anesthesia Intubation Box Anesthesiology Anesthesia Intubation Kit (to be put in the transport bag) Cardiology/Radiology Cardiac CT Scan/Nuclear Medicine Box Maternal Child Health OB Code Stork Bag – Medication Box Oral Surgery Oral Surgery Box Radiology Radiology Contrast Allergic Reaction Kit

Departmental Date: 10/2017 Pharmacy and Therapeutics Committee Date: 10/2017 Medical Executive Committee Date: 11/2017 Board of Trustees Date:

Revised 11.6.2017

Attachment A: List of Specific-Medication Boxes or Kits

Allergy Clinic Kit

Drug Quantity Expiration

Albuterol Inh. 90 mcg/puff HFA Inhaler 1 Diphenhydramine Inj. 50mg/mL 1mL vial 1 Epinephrine 0.3mg auto-injector (Epi-Pen) 2 Methylprednisolone Inj. 125mg vial 1 Opti-haler 1 Syringe for Injection, 3mL 4 Needle, 25G 1½ inches 4 Alcohol Swab 4

Prepared By: ________________________________ Checked By: _________________________________

Date: ______________________________________ Date: _______________________________________

Revised 11.6.2017

Anesthesia Intubation Box


0.9% Normal Saline Inj. 10 ml vial 4 Atropine Inj. 0.1 mg/ml 10 ml syringe 1 Calcium Chloride Inj. 10% 100 mg/ml 10 ml syringe 1 Chloraseptic Topical Spray (Phenol 1.4%) 177 ml bottle 1 Ephedrine Inj. 50 mg/ml 1 ml ampule 1 Epinephrine Inj. 0.1 mg/ml (1:10,000) 10 ml syringe 1 Esmolol Inj. 10 mg/ml 10 ml vial 1 Etomidate Inj. 2 mg/ml 20 ml vial 1 Flumazenil Inj. 0.1 mg/ml 5 ml vial 1 Labetalol Inj. 5 mg/ml 20 ml vial 1 Lidocaine Inj. 2% 20 mg/ml 5 ml syringe 2 Lidocaine Topical Jelly 2% 5 ml tube 2 Naloxone Inj. 0.4 mg/ml 1 ml vial 2 Phenylephrine Inj. 10 mg/ml 1 ml vial 2 Propofol 1% 10 mg/ml 20 ml vial 1 Rocuronium Inj. 10 mg/ml 10 ml vial 1 Succinylcholine Inj. 20 mg/ml 5 ml syringe 2 Sodium Citrate/Citric Acid (Bicitra) Oral Solution 15 ml UD cup 2


Date: ______________________________________ Date: _______________________________________

Revised 11.6.2017

Anesthesia Intubation Kit (to be put in Anesthesia Airway Backpack)


Atropine Inj. 0.1 mg/ml 10 ml syringe 1

Ephedrine Inj. 5 mg/ml 5 ml syringe 1

Epinephrine Inj. 0.1 mg/ml (1:10,000) 10 ml syringe 1

Etomidate Inj. 2 mg/ml 10 ml vial 1

Phenylephrine Inj. 100 mcg/ml 10 ml syringe 1

Propofol Inj. 10 mg/ml 20 ml vial 2

Rocuronium Inj. 10 mg/ml 10 ml vial 1

Succinylcholine Inj. 20 mg/ml 5 ml syringe 2

Sugammadex 100 mg/ml 2 ml vials 7


Date: ______________________________________ Date: _______________________________________

Revised 11.6.2017

Cardiac CT Scan/Nuclear Medicine Box


Albuterol Inhaler 90 mcg/puff 8 gm inhaler 1 Aminophylline Inj. 25 mg/ml 10 ml vial 2 Atropine Inj. 0.1 mg/ml 10 ml syringe 2 Digoxin Inj. 0.25 mg/ml 2 ml ampule 4 Diphenhydramine Inj. 50 mg/ml 1 ml vial 4 Epinephrine Inj. 0.1 mg/ml (1:10,000) 10 ml syringe 2 Esmolol Inj. 10 mg/ml 10 ml vial 2 Furosemide Inj. 10 mg/ml 4 ml vial 4 Glucagon Inj. 1 mg vial 2 Methylprednisolone Succinate Inj. 125 mg vial 1 Metoprolol 100 mg oral tablet 6 Metoprolol Inj. 1 mg/ml 5 ml vial 6 Nitroglycerin Inj. 5 mg/ml 10 ml vial 4 Nitroglycerin Spray 400 mcg/spray aerosol solution bottle 1 Nitroglycerin Sublingual 0.4 mg tab 25 tabs bottle 1 Ondansetron Inj. 2 mg/ml 2 ml vial 2 Phenylephrine Inj. 10 mg/ml 1 ml vial 2 Sterile Water Inj. 10 ml vial 2


Date: ______________________________________ Date: _______________________________________

Revised 11.6.2017

OB CODE STORK BAG – MEDICATION BOX

Prepared by: _______________ Date: ___________________

Checked by: ________________ Date: ___________________

Quantity Drug Expiration Date

2 Oxytocin (Pitocin) 10 units/ml 1 ml vial

5 Misoprostol (Cytotec) 100 mcg tablet

Revised 11.6.2017

Oral Surgery Box

Drugs

Qty. Expiration Date

Atropine Inj. 0.4 mg/ml 1 ml Vial 2 Dextrose 50% Inj. 0.5 gm/ml 50 ml Syringe 1 Diphenhydramine Inj. 50 mg/ml 1 ml Vial 1 Ephedrine Inj. 50 mg/ml 1 ml Ampule w/ Filter needle 1 Epinephrine 1:10,000 Inj. 0.1mg/ml 10 ml Syringe 2 Epinephrine 1:1000 Inj. 1 mg/ml 1 ml Ampule 1 Flumazenil Inj. 0.1 mg/ml 5 ml Vial 1 Labetalol Inj. 5 mg/ml 20 ml vial 1 Lidocaine 2% Inj. 20 mg/ml 5 ml Syringe 3 Lidocaine Gel 2% 5 ml Tube 2 Methylprednisolone Inj. 125 mg Vial 1 Naloxone Inj. 0.4 mg/ml 1 ml Vial 2 Nitroglycerin SL Tablet 0.4 mg/tab #25 tab Bottle 1 Normal Saline 250 ml Bag 1 Sterile Water Inj. 10 ml Vial 2 Succinylcholine Inj. 20 mg/ml 5 ml Syringe 2 Terbutaline Inj. 1 mg/ml 1 ml Vial 2 Verapamil Inj. 2.5 mg/ml 2 ml Vial 2

Prepared By: __________________________________ Checked By: ______________________________________

Date: ________________________________________ Date: ____________________________________________

Drugs are replaced by pharmacy. Supplies are replaced by dental dept. oral surgery staff.

Supplies Qty.

Alcohol Pads 8

BD 10ml Syringe w/ Luer Lock Tip Blunt Fill Needles

2

BD 5 ml Syringe 3

BD Eclipse 18G x1½” Needles 4

BD Eclipse 3 ml Syringe w/ 21G x1½” Needle 3

CPR Mask 1

Extension Set w/ y-site 1

IV Catheter 18G x1¼” 2

IV Catheter 20G x1¼” 2

IV Catheter 22G x1” 2

IV Start Kit w/Chloral Prep 2

Oxygen Mask 1

Regular IV Set 1

Revised 11.6.2017

Kit #: ___________

Radiology Contrast Allergic Reaction Kit

Medication Quantity Expiration

Diphenhydramine Inj. 50 mg/ml 1 ml Vial 1

Epinephrine Inj. 1 mg/ml (1:1000) 1 ml Vial 2

Methylprednisolone Inj.125 mg Vial 1

Prepared By: ____________________ Checked By: __________________________

Date: _____________________________ Date: _______________________________

IM administration in the anterolateral aspect of the middle third of the thigh is preferred in the setting of anaphylaxis. Subcutaneous administration results in slower absorption and is less reliable.

Epinephrine Dosing: Hypersensitivity Reaction (e.g. anaphylaxis):

IM (preferred): Adults: 0.2 to 0.5 mg (0.2 to 0.5 ml) of 1 mg/ml solution every 5 to 15 minutes. Peds: 0.01 mg/kg (Max 0.3 mg) of 1 mg/ml solution (AAAAI [Lieberman 2015]; AHA [Vanden Hoek 2010]; WAO [Kemp 2008])

Revised 11.6.2017

Attachment B: List of Medication Kits Stored in Automated Dispensing Machines (Pyxis)

CHEMOTHERAPY AGENT EXTRAVASATION KIT

Quantity Medication Expiration date

1 Sodium Bicarbonate 8.4% - 50mEq/50ml Vial

1 Sodium Thiosulfate 25% - 12.5 gm/50ml vial

1 Hyaluronidase 150 units/1 ml vial (Amphadase) ***(Stored in Refrigerator)***

1 Topical DMSO 50% -- 50 ml vial (RIMSO-50)

4 0.9 % Sodium chloride inj. USP- 10 ml vials

2 Dexrazoxane 500mg vial

Hyaluronidase inj (Amphadase) is good for up to 30 days at room temperature.

EXPIRATION DATE: _________________________________ CHECKED BY: ______________________________________ (Pharmacist) DATE: ______________________________________________ ***Please call Inpatient Pharmacy at 44223 or 44222 if you need the replacement of any medication in the extravasation kit.***

Revised 11.6.2017

CALCIUM GLUCONATE KIT

Quantity Content Expiration 1 D5W 100 ml Bag

1 Calcium Gluconate 1gm/10 ml vial

1 Syringe 10 ml

1 18G Needle

Add 10 ml of calcium gluconate (1gm/10ml) to 100 ml D5W and infuse over 30 minutes.

For hyperkalemia, calcium gluconate 1 gm/D5W 100 ml bag can be infused over 5 minutes.

Beyond Use Date (BUD): Administer within 1 hour of mixing for immediate use. After starting administration, the bag is good for a total of 24 hours from time of mixing.

Please put a BUD sticker on bag.

Tech/RPh:_________/___________

Date:_________________________

Revised 11.6.2017

Electrocardiography (EKG) Kit

Medication Strength Quantity Expiration Atropine inj. 1 mg/10 ml Syringe 1

Diphenhydramine inj. 50 mg/1 ml Vial 1

Dobutamine 500 mg/250 ml Bag 1

Metoprolol inj. 5 mg/5 ml Vial 1

Nitroglycerin SL tablet 0.4 mg 2 bottles (25 tabs/bottle)

Revised 11.6.2017

HEART ALERT (STEMI) Kit (STEMI = ST-Elevation Myocardial Infarction) Medication Name with Earliest Expiration: _______________________ Expiration Date: _________________________

This kit is replaced by pharmacy. When it is removed from Pyxis, a refill or stock out report will prompt pharmacy to replace the used kit. Place the USED kit in the pharmacy pick up bin.

Prepared By: ________________ Checked By Pharmacist: _______________ Date Checked: ____________

Medication Name Dose Given

Time Route Documented in MAR

Quantity in Kit

Exp. Date Quantity Used

Atropine Inj 1mg (0.1 mg/ml) 10 ml prefilled syringe

Epinephrine Inj 1mg (1:10,000) 10 ml prefilled syringe

Lidocaine Inj 2% (100mg/5ml) 5 ml prefilled syringe

Amiodarone Inj 150mg (50mg/ml) 3 ml vial

Diphenhydramine Inj 50mg/ml 1 ml vial

Heparin Inj 1000units/ml 10 ml vial

Nitroglycerin Inj 50mg/250ml (200 mcg/ml) bottle

Aspirin 81 mg chewable tablet

Clopidogrel 75 mg tablet

Metoprolol 25 mg tablet

Nitroglycerin 0.4 mg sublingual tablets

Revised 11.6.2017

Anesthesia Support Kit

Quantity Medication Expiration

1 Ephedrine 50 mg/ml (1 ml) vial/ampule

1 Etomidate 2 mg/ml (10 ml) vial

1 Norepinephrine 1 mg/ml (4 ml) ampule

1 Propofol 10 mg/ml (20 ml) vial

1 Rocuronium 10 mg/ml (10 ml) vial

1 Succinylcholine 20 mg/ml (5 ml) syringe

Back up medications for situations like power outage and Pyxis failure. The kit is stored in a locked box.

Revised 11.6.2017

Rapid Sequence Intubation (RSI) Kit

Quantity Medication Expiration 1 Etomidate 2 mg/ml (20 mg/10 ml) vial

1 Rocuronium 10 mg/ml (100 mg/10 ml) vial

2 Succinylcholine 20 mg/ml (100 mg/5 ml) syringes

Prep by: __________________ Checked by: __________________

Date: _____________________ Date: ________________________

Revised 11.6.2017

Tranexamic Acid (TXA) Kit – ED Massive Transfusion Protocol (MTP)

Quantity Content Expiration

2 Tranexamic Acid 1000 mg/10 ml

1 Normal Saline (NS) 100 ml Bag

1 Normal Saline (NS) 500mL Bag

1 Filter Needle* (only if ampoules are used)

*Draw up drug with filter needle from ampoule Indication: MTP activated patient within 3 hours

of his/her injury

Loading dose: 1000 mg in 100 ml NS infuse over 10 minutes Second dose: 1000 mg in 500 ml NS infuse over 8 hours Beyond Use Date (BUD): Administer within 1 hour of mixing for immediate use. After starting administration, the bag is good for a total of 24 hours from time of mixing.


Prep by: ____________________ Checked by: ____________________ Date: ______________________ Date: __________________________

Revised 11.6.2017

Tranexamic Acid (TXA) Kit -- OR Massive Transfusion Protocol (MTP)

Quantity Content Expiration

1 Tranexamic Acid 1000 mg/10 ml

1 Normal Saline (NS) 500 ml Bag

1 Filter Needle* (only if ampoules are used)

*Draw up drug with filter needle from ampoule Indication: MTP activated patient within 3 hours

of his/her injury

Second dose: 1000 mg in 500 ml NS infuse over 8 hours Beyond Use Date (BUD): Administer within 1 hour of mixing for immediate use. After starting administration, the bag is good for a total of 24 hours from time of mixing.

Prep by: ____________________ Checked by: ____________________


Date: ______________________ Date: __________________________

Page 1 of 5

Alameda Health System MEDICATIONS: LOOK-ALIKE, SOUND-ALIKE

Department Pharmacy, Nursing, Medical Staff Effective Date New Policy Campus AHS System Date Revised 5/2017 Unit Pharmacy Next Scheduled Review 5/2020 Manual Multidisciplinary, Clinical Author Director, Pharmacy Replaces the following Policies: Responsible Person CNE, CMO, CAO

Printed copies are for reference only. Please refer to electronic copy for the latest version.

Purpose

To ensure Alameda Health System (AHS) has a system in place to eliminate medication errors caused by the procurement, storage, dispensing and administration of look alike, sound alike medications.

Policy

1. The Institute of Safe Medication Practices will be reviewed to identify those medications to add to AHS Sound Alike Look Alike List.

2. At least annually, AHS Pharmacy and Therapeutics Committee will review and update (if needed) the list of look-alike/sound alike drugs used by the organization

3. AHS will regularly provide information to professional staff on drugs that have been

determined be problematic through published reports or internal issues.

4. To assist with the reducing the likelihood of medication events associated with Look Alike/Sound Alike medications, AHS will make every effort to comply with the following risk reduction strategies:

a. Pre-printed order forms or order sets will be used whenever possible. b. Prescribers will give verbal or telephone orders only when truly necessary, and never

for chemotherapeutics. Staff to read back all orders, spell the product name, and state its indication.

c. Computer screen selection and automatic dispensing machine screens (ADM’s) will use Tallman Lettering to display easily confused medications whenever possible.

d. Medications labels will include both generic and trade names to make them easier to distinguish whenever possible.

e. Separate look-alike or sound-alike medications in the pharmacy and in the automated dispensing machine in the units.

5. Problematic medications and safety strategies identified by the Medical Staff and Pharmacy

will be instituted per the guidelines referenced below.

Page 2 of 5

ACUTE CARE HOSPITALS

MEDICATIONS SAFETY STRATEGY ALPRAZolam LORazepam • Store separately from each other in different cubies in the ADM.

• Tallman lettering and Auxiliary label amanTADINE AmioDARONE • Store separately from each other in different cubies in the ADM.

• Tallman lettering and Auxiliary label buPROPion BuSPIRone • Store separately from each other in different cubies in the ADM.

• Tallman lettering and Auxiliary label carBAMazepine OXcarbazepine • Store separately from each other in different cubies in the ADM.

• Tallman lettering and Auxiliary label CISplatin (Platinol)

CARBOplatin (Paraplatin ) • Pre-printed order forms are used to clearly identify medication being ordered. • stored solely in the pharmacy. • Products are separated by at least one shelf and clearly marked. • No medication abbreviations are accepted. • Orders are double checked by two pharmacists and two nurses prior to

administration. DOPamine DOBUTamine • Store separately from each other in different cubies in the ADM.

• Tallman lettering and Auxiliary label glipiZIDE GlyBURIDE • Store separately from each other in different cubies in the ADM.

• Tallman lettering and Auxiliary label Heparin

HEPARIN (pediatric strength versus adult)

• Stored in limited supply in Automated Dispensing machines. • Double checked by pharmacy before restocking Automatic Dispensing Machine

(ADM) • Heparin drip requires double RN signature during medication administration and

each dose titration hydrALAZINE hydrOXYzine • Store separately from each other in different cubies in the ADM.

• Tallman lettering and Auxiliary label

predniSONE prednisoLONE • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label

levoFLOXacin levETIRAcetam • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label

Tdap Dtap • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label

riFAMpin riFAXimin • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label

HYDROmorphone (Dilaudid)

morphine (Astramorph, Duramorph)

• The PF morphine injection (Duramorph) is restricted to pharmacy for compounding.

• Dispensing of these medications are controlled and tracked through the Automated dispensing machines.

• Stored in the ADM in different cubies and/or different drawers. • Tallman lettering.

Insulin products • Lantus and Lente • Humalog and • Humulin • Novolog and • Novolin • Humalog and • Novolog • Novolin 70/30 and • Novolog Mix • 70/30

HumuLIN HumaLOG NovoLOG NovoLIN

• Only approved insulin products are stocked in the nursing unit to limit the variety. • The removal of insulin doses are recorded and tracked through the automated

dispensing machines. • All insulin short acting medications are available as vials while insulin long acting

medications are available as pens whenever possible. • All insulin medications are patient specific and clearly marked with auxiliary

labels to differentiate the products and are patient specific (except for the ED). • Tallman lettering

Page 3 of 5

MEDICATIONS SAFETY STRATEGY DOXOrubicin

DAUNOrubicin

• Pre-printed order forms are used to clearly identify medication being ordered. • stored solely in the pharmacy. • Products are separated by at least one shelf and clearly marked. • No medication abbreviations are accepted. • Orders are double checked by two pharmacists and two nurses prior to

administration. PACLitaxel (Taxol) DOCEtaxel (Taxotere)


administration. vinCRIStine (Oncovin)

vinBLAStine (VELBAN)


administration. MetFORMIN (GLUCOPHAGE)

metroNIDAZOLE (FLAGYL)

• Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label

FOSphenytoin (Cerebyx) • Store separately from each other in different cubies in the ADM. PHENYtoin (Dilantin)

• Tallman lettering and Auxiliary label

HYDROcodone • Store separately from each other in different cubies in the ADM. OxyCODONE (immediate release) • Tallman lettering and Auxiliary label

MS Contin (morphine extended release)

• Store separately from each other in different cubies in the ADM. OxyCONTIN (extended Release) • Tallman lettering and Auxiliary label

PHENYLephrine (Neo-Synephrine)

NOREPInephrine (Levophed)


Levofloxacin (Levaquin) LevETIRAcetam (Keppra) LevOCARNitine

LevETIRAcetam (Keppra) LevOCARNitine


methylene blue VisionBlue • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label

soluCORTEF soluMEDROL • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label

Ambulatory Care, Behavioral Health, and Long Term Care

MEDICATIONS SAFETY STRATEGY buPROPion busPIRone • Store separately from each other in different cubies in the ADM.

• Tallman lettering and Auxiliary label citalopram hydrobromide (CeleXA)

Celecoxib (CeleBREX)

• Prescribers will give verbal or telephone orders only when truly necessary. • Staff to read back all orders, spell the product name, and state its indication. • Whenever possible, prescribers will include brand and generic names when

writing orders and use computer generated or typed prescriptions. cloNIDine (Catapress)

ClonazePAM (Klonopin)


writing orders and use computer generated or typed prescriptions. Concentrated: morphine oral liquid Roxanal, MSIR

Conventional: morphine oral liquid

• Concentrated oral morphine solutions are only dispensed upon receipt of an order for a specific patient (not as unit stock).

• The concentrated solution is segregated from the other concentrations in the

Page 4 of 5

References

The Joint Commission Medication Management MM.01.02.01 Institute for Safe Medication Practices: ISMP’s List of Confused Drug Names https://www.ismp.org/tools/confuseddrugnames.pdf

Pyxis C2 Safe. • Concentrated solutions are purchased and dispensed in dropper bottles and

dispensed as unit dose for inpatients. chlorproMAZINE chlordiazePOXIDE • Store separately from each other in different cubies in the ADM.

• Tallman lettering and Auxiliary label DULoxetine FLUoxetine

PARoxetine • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label

Insulin products • Lantus and Lente • Humalog and • Humulin • Novolog and • Novolin • Humalog and • Novolog • Novolin 70/30 and • Novolog Mix • 70/30 •

HumuLIN HumaLOG NovoLOG NovoLIN

• Only approved insulin products are stocked in the nursing unit to limit the variety.

• The removal of insulin doses are recorded and tracked through the automated dispensing machines.

• All insulin short acting medications are available as vials while insulin long acting medications are available as pens.

• All insulin medications are patient specific and clearly marked with auxiliary labels to differentiate the products and are patient specific (except for the ED).

• Tallman lettering

lamiVUDine lamoTRIgine • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label

Terbinafine (LamISIL)

Lamotrigine (LaMICtal)


writing orders and use computer generated or typed prescriptions.

ThioTHIXine thioRIDazine • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label

traZODone traMADol • Store separately from each other in different cubies in the ADM. • Tallman lettering and Auxiliary label

Nefazodone (Serzone )

Quietapine (SEROquel)


writing orders and use computer generated or typed prescriptions. Olanzapine (ZyPREXA) Cetirizine (ZyrTEC)


writing orders and use computer generated or typed prescriptions. Hep A Vaccine ADULT HAVRIX 1440 • For those campuses that carry both Adult and Pediatric doses, adult dosing

syringes will be labeled “Adult” • ADULT dose syringes stored on separate shelf from pediatric dose syringes • Pharmacist to double check all syringes & dosage prior to loading in Pyxis • Nurses to confirm ADULT and dosage prior to administration

https://www.ismp.org/tools/confuseddrugnames.pdf�

Page 5 of 5

Approvals:

AHS Core Alameda Hospital San Leandro Hospital

Pharmacy Department Date 12/2016 12/2016 12/2016 Pharmacy and Therapeutics Date 2/2017 4/2017 3/2017 Clinical Practice Council Date 6/2017 Patient Care Leadership Team Date 7/2017 Medical Executive Committee Date 11/2017 11/2017 11/2017 Board of Trustees Date:

Page 1 of 5

Alameda Health System MEDICATIONS; PRESCRIBING AND ORDERING Department Pharmacy Effective Date 10/06 Campus AHS Core Date Revised 10/06, 2/2011, 3/2017 Unit All Next Scheduled Review 3/2020 Manual Clinical Practice Author Director of Pharmacy

Medication safety officer Replaces the following Policies: Responsible Person Chief Nurse Executive Printed copies are for reference only. Please refer to electronic copy for the latest version.

Purpose

1. The formulary system improves patient care by promoting rational and discriminate drug therapy, providing medications in a timely manner and generally at a lower cost to the patient because of the contractual prices.

2. Non-formulary medications may be required; therefore, an efficient mechanism to assist in

expediting the procurement of those medications is necessary for optimal patient care. 3. To support safe prescribing or ordering of all medications.

Policy

Medications are prescribed or ordered in compliance with all applicable law, regulation, licensure, and professional standards of practice. The Pharmacy and Therapeutics (P&T) Committee develops and maintains a drug formulary based on need, effectiveness, risks, and cost criteria. There is also a mechanism in place to procure non-formulary medications that are prescribed. The hospital will also maintain appropriate policies and procedures that support prescribing or ordering practices.

Procedure

Hospital Formulary

1. The hospital formulary or drug list is available on the AHS Intranet. Requests for the addition of drugs to the formulary are presented to the P&T Committee by individual physicians following department or service review. Completion of the Formulary Requests is required. The P&T Committee reviews the medications based on:

a. Need – based on the diseases and conditions treated by the medication b. Effectiveness – efficacy, toxicity, pharmacokinetics, bioequivalence, pharmaceutical

equivalence, and therapeutic equivalence. c. Risk – incidence of adverse reactions and tendency to be problem prone d. Cost – cost impact on the organization.

Page 2 of 5

2. The P&T Committee will approve medications for formulary addition for a three month trial to assess the utilization. Medications that are not utilized during the trial period may be removed from the formulary. In addition, any medication which is not utilized for one year will be deleted from the formulary unless a special circumstance exists.

Non-Formulary Medications

1. Medications not on formulary may be requested and procured. However, the pharmacist receiving the order may suggest a therapeutically equivalent formulary approved medication if one exists. If the physician insists upon a non-formulary item, the medication will be procured in the smallest amount possible. Procuring a non-formulary item may result in a delay of treatment and a higher cost may be incurred by the patient (See Pharmacy Non-Formulary Medication procedure).

Medication Shortages and Outages

1. The hospital communicates when medication is unable to be procured. Pharmacy notifies appropriate physicians, nursing and staff by way of multiple avenues including interdepartmental memos, email, newsletters and appropriate committees.

2. In the event of a disaster, medications will be obtained in accordance with Emergency

Preparedness plan.

Sample Medications

1. Medication samples from manufactures are not allowed to be brought into the hospital by physicians, patients, or pharmaceutical sales representatives to be stocked or dispensed to patients, except:

a. In the case of special clinical circumstances deemed appropriate by the physician or, b. When the medication cannot be procured through regular means, in such cases, the

patient or his/her physician can supply the medication (this may include sample medications). The medications must be sent to Pharmacy for appropriate identification and labeling prior to distribution to the patient.

Drug Order Renewal

1. See Clinical Practice policy Medications: Automatic Stop Order

STAT Orders

1. STAT orders entered in the Pharmacy computer system should be verified by Pharmacy within 30 minutes unless the order is in question and delivered to the requesting unit to assure administration to the patient within 1 hour of the order

“As Needed” (PRN) Orders

Page 3 of 5

1. Orders for PRN medications must be accompanied by an indication for which the use of the drug is intended and frequency of use.

“Hold” & “Restart” Orders

1. Medication orders for patients going to surgery are discontinued. Blanket reinstatement of previous medication orders is not acceptable.

Titrate Orders

1. Medication orders for patients that receive an IV medication admixed in an IV solution (per manufacturer’s recommendations) and administered at an increasing or decreasing dose/rate until a desired response is achieved per MD parameters.

Taper (“Wean”) Orders

1. Medication orders for patients that receive an IV medication admixed in an IV solution (per manufacturer’s recommendations) gradually reduce/discontinued per a physician’s order of discontinuance.

Resume and Range Orders are not accepted

Medication related devices require an order

.

Orders for compounded drugs or drug mixtures not commercially available will be specified by the ordering prescriber.

Medication Prescribing

1. Physicians, Dentists, and Podiatrists with staff privileges may prescribe medications at AHS. Mid-level Practitioners may prescribe medications at AHS under the scope of practice as defined by the Interdisciplinary Practice Committee. Verbal/telephone orders for drugs shall be given only to licensed personnel within their scope of practice by a person lawfully authorized to prescribe and shall be recorded promptly in the patient’s medical record, noting the name of the person giving the order and the signature of the individual receiving the order and the Read Back completed. The use of verbal and telephone orders will only be utilized as deemed absolutely necessary. The prescriber shall countersign the order with 48 hours. For outpatient prescriptions, the following professionals may prescribe medications to be filled at AHS: physicians, dentists and podiatrists. Written and verbal/telephone orders shall include the name of the drug, the dosage and the frequency of administration, the route of administration, if other than oral, and the date, time and signature or the prescriber. Orders for drugs shall be clear by the prescriber. There is a documented diagnosis, condition, or indication-for-use for each medication ordered in the patient’s record. Medications may be ordered as generic or brand. Prescription pads will be kept in a secure place away from public access at all times.

Page 4 of 5

2. Patient specific information is readily accessible, utilizing the H&P, chart, MAR and computerized lab, registration and ED software.

3. Licensed practitioner involved in the management of the patients medications shall have the

following accessible: a. Patient identifiers b. Age c. Sex d. Diagnosis, comorbidities or problems e. Allergies f. Height, weight, pregnancy and lactation status g. Laboratory information

4. All medication orders for pediatric patients must be ordered as a weight-based dose, i.e as

“mg/kg” or “mcg/kg”, though total dose may be included in the order. The pharmacist will verify that total dosage amounts are correctly calculated.

5. Medication orders must contain: a. The name of the drug (generic and/or brand) b. The dose c. The route d. The frequency. e. Indication of use (if not found in the medical record) f. Indication or reason for use is required for ALL as needed (PRN) medications g. The name of the ordering prescriber. h. The date and time the order. i. If the order is a telephone order, the name and title of the person receiving and

recording the order j. Source of authorization (e.g. Anti-Coagulation policy, per Vancomycin Protocol),

Renal Dosing Protocol and Autosubstitution Policy if ordered on behalf of Medical Staff.

Medication Orders for Standardized Procedures

1. All standardized procedures that contain medication orders as specified by the Interdisciplinary Practice Committee must be reviewed and approved by the Pharmacy and Therapeutics Committee.

Standing/Pre-printed Medication Orders

1. Standing and/or Preprinted orders must: a. Be reviewed and approved by the P&T Workgroup for Pharmacy-related orders. b. Standing orders must be reviewed every three years? c. Preprinted orders must be reviewed every three years? d. Have a revision date indicated at the bottom of the order.

Page 5 of 5

Radiographic Contrast Media

See Clinical Practice policy Medications: Contrast Media

Radioactive Medications

See Clinical Practice policy Radioisotope Therapy

Dialysis Medications

See Dialysis policy and procedure manual

Respiratory Therapy

See Respiratory Therapy policy and procedure manual.

Environmental Services

See Environmental Services (EVS) policy and procedure manual on repackaging and relabeling of bulk cleaning agents, and disposal of hazardous waste materials.

Discharge Prescriptions

Clinical Practice policy Medications: Discharge Prescriptions

Reference

The Joint Commission MM.02.01.01, MM.04.01.01, Approvals


Alameda Health System

SCOPE OF SERVICE - HEALTH INFORMATION MANAGEMENT

Department Health Information Management

Effective Date 5/03 Campus System-wide Date Revised 8/2017 Unit Health Information Management Next Scheduled Review 8/2020 Manual Health Information Management Author Director, HIM Replaces the following Policies: Responsible Person Chief Financial Officer (CFO) Printed copies are for reference only. Please refer to electronic copy for the latest version.

Purpose

To ensure adequate information is available to the members of the healthcare team and other health care providers and when necessary to provide effective patient treatment. To process and maintain patient care information for the continuity of patient care research, legal purposes, and justification for reimbursement, service utilization and other administrative purposes. Develop and coordinate medical record reviews, evaluate and make available to all employees the tools and supplies needed to efficiently perform their duties. Continue monitoring all of the chart requests to increase/maintain chart availability. Monitor unit expenses to avoid exceeding the approved budget.

The department is responsible for maintaining the patient’s hybrid medical record, as well as the accuracy of the computerized patient index. It maintains the indices required by the Joint Commission and the California Department of Public Health through accurate and timely abstracting and coding and secure storage. Provide and maintain a unit record, in a timely and efficient manner. Maintaining the confidentiality of protected health information. Assuring availability to patient requestors of the patient’s medical record information. Assuring accurate reporting is provided to OSHPD by coding and reporting data as required. Provide records or statistical information to hospital users for research, statistics, reimbursement, and related activities.

Policy

Retain, house and make reasonably accessible, all patient related information obtained during the course of inpatient and/or outpatient medical treatment for a period of not less than ten years (per CHA Retention Laws). Abstract and code data from inpatient admissions for both internal and external uses in a format that satisfies requirements of the Office of Statewide Health Planning and Development. Provide sub-registrar function for Office of Vital Record for fetal deaths and live births not occurring and occurring in the hospital. Ensure medical records compliance with governmental and hospital Medical Staff Bylaws regulations. Process and provide information in the medical record for all professional staff, patients and outside agencies as outlined in departmental and hospital policies and procedures. Handle physician requests for information for Peer Review, Statistical Data, etc. The department also provides patient information to other health care providers when valid and deemed necessary for adequate

patient treatment, maintaining legal criteria, which applies to HIPAA and the confidentiality of the patient’s record.

Future goals of the department are to achieve a level of adequate information systems in our department such as; a master patient index, chart locator, physicians’ statistical data reporting system and electronic medical record that are automated. Maintain an environment for the continuous education and training necessary for the compliance of the laws, governing the patient’s medical record. Comply with regulatory agencies’ policies. Remain survey ready. Continue staff development plans for each employee and correct all duplicate medical record numbers. The continuous goal is to provide quality and cost effective services with a continued emphasis on providing patient medical records for all patient care related activities and continue to code diagnosis and procedures for patients with accuracy and in a timely manner.

Procedure

I. ORGANIZATION OF THE DEPARTMENT

a. Hours of Operation: Health Information Management is open seven days a week, 8:00am – 4:30pm. The Release of Information unit’s business hours are from 8:00am– 4:30pm, Monday thru Friday.

b. Location: Location of HIM Department varies by facility.

II. REQUIREMENTS FOR STAFF

a. Required certifications

The Health Information Management Coders are credentialed by the American Health Information Management Association as a Certified Coding Specialist (CCS), or a Certified Coding Associate (CCA). The Director of Health Information Management must be credentialed through the American Health Information Management Association as either a Registered Health Information Administrators (RHIA), Registered Health Information Technologist (RHIT)

III. RECOGNIZED STANDARDS/GUIDELINES USED

The Health Information Management Department adheres to the Center of Medicare and Medicaid Services (CMS), California Department of Public Health (CDPH), The Joint Commission of Accredited Hospital Organization (TJC) rules and regulations. The Coders follow the coding guidelines as documented from Coding Clinic, American Medical Association, American Health Information Association and American Hospital Association. They also follow the coding and sequencing instructions in the ICD-9-CM Coding Manual as well as the Coding Clinic. The California Department of Public Health, Title 22 and the Conditions of Participation from the Center of Medicare and Medicaid Services (CMS) provide the regulations for the completion of medical records and suspension functions of the Health Information Management Department.

Approvals:

AHS Core Alameda Hospital San Leandro

Hospital Pharmacy Department Date 8/2017 8/2017 8/2017 HIM Committee Date 8/2017 Medical Executive Committee Date 11/2017 11/2017 11/2017 Board of Trustees Date:

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Alameda Health System VANCOMYCIN PHARMACY DOSING PROTOCOL Department Pharmacy Effective Date 2/2011 Campus Highland Date Revised 10/2017 Unit Pharmacy Next Scheduled Review 10/2020 Manual Pharmacy Author Director, Pharmacy Services Replaces the following Policies: Responsible Person Chief Administrative Officer Printed copies are for reference only. Please refer to electronic copy for the latest version.

Purpose

To enhance the safe and effective use of vancomycin and to increase antibiotic stewardship for this medication with a pharmacist dosing and monitoring protocol.

Definitions/Equations

AdjBW Adjusted body weight = ) AUC Area under the curve = TDD/CLVa AUC:MIC Ratio of AUC to MIC = AUC/MIC Modified Cockroft-Gault equation (see number 1, part C).

BMP Basic metabolic panel CL Creatinine clearance (mL/min) Cr

Modified Cockroft-Gault equation to be used CL Vancomycin clearance (L/h) = CLVa Cr (mL/min) 0.045 DBW Dosing Body Weight:

If TBW ≤ (IBW x 120%), use TBW If TBW > (IBW x 120%), use AdjBW

IBW Ideal Body Weight(kg) For FEMALES = 45.5 + (2.3 x [height(in) - 60]) For MALES = 50 + (2.3 x [height(in) - 60])

MIC minimum inhibitory concentration Scr serum creatinine TBW total body weight (kg) TDD Total Daily Dose of vancomycin (mg) Vd Vancomycin volume of distribution = 0.7 x DBW

Policy

All adult patients on intravenous vancomycin, excluding 24-hour pre-op/post-op prophylaxis orders, will be dosed by the pharmacy department.

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1. The prescriber will initiate vancomycin therapy by ordering “Vancomycin Dosing per Pharmacy.”

2. The prescriber will include the indication for vancomycin use on the vancomycin order. If

the indication is not readily apparent, the validating pharmacist will contact the prescriber to establish an indication. The pharmacist will determine the goal vancomycin trough level as per the ACMC Vancomycin Pharmacy Dosing Protocol (see Dosing Protocol below).

a. Note: vancomycin therapy should not be withheld while awaiting an indication. If an indication cannot be established in a timely manner, the pharmacist will proceed with initial vancomycin dosing and assume an initial target trough of 15-20 mcg/mL.

b. If a prescriber elects to order a specific vancomycin dosing regimen, the pharmacist may modify the initial regimen in accordance with the Dosing Protocol.

3. The pharmacist will use his/her clinical judgment in conjunction with the Dosing Protocol

when writing orders for vancomycin.

4. Under the vancomycin dosing protocol the pharmacist will have authority to a. Order sCr and/or BMP as needed b. Order vancomycin trough and/or random levels as needed c. Adjust vancomycin dosing regimen as needed d. These orders will be designated “per vancomycin protocol.”

5. If the pharmacist determines that vancomycin cannot be safely and effectively dosed for a

particular patient and indication (e.g. vancomycin MIC ≥ 2 mcg/mL in Staphylococcus aureus infection), the pharmacist will contact the physician to recommend an alternative agent and/or consultation with the Infectious Disease service.

Dosing Protocol

1. Pharmacokinetic parameters a. Vancomycin will be dosed to target steady-state trough values based on indication.

Indication Trough (mcg/mL)

• Brain/Epidural Abscess • Endocarditis • Meningitis • Osteomyelitis • Pneumonia • Prosthetic joint infection • Sepsis

15-20

• Cellulitis, Skin and Soft tissue infection • Cystitis • Neutropenic fever • Prophylaxis (i.e. drains, shunts)

10-15

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Indication Trough (mcg/mL)

*Note: these targets are applicable only to adult patients, and only for empiric therapy or directed therapy with vancomycin MIC ≤ 1 mcg/mL *Note: the pharmacist, in collaboration with the prescriber and the Infectious Disease service, may elect instead to dose vancomycin to a targeted AUC:MIC. This decision must be a consensus among the three listed parties, and must be clearly documented in the patient chart.

b. Vancomycin dosing body weight (DBW) will be used for all initial dosing. c. Vancomycin clearance (CLVa) will be calculated using creatinine clearance.

Creatinine Clearance (CLCr)

i. For patients with TBW < IBW and sCr < 0.8 mg/dL, round sCr to 0.8 mg/dL.

will be calculated using the Cockroft-Gault equation, whenever appropriate, with the following adjustments:

ii. For patients aged ≥ 65 yrs with sCr < 1 mg/dL, round sCr to 1 mg/dL. d. Doses will preferentially be rounded to the nearest 250 mg increment.

2. Loading Dose

a. Patients with acute infection and/or with impaired renal function (including dialysis) should receive a loading dose of 20-25 mg/kg (using DBW) to a maximum of 2000mg.

b. In the event that a first vancomycin dose of less than 20-25 mg/kg is administered to the patient, the pharmacist will use clinical judgment to adjust dosing, e.g.:

i. Ordering a supplemental dose to achieve a full loading dose. ii. Retiming subsequent doses to achieve desired steady-state concentrations.

3. Initial Maintenance Dose

a. Initial maintenance dosing will be calculated based on patient-specific pharmacokinetic factors, e.g. Vd, CLVa

b. The pharmacokinetic software T.D.M.S. 2000Precise PK should be used as an approved aid to clinical judgment in creating vancomycin regimens (see Appendix A: T.D.M.SPrecise PK.). If the T.D.M.S.Precise PK software is unavailable for any reason, a dosing nomogram based on recommendations from T.D.M.S. 2000 Precise PKmay also be used (see Appendix B: Vancomycin Dosing Nomogram).

, targeted vancomycin trough.

c. The initial maintenance dose should not exceed a 4000mg/24 hour period,

d. In patients with severe renal impairment (i.e. CL

unless patient history warrants otherwise. Doses will be rounded to the nearest 250mg.

Cr

< 20 ml/min) subsequent dosing status post the loading dose will be based on interpretation of vancomycin levels.

4. Monitoring a. Serum creatinine levels (Scr) are recommended:

i. At initiation of the vancomycin maintenance dosing regimen. Loading doses should be administered regardless of serum creatinine availability.

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ii. Every 48-72 hours during vancomycin therapy if not already ordered by prescriber.

iii. Additionally as deemed appropriate by the pharmacist b. Vancomycin trough levels are recommended for patients who:

i. Receive dosing to target trough levels of 10-20 mcg/mL. ii. Receive dialysis.

iii. Are at heightened risk of nephrotoxicity (i.e. receiving concurrent IV contrast, loop diuretics, NSAIDs, aminoglycosides, amphotericin, cyclosporine, tacrolimus, vasopressors, or chemotherapy.)

iv. Have changing renal status. Significant change in renal function is defined as: • Abrupt change in Scr by ≥ 0.3mg/dL (within 48h), or • A percentage change in Scr by ≥ 50% from baseline, or • A reduction in UOP (documented oliguria of < 0.5mL/kg/h for > 6h)

v. Have atypical or dynamic Vd (e.g. morbid obesity, burns, dialysis). c. Vancomycin trough levels should be obtained as deemed appropriate per the

pharmacist: i. Within the first three days of therapy.

• It is recommended to obtain levels near steady state (e.g. fourth or fifth dose of regimen, including loading doses where applicable). If level obtained prior to steady state, interpretation of levels is warranted.

ii. Once patient is stable on a regimen; it is recommended to obtain weekly levels thereafter pending patient has stable renal function with an appropriate clinical response.

d. Vancomycin “random” levels may be obtained at the discretion of the pharmacist, and may be appropriate for patients who:

i. Have severe renal impairment (e.g. CLCrii. Have atypical or dynamic Vd (e.g. morbid obesity, burns, dialysis)

< 20 ml/min)

5. Instructions for drug administration around trough levels:

a. All vancomycin doses should be administered to patients as scheduled. b. If appropriate, a pharmacist may elect to defer vancomycin administration until a

satisfactory vancomycin level has been achieved. The choice to hold a vancomycin dose while awaiting a level must be communicated to the responsible nurse through either oral or electronic communication by the pharmacist or the prescriber.

i. In this situation, the pharmacist will discontinue the discrete vancomycin regimen, adding and just keep the “Vancomycin per pharmacy” placeholder on the patients MAR/MAK. The pharmacist will enter a replacement vancomycin regimen when supported by pharmacokinetic and clinical data.

6. Maintenance Dose Adjustment:

a. The pharmacist will assess all vancomycin levels for accuracy and validity, and adjust vancomycin accordingly to achieve intended pharmacokinetic parameters based on pharmacokinetic and clinical interpretation of patient- and lab-data.

b. The pharmacokinetic software T.D.M.S. 2000Precise PK should be used as an approved aid to clinical judgment in adjusting vancomycin regimens. Round dose to the nearest 250mg.

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7. Maintenance Dose Adjustment in Special populations: a. The “Vancomycin Dosing per Pharmacy” order will remain active on the MAR/MAK

for the duration of vancomycin therapy for the below patient populations. b. Patients on Chronic Intermittent Hemodialysis:

i. An initial level prior to 1st

ii. Assume an approximate of 25% drug removal by standard high-flux hemodialysis at Highland Hospital.

hemodialysis session will be obtained (e.g. just prior to dialysis by the hemodialysis nurse). If a level cannot be obtained prior to dialysis, it may be obtained at a minimum of four hours after dialysis (to allow for drug redistribution).

iii. If the pre-dialysis level is > 23mcg/mL hold post-dialysis dose and obtain another random level prior to next dialysis session.

iv. If pre-dialysis level is between 18-23 mcg/mL, give the below maintenance dose post-dialysis:

Patient’s DBW ≤ 49kg = 250 mg Patient’s DBW = 50-90kg = 500 mg Patient’s DBW ≥ 91kg = 750 mg

v. If pre-dialysis level is < 18 mcg/mL, add an additional 250mg to current post-dialysis maintenance dose. Obtain another random level prior to next dialysis session.

vi. If level was obtained post dialysis, extrapolate pre-dialysis level by multiplying obtained level by 1.25 and adjust dosing as per above for pre-dialysis levels.

v. Once patient has had two levels within range on the same regimen, levels should be drawn at least weekly thereafter.

c. Patients receiving pulse hemodialysis (not chronic): i. Hemodialysis schedule will be followed on a daily basis via: nephrology team,

hemodialysis nurse, bedside nurse and/or primary team. ii. Subsequent dosing status post the loading dose will be based on interpretation

of vancomycin levels. A pulse dose should be given once a random vancomycin level falls below the desired the goal.

iii. Refer to chronic hemodialysis section for pulse dose recommendation.

8. Storage and Documentation a. Patient information and dosing history will be securely stored in the T.D.M.S.

2000Precise PK database located on the central hospital server and on the paper vancomycin daily monitoring sheets. Pharmacists

b. The pharmacist will complete a pharmacokinetic progress note at minimum on initiation of therapy and with each vancomycin level interpretation. The progress note will be included in the “consultations” section of the patient chart.

will update patient information for monitoring safety and efficacy of vancomycin for the duration of vancomycin therapy.

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Protocol Review:

The vancomycin protocol will be assessed annually by pharmacy to ensure optimized dosing and clinical outcomes, and to seek opportunities for improvement.

References

1. Centers for Disease Control and Prevention. Recommendations for preventing the spread of vancomycin resistance: recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR Morb Mortal Wkly Rep. 1995; 44(No. RR-12):1-13.

2. Rybak M, Lomaestro B, Rotschafer JC, et al. Therapeutic monitoring of vancomycin in adult patients: a consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm. 2009; 1:82–98.

3. Ariano RE, Fine A, Sitar DS, Rexrode S, Zelenitsky SA. Adequacy of a vancomycin dosing regimen in patients receiving high-flux hemodialysis. Am J Kidney Dis. 2005 Oct;46(4):681-7.

4. Pai AB, Pai MP. Vancomycin dosing in high flux hemodialysis: a limited-sampling algorithm. Am J Health Syst Pharm. 2004 Sep 1;61(17):1812-6.

5. Zelenistky, SA et al. Initial vancomycin dosing protocol to achieve therapeutic serum concentrations in patients undergoing hemodialysis. Clin Infect Dis. 2012 Aug;55(4):527-33.

6. Brown, M et al. Weight-based loading of vancomycin in patients on hemodialysis. Clin Infect Dis. 2011;53(2):164.\

Approvals


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Appendix A: T.D.M.S. now also know as Precise PK

T.D.M.S. 2000TM

Therapeutic Drug Monitoring System (Healthware, Inc. ©1986-2012, http://www.tdms2000.com/) is a software package for therapeutic drug monitoring, with capability to monitor and interpret levels for 16 different drugs. It has a 30 year track record of clinical use, and is beta-tested by the Applied Pharmacokinetics Service at UC San Diego Medical Center and at Rady Children’s Hospital, San Diego.

T.D.M.S. 2000TM uses a set of pharmacokinetic equations to calculate population pharmacokinetic parameters based on patient-specific data, predicting steady-state drug levels for regimens inputted by the user. The equations are assessed and updated twice annually. When analyzing drug levels, T.D.M.S. 2000TM

uses Bayesian and nonlinear least-squares fitting algorithms, combining dosage and serum concentration data with population pharmacokinetic parameters, to create modified pharmacokinetic parameters and predictions of steady-state levels for regimens inputted by the user.

T.D.M.S. 2000TM

allows for creation of a patient database, retaining patient drug history, patient-specific pharmacokinetic parameters, and inter-user communication via patient- and case-specific notes. It also can create a pre-populated note that can be used for patient charting.

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Appendix B: Vancomycin Dosing Nomogram

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Alameda Health System INFECTION PREVENTION AND CONTROL ANNUAL PLAN: 2016 ASSESSMENT 2017 PLAN Department Infection Control Effective Date New Plan Campus AHS Core Date Revised 10/2017 Unit Infection Control Next Scheduled Review 10/2020 Manual Infection Control Author Director, Infection Control Replaces the following Policies: Responsible Person Interim VP of Quality Printed copies are for reference only. Please refer to electronic copy for the latest version. Table of Contents

EXECUTIVE SUMMARY ..................................................................................................................................... 2 INTRODUCTION................................................................................................................................................. 4

Infection Prevention and Control .................................................................................................................... 4 Vision Statement ............................................................................................................................................. 4 Mission Statement ........................................................................................................................................... 4 Scope of Service ............................................................................................................................................. 5 Geography, Community, Population, Care, Treatment and Services ............................................................. 5 Authority and Responsibilities ........................................................................................................................ 8 Surveillance..................................................................................................................................................... 9

EFFECTIVENESS OF 2016, RISK ASSESSMENT, and PLANNING FOR 2017 ............................................... 10 Surveillance Activity: Hand Hygiene .......................................................................................................... 10 Surveillance Activity: Central Line-Associated Blood Stream Infections .................................................. 11 Surveillance Activity: Catheter-Associated Urinary Tract Infections ......................................................... 13 Surveillance Activity: Surgical Site Infections by Procedure ...................................................................... 15 Surveillance Activity: Hospital-Acquired Multi-Drug Resistant Organisms .............................................. 18 Surveillance Activity: Hospital-Acquired Clostridium difficile .................................................................. 20 Surveillance Activity: M. tuberculosis Statistics ......................................................................................... 21 Fairmont Hospital IRF .................................................................................................................................. 23 Surveillance Activity: Influenza Vaccination .............................................................................................. 24 Employee Health: Bloodborne Pathogen Exposures .................................................................................... 25 Surveillance Activity: Antibiotic Stewardship ............................................................................................ 26 Surveillance Activity: High Level Disinfection (HLD)............................................................................... 27 Surveillance Activity: Immediate Use Steam Sterilization (IUSS) ............................................................. 27 Surveillance Activity: Compliance with Isolation Precautions ................................................................... 28

PROGRAM ELEMENTS .................................................................................................................................... 28 Resource Allocation: Needs for 2017 to effectively manage IP program ................................................... 28 Infection Control Log: Major Incidents/Investigations 2016 ...................................................................... 29 Strategies to Minimize, Reduce, and Eliminate Infection Risk .................................................................... 29

APPENDIX A: Employee Health ...................................................................................................................... 36 Influenza Vaccination Compliance Grid, 2015-2016 Season ....................................................................... 36 Bloodborne Pathogen Exposures in 2016 ..................................................................................................... 36 Bloodborne Pathogen Plan Annual Review Statement ................................................................................. 37

APPENDIX B: TB Exposure Control Plan ...................................................................................................... 37 APPENDIX C: Infection Control Risk Assessment 2017 ..............................................................................

39

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EXECUTIVE SUMMARY

• Hand Hygiene: In 2016, the HH program is enhanced with unit based HH champions who are trained to do HH interventions and collect HH compliance data. This data will be provided to AHS managers on a monthly basis for timely feedback of performance improvement trends and activities. The hand hygiene program continues to make HH an organizational priority and is part of the Culture of Safety. John George and Fairmont Rehab achieved goal of >90% compliance. Highland and Fairmont SNF averaged 84% and 79% respectively. Action: Continue unit based champions, increase Hand Hygiene campaigns within all facilities.

• Device Related, Central Lines and Urinary Catheters: Central Lines Associated Blood stream infections (CLABSIs) did not meet goal in the IUC, and trended up for 2016, with a SIR of 1.23. Goal was met in the non-ICU areas with a SIR of 0.56. Action: Continue to analyze data in NHSN. Stratify data to reflect number of days from CVC insertion, to identify area of opportunities between insertion best-practice and maintenance best-practice. Physician led development of CVC insertion checklist. Continue Prevalence studies focusing on central line management and daily line necessity. Catheter-Associated Urinary Tract Infections: did not meet goal facility-wide (ICU and non-ICU) with a SIR of 2.10 (ICU) and 1.22 (non-ICU). Data analysis of Standardized Utilization Ratio (SUR), shows that our line days are higher than predicted. Action: Continue implementation of nurse-driven protocols for removal of Foleys. Reassess indications for continued indwelling vs. intermittent catherization. Implement and monitor elements of performance for CAUTI prevention, by Joint Commission’s National Patient Safety Goals)

• Surgical Site Infections (SSI): Surgical site infections between 2015 and 2016 showed a significant reduction with a 2016 SIR of 0.879, which is below national benchmark, thus achieving our goal of <1 SIR. Action: However, Open-fracture reductions and Colon surgeries remain the highest percentage of SSIs of all surgeries being followed. A coordination of QAPI project and a root-cause analysis into Open-fracture reductions (FX) SSI is ongoing into 2017.

• AHS Program involvement in the community: o Highland Hospital received Certificate of Appreciation for outstanding contribution to the 2015

Emerging Infection Program Hospital Healthcare-Associated Infection and Antimicrobial Use Prevalence Survey

o Highland Hospital was also recognized by CALNOC for the CALNOC Annual Performance Excellence Awards, for exemplary work in reducing hospital acquired conditions in 2016, for hospitals with an ADC of 200+, with an annualized average SIR at or below the 50th

quartile in CALNOC.

o AHS remain highly involved in with Alameda County Public Health Department in identification and control of TB within our community.

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INTRODUCTION This document is a comprehensive evaluation, risk assessment, prevention and control plan completed annually. This document may be revised at any time based on significant changes in the healthcare setting and infection control field.

Infection Prevention and Control The purpose of the Infection Prevention and Control Department is to minimize the morbidity, mortality, and economic burden associated with healthcare-associated infections (HAI) through prevention and control endeavors in both patient and staff populations. Using epidemiological principles, pertinent data are collected and analyzed in order to determine risk factors associated with infection and to define mechanisms of transmission and prevention. The most current CDC/NHSN/McGeer surveillance definitions and comparative databases are utilized to evaluate patient outcomes. The Infection Preventionist uses this information to seek opportunities for improvement; and then plans, implements, and evaluates control strategies. As a resource within Highland Hospital and the community, the Infection Preventionist educates other professionals and the public about risk of infection and measures to minimize and eliminate risk, and to enhance patient safety and quality.

The objectives of the program are to:

1. Monitor and evaluate the infection risks and the appropriateness of risk intervention and reduction activities for all patients and personnel

2. Promote prevention, identification, and control of healthcare-associated infections in patients, staff, practitioners, visitors and families

3. To provide directions, information and guidelines in relation to: o Facilities, equipment, and procedures necessary to implement standard and additional

(transmission-based) precautions for control of infections o Cleaning, disinfecting and reprocessing of reusable equipment o Waste management o Protection of health care workers from transmissible infections o Infection control practices in special situations

Vision Statement Alameda Health Systems is committed to providing superior patient care. Alameda Health System’s Infection Prevention and Control’s program reduces health care associated infections. Mission Statement The mission of the infection prevention and control program is to promote a healthy and safe environment by preventing transmission of infectious agents among patients, staff and visitors. The goal of the infection prevention program is to provide surveillance, prevention, and control strategies in order to reduce/eliminate HAIs to the irreducible minimum. This will be accomplished in an efficient and cost effective manner by a continual assessment and modification of our services based on regulations, standards, scientific studies, internal evaluations and guidelines. These strategies are intended to support the Alameda Health Systems in the areas of People, Service, Quality, Growth/Community, and Finance.

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A. People • To facilitate participation of each healthcare worker in infection prevention strategies at their level • To promote disease prevention, and control, in HAI reduction • To promote a safe environment for patients, families, visitors, staff, physicians, and others • To limit unprotected exposure to pathogens

B. Service

• To provide service excellence

C. Quality • To ensure the safety, health, and welfare of all patients • To evaluate processes and outcomes in order to continuously improve quality, safety, and efficiency

D. Growth/Community

• To promote education for patients, and as needed, their families about infection prevention • To enhance patient volume by improving quality of care through reducing HAIs

E. Finance

• To provide evidence based infection prevention strategies in a cost effective manner • To enhance cost savings through continuous reduction of HAIs

Scope of Service The Infection Control Program Plan applies to Alameda Health System (AHS), inclusive of Highland Hospital, John George Psychiatric Pavilion, Fairmont Hospital, and the Ambulatory Clinics. Infection prevention and control is a facility-wide patient safety component involving all departments. The infection prevention program reports through the Alameda Health Systems Patient Safety and Quality, and Medical Executive Committees. The Infection Preventionist, along with the Infection Prevention and Control Committee, determine the specific focus of surveillance, education, and consultation efforts on an ongoing basis, dependent on hospital epidemiology, community disease surveillance and real or perceived local or world threats. San Leandro Hospital and Alameda Hospital data and Infection Prevention assessments and plans are presented separately, as those facilities continue to operate under their own licenses. Geography, Community, Population, Care, Treatment and Services Alameda Health Systems (AHS) is headquartered in the east bay area in Oakland, California. This plan includes the care of inpatients, outpatients, all diagnostic or treatment areas, and support services at Alameda Health Systems. AHS is comprised of three hospital campuses (Highland Hospital, John George Psychiatric Pavilion, Fairmont Hospital) and clinics (Highland, Eastmont, Hayward, and Newark) all located in Alameda County, California. Specifically, Highland Hospital is a 445 bed acute care hospital which encompasses level 1 trauma, level 2 NICU, medical, surgical, critical care, maternal-child, interventional radiology, acute psychiatric, skilled nursing, acute rehabilitation and emergency services. Fairmont Hospital is a 206 bed inpatient rehabilitation facility (also housed within is subacute and Skilled nursing), and John George is an 80 bed inpatient behavioral health facility. Outpatient includes Highland, Eastmont, Hayward, Newark, and Fairmont Wellness Clinics. AHS is also a teaching/training institution, and is committed to maintaining an environment that is supportive of a wide range of educational programs and activities including education of medical students, interns, residents, and fellows. AHS provides continuing education for medical, nursing and other staff, along with medical

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research. AHS has been a nationally recognized teaching institution since 1927, providing 5 major graduate physicians’ residency training programs in internal medicine, general surgery, oral surgery, emergency medicine and primary care. Statistics for FY 2016 (July 2015- June 2016) AHS Facilities Statistics

- Overall discharges 14,911

- Average daily census 257

- Regional Level I Trauma Center patients served 1,777

- Emergency room visits total 73,962

- Surgeries performed - inpatient and outpatient 5,264

- Maternal-Child Health services deliveries (including NICU) 1,144

Licensed Beds 445

- Highland General Hospital (HGH) 206

- Fairmont Hospital (FH) 159

- John George Psychiatric Pavilion (JGPP) 80

Admissions 14,918

- Highland General Hospital 11,364

- Fairmont Hospital 453

- John George Psychiatric Pavilion 3,101

Average Length of Stay (ALOS; days) (HGH, FH, JGPP) 6.70

- Highland 2.70

- Fairmont 94.87

- John George 8.02

Outpatient Clinic Statistics

- Highland Clinic Visits 170,535

- Eastmont Clinic Visits 65,764

- Hayward Clinic Visits 30,070

- Newark Clinic Visits 27,221

- Fairmont Outpatient Clinic Visits 1,225

- Psych Day Care (patient days) 24,969

Alameda County is the 7th

most populous county in California, with a population of approximately 1,647,704 people as reported by the US Census Bureau in 2016 (not including those who are uncounted due to homelessness or illegal immigration).

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Alameda County Demographics*

Age and Sex

Persons under 18 years 21.0%

Persons 65 years and over 13.1%

Female persons 50.9%

Race and Hispanic Origin

White alone 50.9%

Black or African American alone 11.6%

American Indian and Alaska Native alone 1.1%

Asian alone 30.2%

Native Hawaiian and Other Pacific Islander alone, 1.0%

Two or More Races 5.3%

Hispanic or Latino 22.5%

White alone, not Hispanic or Latino 32.1%

Language

Language other than English spoken at home, percent of persons age 5 years+, 2011-2015 43.5

Population Characteristics

Foreign born persons, percent, 2011-2015 (1 in 3 residents is an immigrant)** • Asia (62%) • Latin America (26%) • Europe (7%) • Africa (2%) • Oceania (2%) • Northern America (1%)

31.4%

Documented Immigrants** 75%

Undocumented Immigrants** 25%

Health

With a disability, under age 65 years, percent, 2011-2015 6.1%

Persons without health insurance, under age 65 years, percent

6.0%

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Income & Poverty

Median household income (in 2015 dollars), 2011-2015 $75,619

Per capita income in past 12 months (in 2015 dollars), 2011-2015 $37,285

Persons in poverty, percent 11.5%

*United States Census Bureau, Alameda county, California Quick Facts, Retrieved, June 2017 from

https://www.census.gov/quickfacts/fact/table/alamedacountycalifornia/PST045216

**Immigration in Alameda County, Retrieved August, 2017 from http://www.acphd.org/media/470440/immig_infog.pdf

Incidence of Reportable Communicable Diseases, Alameda County 2013

Communicable Disease Incidence rate/1000,00 population

Campylobacteriosis 23.9*

Meningitis 6.1*

Salmonellosis 16.1*

Pertussis (whooping cough) 8.9*

HIV All races

Prevalence Rates/100,000 population

African American White

1,3822 374.0

Tuberculosis All races

Incidence rate/100,000 population 9.1

African American Asian Pacific Islander

6.8 21.2

Birthplace United States Birthplace Outside of United States

1.5 22.3

Alameda County Public health Department, Data & Reports, Retrieved, August, 2017 from http://www.acphd.org/data-reports.aspx *Communicable Diseases, Published May 2016 ** HIV in Alameda County, Published February 2017 *** Tuberculosis n Alameda county, Published March 2017

Authority and Responsibilities The Infection Prevention and Control Committee (IPCC), is a committee of multidisciplinary members, who have the overall authority and responsibility for the Infection Prevention and Control Program. The Infection Preventionist has primary responsibility for the daily management of infection prevention and control activities. This includes developing and implementing policies that govern control of infections and communicable diseases and developing a system for identifying, reporting, investigating and controlling infections and communicable diseases. The Infection Preventionist, Infection Control Committee Chair and/or the Chief Medical Officer has authority to institute any surveillance, prevention, and control measures or studies when there is reason to believe that any patient or personnel may be in danger from a potential or actual outbreak of, or exposure, to infectious disease. All employees have responsibility for adherence to infection prevention and control processes/strategies. The specific verbiage regarding responsibility is detailed in AUTHORITY OF INFECTION CONTROL COMMITTEE, 2017. The IPCC reports directly to the Medical Executive Committee and provides oversight for the infection control program. The IPCC shall be a medical center wide multidisciplinary committee chaired by a physician who has credentials, knowledge and special experience in infection control. The chairperson must complete the infection control educational requirements mandated by the State of California (SB 1058). The committee shall be

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composed of physicians, nurses including the infection control practitioners, administration and other assigned members as necessary and appropriate. Membership includes representation from AHS hospitals and ambulatory care clinics. Infection Control Committee Responsibilities:

• Meet every other month or more often if needed

• Maintain a record of its proceedings and shall submit reports of its activities and recommendations to Quality & Patient Safety and the Medical Executive Committee

• Review and maintain policies and procedures pertaining to the infection control program at least every three years.

• Update the annual IC Program plan and Risk Assessments.

• Develop and implement a preventive program designed to minimize infection risks.

• Review the antimicrobial susceptibility/resistance trend studies in conjunction with the Antimicrobial Stewardship Program.

• Reviews proposals, protocols and findings for special infection control studies to be conducted throughout the hospital.

Surveillance The surveillance plan at AHS is determined by the annual IC Risk Assessment, regulatory requirements, mandated public health reporting, and IC staffing resources. CDC National Healthcare Safety Network (NHSN) definitions are used to determine healthcare-associated infections (HAI). AHS Infection Prevention team identifies HAI, communicable diseases and significant microorganisms by reviewing a combination of the following:

• Microbiology reports • Referrals from hospital staff and physicians • Daily admissions case finding • Public Health Department communications • Patient records • IC rounding

The ID physician who serves as Chair of the IC Committee is available as needed to consult on SSI, CAUTI and CLABSI cases.

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EFFECTIVENESS OF 2016, RISK ASSESSMENT, AND PLANNING FOR 2017 Surveillance Activity: Hand Hygiene Evaluation of 2016 Program Effectiveness

Goal 2016 Target 2016 Outcome 2016 Effectiveness 2016

Increase compliance and observations

Alameda Healthcare target: 90%

Highland Hospital 84% Fairmont Hospital SNF 79% Fairmont Rehab 99% John George Psychiatric 95%

Goal not met Goal not met Goal met Goal met

2016 Activities/Analysis Hand hygiene compliance is audited by observations of gel in / gel out activity. The observers will captures HH activity of all disciplines in the patient care area with the goal to have a significant sample size for each discipline. These data are submitted to IC for collating and reporting purposes.

In 2016, the HH program is enhanced with unit based HH champions who are trained to do HH interventions and collect HH compliance data. This data will be provided to AHS managers on a monthly basis for timely feedback of performance improvement trends and activities. The hand hygiene program continues to make HH an organizational priority and is part of the Culture of Safety.

2017 Surveillance Plan Goal 2017 Program

Priority Planned Actions for 2017

Continue high compliance Goal 95%

High * • Continue peer audits on floor • Continue education in New Hire Orientation • Continue staff and public education • Continue IPC observations • Continue Hand Hygiene Champions • Hand Hygiene campaign during International Infection

Prevention Week, October 15-21, 2017 • Include wellness clinics in Hand Hygiene monitoring

* Also required by regulatory agencies and Alameda Health Systems [National Patient Safety Goal (NPSG)] Patient Population: Inpatient populations Analysis: Incident rate, number compliant over total number observations Case Finding Methodology: 1. Peer observations on units as detailed above 2. IPC staff observations

3. Secret Shoppers

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Surveillance Activity: Central Line-Associated Blood Stream Infections Evaluation of 2016 Program Effectiveness

Goal 2016 Target 2016* Outcome 2016 Effectiveness 2016

Reduce and eliminate CLABSI HAI

Zero central line infections, and or SIR <1

ICU 1.23

Med Surg 0.56

ICU Goal not met

Med Surg Goal , met

2016 Activities/Analysis Analysis: In 2016 there were 4 CLABSI’s identified in the ICU compared to zero in 2015. 20% more than predicted. There were 3 CLABSIs identified in Med/Surg, 44% lower than national benchmark, statistically significantly lower than benchmark. Central Line log on nursing units to document daily necessity CLABSI prevention bundle monitoring (eg. Disinfectant caps on all ports, appropriate labeling on bags and tubing) Met with Nursing leadership and education to discuss 2017 competencies. Training will include information on CLABSI prevention bundle Physician and Licensed Independent Practitioner (LIP) training has been created.

Central Line blood draws are prohibited for Blood Cultures.

*(2015 Re-base-lining)

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Reduce and eliminate CLABSI Zero central line infections, and/or SIRs < the national benchmark: ICU SIR < 0.613** Med Surg SIR < 0.560 PRIME metric goal < 0.613

High* • Continue the following engineered systems currently in place:

o Central line insertion kit with CHG patch o Alcohol Line Caps o Daily CHG bathing in ICU o Occlusive dressings and use of line securement

device • Physician led development of CVC insertion checklist • Continue Prevalence studies focusing on central line

management and daily line necessity • Continue annual education to physicians and staff • Continue MIDAS processes for best mechanism of

documentation of central lines • Develop nursing initiated protocols to remove unnecessary

Central Lines * Also required by regulatory agencies and Alameda Healthcare Systems [National Patient Safety Goal (NPSG)] **CMS HAC prevention program 70th

percentile

Patient Population: All patients with central lines (ICU and Med/Surg, adult, pediatric) Analysis: Incidence rate per 1000 line days or NHSN Standardized Infection Ratio (SIR) Case Finding Methodology: 1. Infections will be identified through a review of blood cultures and clinical

record using the CDC/NHSN definitions and entered into NHSN and the Prime Healthcare PI Dashboard as appropriate 2. Process Review: Prevalence studies to include occlusive dressing, CHG protective disk, labeling, and use of alcohol swab caps, securement devices, daily line necessity, and immediate change of soiled dressings or gauze dressings

Page 13 of 43 Surveillance Activity: Catheter-Associated Urinary Tract Infections Evaluation of 2016 Program Effectiveness

Goal 2016 Target 2016* Outcome 2016 Effectiveness 2016

Reduce and eliminate CAUTI

Zero catheter associated infections, and or SIR <1

ICU 2.10

Med Surg 1.22

ICU Goal not met

Med Surg Goal not met

2016 Activities/Analysis In 2016 there were 11 CAUTI’s identified in the ICU, 120% more than national. There were 7 CAUTIs identified in non-ICU units, 22% more than national bench march. Updated Foley Cather log on the nursing units to document daily necessity Monitoring of CAUTI prevention bundles (eg, foley catheter has securement device, bags not on floor, seal not broken, bag not above bladder). Met with Nursing Leadership and the Education department to discuss 2017 competencies. Training will include information on preventing infections associated Foley Catheters.

Implemented the requirement of the presence of pyuria to process culture.

*(2015 Re-base-lining)

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Reduce and eliminate CAUTI 0/1000 catheter days, and/or SIR < the national benchmark: ICU CAUTI < 1.035** Med Surg CAUTI < 0.802 PRIME metrics SIR goal ≤ 1.035

High* • Continue engineered systems currently in place: o Assessment of Foley insertion Tray o Use of Foley securement device

• Perform Prevalence studies focusing on Foley catheter line management

• Continue annual education to physicians and staff • Support the SCIP and endeavors to remove the urinary

catheter within 48 hours after surgery • IPC serve as a resource in developing nurse driven

protocols to remove Urinary catheters • Continue processes for best mechanism of documentation

of Foley catheter days in electronic medical record • Implement and monitor elements of performance for

CAUTI prevention, by Joint Commission’s National Patient Safety Goals)

* Also required by regulatory agencies and Alameda Healthcare Systems [National Patient Safety Goals (NPSG)] **CMS HAC prevention program 70th

Patient Population: Patients with urinary catheters (ICU and Med/Surg) percentile

Analysis: Incidence rate per 1000 catheter days or NHSN SIR Case Finding Methodology: 1. Review of cultures and clinical record – use NHSN definitions to

diagnose CAUTI and enter into NHSN and the Prime Healthcare PI Dashboard as appropriate. Include CAUTI in Rehab Units, Skilled Nursing and Inpatient Behavioral Medicine, as applicable 2. Process Review: Prevalence studies to include appropriateness, care of tubing/bag, securement, tamper seal, prompt removal

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Surveillance Activity: Surgical Site Infections by Procedure Evaluation of 2016 Program Effectiveness

Goal 2016 Target 2016 Outcome 2016 NHSN Proc # Proc # observed HAIs SIR

Effectiveness 2016

Reduce and eliminate SSI

Zero SSIs, and or SIR <1

All procedures

1985 38 0.879 Goal met

APPY 95 2 BILI 26 2 CEA 3 0 CHOL 254 0 COLO 100 7 CSEC 277 3 FUSN 53 4 FX 259 14 GAST 28 0 HPRO 69 3 HYST 78 0 KPRO 50 0 KTP 1 0 LAM 62 0 NECK 1 0 NEPH 38 0 OVRY 125 0 PACE 9 0

All procedures include those reported as required by CMS and State of California

REC 26 0 SB 116 3 SPLE 10 0 THOR 44 0 THYR 2 0 VHYS 24 0 VHSN 6 0 XLAP 229 0

2016 Activities/Analysis Includes only procedure and associated SSIs that are reported with primary closure technique SSIs by date of event of all procedures, all wound classes = 38, with an SIR of 0.883, 11% less than national benchmark. Of all SSIs FX and COLO showed the highest number of SSIs with 14 and 7 respectively accounting for over 50% of all SSI in all procedure types

• Presented SSI data to the Operating Room Executive Committee. • FX and Colon procedures presented to Perioperative Services System • IC and PI to form QAPI project FX SSI’s with Chief of Orthopedic Surgery • A list of patients identified with FX Surgical Site infections was sent to the Quality Department for review. • Surgical Site Infection Prevention policy approved by IC Committee needs organizational approval. • Physician and Licensed Independent Practitioner training have been developed that includes SSI prevention.

Current SSI prevention bundle processes in place: • CHG pre-op showers • Screening for MRSA • Pre-op antibiotic dosing within 1-2 hours of incision

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Priority Planned Actions for 2017:

Reduce and eliminate SSI Zero SSI infections, and/or SIR < national benchmark: COLO SIR < 0.919 HPRO SIR < 0.734 KPRO SIR < 0.600 HYST SIR < 0.862 FX SIR ≤ 0.734 FUSN and CSEC – zero infections or reduce rate from 2016

High for FX and COLO Medium for all other procedure types

• Continue surveillance of the same procedures from previous year

• Continue utilizing CDC, IHI, SHEA and APIC Guidelines for Prevention of SSIs

• Continue serving as a resource for SCIP measures • Continue with QAPI project on FX

o Planned OR tracers ( minimum of 7) • Continue education to physicians and staff as needed • Discuss with relevant committees further SSI prevention

initiatives to include: o OR Traffic Control o Enforce AORN Surgical Attire o Nasal decolonization for MRSA o CHG wound irrigation o Enhance AAMI guidelines for point-of-use pre-

cleaning • Continue use of UV light as part of terminal/end –of-day

cleaning and disinfection of the OR Patient Population: Patients that receive the procedures Analysis: Incidence rate per 100 procedures or NHSN SIR Case Finding Methodology: 1. Infections will be identified through review of both inpatient and

outpatient records including; wound cultures, antibiotics, and readmissions using the CDC/NHSN definitions and enter into NHSN and Quality Council reporting. 2. Process Review: Prevalence studies to include compliance with the 7 Step Bundle and infection prevention surgical processes

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Surveillance Activity: Hospital-Acquired Multi-Drug Resistant Organisms Evaluation of 2016 Program Effectiveness


Reduce and eliminate HAIs associated with MDROs

MRSA Bacteremia: <1 SIR CRE Bacteremia: 0.5/1000 patient days VRE Bacteremia: 1.06/10,000 patient days

MRSA: 1.059 Goal not met

CRE: 0 Goal met

VRE: 0.017 Goal met

2016 Activities/Analysis Implementation of MDRO reduction strategies: CHG bathing of ICU patients, contact precautions, environmental decontamination, on-demand PCR testing for immediate identification of MRSA for improved isolation and antimicrobial stewardship. AHS enacts CRE prevention measures as described in the CDC 2015 CRE Toolkit, including application of contact precautions for CRE cases. Active surveillance screening of patients housed in the same area as a CRE case may be performed on recommendation of Infection Control. AHS will use an Interfacility Transfer Form for all CRE case transfers between healthcare facilities. AHS will participate in the CDPH Bay Area CRE Collaborative that will be in effect from May 2016 - May 2017. 2017 Surveillance Plan Goal 2017 Program


Reduce and eliminate MDROs CRE, VRE <0.5 / 10,000 patient days LabID Event HO MRSA bacteremia: SIR < 0.917

Low

• Continue use of MDRO evidence based practice strategies using CDC, SHEA, APIC guidelines

• Continue use of CDC, APIC Guidelines for C difficile • Continue annual education to physicians • Implement education in New Hire Orientation • Continue staff and patient/family education upon isolation • Alameda County requirement to report All LabID events

for CRE

Patient Population: All patients Analysis: Incidence rate per 1000 patient days LabID Event HO MRSA bacteremia SIR or CRE and VRE rate/10,000 Case Finding Methodology: 1. Infections will be identified through review of cultures and screenings,

clinical records, antibiotics, and readmissions using the CDC/NHSN definitions and enter into NHSN.

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MRSA Screening (per state requirements) and NHSN MRSA Bacteremia Evaluation of 2016 Program Effectiveness Goal 2016 Target 2016 Outcome 2016 Effectiveness 2016

Comply with state requirement for MRSA screening LabID MRSA BSI

Screening on Admission 100% (per facility policy and procedure) <1 SIR

Screening on Admission 100% SIR 1.059

Goal Met Goal not met

2016 Activities/Analysis: Screen high risk patient on admission as per required by State of California HAI (patient’s on dialysis, ORTHO surgeries, admission into the ICU) LabID events MRSA Bacteremia for 2016 = 3 Hospital Onset with a SIR of 1.059.

2012 2013 2014 2015 2016 2016RBSIR 3.3 2.1 0 0.7 0.9 1.059Observed Count 11 7 0 2 3 3Predicted Count 3.4 3.4 4.1 2.9 3.3 2.8

0

0.5

1

1.5

2

2.5

3

3.5

SIR (O

bserve

d/Pre

dicted

)

Healthcare Onset MRSA Bacteremia SIR, by Year



Screening on Admission 100% SIR <1

Low • Continue screening on admission with same risk indicators

• Consider using MRSA nasal decolonization for ICU patients

• Implement education on New Hire Orientation on MDRO

• Continue staff and patient/family education upon isolation

Patient Population: All patients Analysis: Incidence rate or NHSN LabID Event HO MRSA bacteremia SIR

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Case Finding Methodology: 1. Infections will be identified through review of cultures and screenings, clinical records, antibiotics, and readmissions using the CDC/NHSN definitions and enter into NHSN and Quality Council reporting as appropriate

Surveillance Activity: Hospital-Acquired Clostridium difficile Evaluation of 2016 Program Effectiveness


Reduce and eliminate HAIs associated with C. difficile

C. difficile: SIR <1

C. difficile: SIR 0.450 Goal met

2016 Activities/Analysis Target of SIR <1 achieved Implementation of MDRO reduction strategies:

• CHG bathing of ICU patients • Enteric contact isolation • Environmental decontamination by use of bleach for C. difficile room disinfection

2012 2013 2014 2015 2016 2016RBSIR 0.75 0.84 0.59 0.80 0.36 0.45Observed Count 23 26 21 28 13 13Predicted Count 30.7 31.2 35.3 35.0 35.9 28.9

0.00

0.20

0.40

0.60

0.80

1.00

1.20

SIR (O

bserve

d/Pred

icted)

Healthcare Onset C. difficile SIR, by Year

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Reduce and eliminate MDROs LabID Event HO CDI SIR < 0.30 PRIME goal ≤ 0.8

High

• Continue use of MDRO evidence based practice strategies using CDC, SHEA, APIC guidelines

• Continue use of CDPH, CDC, APIC Guidelines for C. difficile

• Continue annual education to physicians • Implement education in New Hire Orientation • Continue staff and patient education upon isolation • Continue use of UV light as part of terminal cleaning for

all C. diff isolation rooms.

Patient Population: All patients excluding babies (NICU, nursery, etc.) Analysis: Incidence rate per 10,000 patient days and NHSN LabID Event HO C. difficile SIR Case Finding Methodology: 1. Infections will be identified through review of cultures and screenings, clinical

records, antibiotics, and readmissions using the CDC/NHSN definitions and enter into NHSN and the UHS Dashboard as appropriate

Surveillance Activity: M. tuberculosis Statistics The 2016 TB Statistics and Risk Assessment will be updated in mid-year (June or July) when the County, State and Federal TB statistics become available. Evaluation of 2016 Program Effectiveness


Identify and early isolation of suspected cases of M. tuberculosis

Identify and appropriately isolate suspected TB Cases: 100%

100% based on follow-up screening and no TB exposures resulting in conversions.

Goal met

2016 Activities/Analysis 1. In 2016, there were 39 cases of active TB reported to Alameda County Department of Public Health,

TB Control Program.

2. In 2016, there were no employee TB screening conversions identified by our Employee Health Department. ---- need to verify.

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2012-2016 Count of Cases (Pulmonary and Extra-Pulmonary involvement), Alameda County** & California

(**excludes the City of Berkeley)

YEAR ALAMEDA COUNTY** CALIFORNIA

2012 136 2187

2013 114 2164

2014 108 2134

2015 139 2137

2016 136 2073

2016 TB Cases Rates by Location

Location Rate per 100,000 Population

Alameda County** 9.1

California 5.3

United States 2.9

2016 Biologic Site of TB Infection, Alameda Health System, Highland Hospital

Site

Culture Positive

N (%)

Culture Negative

N (%)

Total

# of employee TB

screening conversions

Pulmonary Lungs 16 (70%) 7 (30%) 23 0 Extra-Pulm Pleural,

Pericardial, Lymphnodes

5 (71%) 2 (29%) 7

Pulm & 8 (89%) 1 (11%) 9

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Extra-Pulm

Total 39



Identify and early isolation of suspected cases of M. tuberculosis. Continuing clinical rounds with pulmonary physician on all high suspect cases of TB.

High 1. Perform contact investigations when exposures occur and review case for educational issues.

2. Continue employee TB screening annually.

3. Review and update TB Control Plan annually.

4. No change to the annual employee TB screening protocol

5. Collaborate with Employee Health for any employee exposures

6. Review cases for performance improvement opportunities related to appropriate precautions

Fairmont Hospital IRF


Reduce and eliminate HAIs

CAUTI CLABSI LabID MRSA Bactermia HO LabID C. diff

0 0 0 1

Goal Met

2016 Activities/Analysis: Continue surveillance activities



Maintain, reduce and/or eliminate MDROs

High Dedicate additional point contact infection preventionist for post-acute care facilities including: Fairmont Hospital John George Psychiatric Hospital

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Surveillance Activity: Influenza Vaccination Evaluation of 2015-2016 Influenza Season Program Effectiveness. This is a collaborative effort between Employee Health and Infection Prevention. Pursuant to California SB 1318, AHS requires all employees, contractors, students, volunteers, persons with privileges on the medical staff, and all other onsite health care workers affiliated with the clinic to either annually receive an influenza vaccination or, as an alternative to the annual influenza vaccination, wear a surgical or procedural mask, or other mask that covers the mouth and nose area of the face while this person is performing his or her duties in any patient care area of the clinic during the influenza season, as defined by the State Health Officer or a local health officer, or both. Acute care hospitals participating in the Centers for Medicare & Medicaid Services' Hospital Inpatient Quality Reporting Program are required to submit summary data on influenza vaccination of healthcare personnel via the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN). Hospitals are required to report vaccinations received by healthcare personnel at the facility, vaccinations received outside the facility, medical contraindications and declinations. Data must be reported for all employees on payroll, licensed independent practitioners (who are physicians, advanced practice nurses, and physician assistants affiliated with the hospital but not on payroll), and students, trainees, and volunteers aged 18 or older. Only healthcare personnel physically working in the facility for at least 30 days between October 1 and March 31 should be counted. Goal 2015-2016 Target 2015-

2016 Outcome 2015-2016 Effectiveness 2015-

2016

Achieve same or better compliance than last season for vaccination and declination rates

90% 90% compliance for vaccinations or signed declinations.

Goal met

2015-2016 Activities: Annual Influenza Immunization Program, Reporting of vaccine program in NHSN

2016-2017 Surveillance Plan Goal 2016-2017 Program

Priority Planned Actions for 2016-2017:

Achieve same or better from 2015-2016 season.

High • Influenza vaccine campaign in September including: o Continue use Flu Champions in key areas such

as the ED, ICU and MCH in administering vaccines

o Continue department Flu Clinics to administer vaccine

o Continue to partner with the Benefits Fair to administer vaccine

o Continue with Department Reports to target those that haven’t participated

• Target top reasons for declinations in previous years

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Population: Clinical and non-clinical employees, volunteers, physicians, LIPs, residents, fellows, students, contractors (optional) working in the facility for at least one day during the influenza season

Analysis: Incident rate, number receiving the vaccine over total number as defined by CDC guidelines. The information is placed in NHSN

Case Finding Methodology: Employee health coordinates data collection to include populations listed above Employee Health: Bloodborne Pathogen Exposures Employee Health Services (EHS) monitors and analyzes trends related to significant employee infections, BBP exposures from splash or sharps injury, communicable disease exposures/outbreaks, annual TB screening and TST conversions, influenza vaccinations, and pre-employment screenings and vaccinations. Employee Health and Infection Control share responsibility in exposure prevention, outbreak management and other activities involving employees, contractors and volunteers. EH provides pre-employment screenings & immunizations including management of the influenza vaccination program for employees. EH provides follow up of occupational exposure to or diagnosis of infectious disease in medical center employees. The Infection Control Team and Infectious Disease physician manages patient exposure situations for isolation and prophylaxis if needed. Evaluation of 2016 Program Effectiveness Goal 2016 Target 2016 Outcome 2016 Effectiveness 2016

Decrease number of sharps exposure

Lower than 2015 Increase/same as previous year

Goal note met

2016 Activities Sharps Safety evaluation, Annual review of Blood borne Pathogen Plan, Annual review of needle stick reduction devices at Infection Control and Environment of Care and Value Analysis if needed.



Reduce the number of exposures from 2014 Benchmark (EPINet) for Needlesticks and Sharp Exposures: 19.46 per 100 occupied beds Benchmark (EPINet) for Blood and Body Fluid Exposures 7.23 per 100 occupied beds

High Implement campaign to encourage safe needle practices, use of protective devices, proper disposal and encourage correct PPE during splash-producing procedures Ensure that proper PPE is available in all departments Develop a specific action plan for employees who are exposed to include 3 key elements: Required evaluation with employee health nurse, devise an action plan based upon exposure circumstances, review to confirm terms of action plan met

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Population: Employees, volunteers, physicians working in the facility Analysis: Incident rate, number of needle sticks/BBP exposures Case Finding Methodology: Exposures reported through loss control Surveillance Activity: Antibiotic Stewardship The Antimicrobial Stewardship Program (ASP) will promote and monitor compliance with evidence based guidelines or best practices regarding antimicrobial prescribing which may include but not limited to the following activities including those recommended by the CDC’s Core Elements of a Hospital Antimicrobial Stewardship Program Evaluation of 2016 Program Effectiveness Goal 2016 Target 2016 Outcome 2016 Effectiveness 2016

Pharmacy interventions accepted by physicians

Publish Antibiograms Antibiograms published Goal Met

2016 Activities Pharmacists review focused/restricted antibiotic usage to determine if ordered appropriately, including the culture results. Recommendations made to physician if issues are identified



Continue to implement components of Antibiotic Stewardship program

Determined by ASP

• Collaborate with Antimicrobial Stewardship Team/Project • Provide data as requested to the team • Assist with education of physicians as requested

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Surveillance Activity: High Level Disinfection (HLD) Evaluation of 2016 Program Effectiveness Goal 2016 Target 2016 Outcome 2016 Effectiveness 2016

Ensure compliance with both the process and documentation of HLD by direct observation of infection prevention

Documentation: 90% Process: 100%

Documentation: 100% Process: Gaps in process

Documentation: Goal met Process: Gaps in processes

2016 Activities Evaluate use of Cidex OPA in Central Sterile processing; and other areas performing HLD, explore the purchase of additional H2O2 Trophon in Vaginal Probe Ultrasound. Both were monitored for process and documentation.



Improve on Process compliance 100% Continue same documentation 100%

High Complete and total assessment of all areas performing HLD Develop and implement overarching AHS policy based on best-practice guidelines by CDC, AAMI and AORN. Re-education and competency of all staff performing HLD

Population: Items needing High Level Disinfectant Analysis: Incidence rate, observations of process and documentation elements Case Finding Methodology: Direct observation and review of documentation Surveillance Activity: Immediate Use Steam Sterilization (IUSS) Sterile Processing reports quarterly to IC Committee on Immediate Use Steam Sterilization performance improvement. Evaluation of 2016 Program Effectiveness


Minimize use of the Express cycle

<2% 4% Goal not met

2016 Activities Standardized system for dirty instrumentation transport 2017 Surveillance Plan Goal 2017 Program Priority Planned Actions for 2017:

Achieve IUSS below the AHS benchmark of <2%

High Continue current processes including exploration of ways to reduce the need to use the express cycle Expand the hours of service for CSP

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Population: Items processed via Express Cycle Analysis: Incidence rate, count of express cycles outlined by AAMI standards Case Finding Methodology: Log review, aggregated results from CSP Supervisor or OR Director Surveillance Activity: Compliance with Isolation Precautions Evaluation of 2016 Program Effectiveness


Ensure compliance with isolation precautions

100% 100% Goal met

2016 Activities/Analysis Daily rounding on units to determine appropriate isolation and documentation of patient/family education Prevalence surveys of isolation technique, isolation supplies and signage was measured by direct observation during IPC rounds 2017 Surveillance Plan Goal 2017 Program Priority Planned Actions for 2017:

100% Low Continue prevalence surveys, report findings to Nursing Leadership, implement immediate corrective action if incorrect signage is visible, immediate correction action for observed breaks in technique Continue with survey of documentation for Isolation Precautions Work with nursing informatics to add measure to EMR

Population: Prevalence of isolation cases on nursing units on a specific day Analysis: Prevalence rate: # incorrect signage/#isolation cases # breaks in technique/#isolation cases # inadequate isolation supplies/#isolation cases Case Finding Methodology: Direct observation during IP rounds on nursing units PROGRAM ELEMENTS Resource Allocation: Needs for 2017 to effectively manage IP program The IC Team is comprised of an Infectious Disease Physician who has training in infection control and is assigned to be the Infection Prevention and Control Committee Chairperson, System Director of Infection Prevention, Infection Preventionists, TB Coordinator, and access to clerical assistance through Quality Division. Needs as assessed through observational and direct use requirements:

• Computer o Microsoft office productivity

software (e.g Word, Excel, Powerpoint)

o Novius Laboratory Information Systems (LIS)

o Midas o Sorian EMR o Sorian Financials o NHSN SAMS access o ORMIS o EDM Pharmacy

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o Wellsoft o Softmed

• Resource Guides o CDC, SHEA guidelines o APIC Text (online access) o CMS Conditions of Participation

(COP) o AORN Standards o The Joint Commission Standards

(TJC)

o AAMI Standards (online access) • Personnel

o Continue to review productivity needs as beds capacity is increased

o 2016 two vacant IP positions for AHS Core

• Supplies o Office Space o Supplies

Infection Control Log: Major Incidents/Investigations 2016 SUBJECT BACKGROUND ASSESSMENT RECOMMENDATIONS/ACTION January 2016 Chicken Pox Exposure at Highland Pediatric clinic

One month old male had rash on head and body areas. Later diagnosed as Chicken Pox

Five patients were exposed and contacted by IC department. No vaccines given, no one developed symptoms with 21 days of monitoring. Five employees were exposed, all with immune status. 21 days monitoring, no symptoms development. No secondary cases identified

No additional actions and/or recommendations per this exposure

Hand/Foot/Mouth Disease

1 patient 1 employee exposure No patient exposure

No cases identified

Head Lice exposure

7th 15 employees had direct contact

Floor of ACT

No patient exposure

15 employees screened 0 reports of lice

TB exposure 1 TB patient 6 Employees exposed No conversions Strategies to Minimize, Reduce, and Eliminate Infection Risk

Strategies Description Plan

A. VAE • Ventilator associated events are monitored and reported by Critical Care Committee Respiratory Therapy

• Report any VAPs identified to Critical Care Committee if identified by IP staff.

B. Environmental

• The Infection Preventionist participates in environmental rounds independently and with other facility team members to assess patient and environmental safety and quality

• Continue environmental rounding processes including:

o Analyze trends o Share the

information o Collaborate with

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• The Infection Preventionist aggregates both IC and Hazard Surveillance rounding data and distributes information to leaders for responses

• ATP testing on all terminal clean isolation rooms, in addition to random testing.

leaders o Encourage posting

of results o Report in

Committees (IPC and Safety as appropriate)

C. Dialysis Testing • Water used to prepare dialysis solutions must meet AAMI Standards for hemodialysis water quality, including endotoxins

• Total viable bacterial counts in water used to prepare dialysate or to reprocess hemodialyzers

o 0-49 CFU/ml Acceptable o 50-199 CFU/ml Action o 200 CFU/ml or greater

Unacceptable • Endotoxins

o 0-0.99 EU/ml Acceptable o 1-1.99 EU/ml Action level o 2 EU/ml Unacceptable

• Action range = Machine is “Ok to use” pending repeat.

• Unacceptable range = Machine is removed “out of Service” pending repeat.

• Continue Dialysis Water, Endotoxins and Dialysate Testing per existing requirements and guidelines

• Continue to work with

vendor in OP dialysis area to ensure compliance with IPC standards

• Continue to report data monthly to Infection Prevention

D. Sterilizer Testing

• Sterilizer testing is done in accordance to AORN, AAMI and CDC recommendations

• Ensure adequate reporting to the IPC committee

E. Water system

Testing • The Infection Preventionist

collaborates with Engineering regarding facility waterborne pathogen prevention strategies, including Legionella water testing plan.

• Facility establishes and continues process for waterborne pathogen prevention strategies

• Continue testing and reporting of water results as appropriate

• Engineering manages Water Management Plan Tools and Training through HC Info LAMPS ( Legionella assessment and management plan support)

F. Construction • An infection control risk

assessment (ICRA) is completed on areas for renovation or new

• Work with construction team prior to construction in determining infection

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construction in the facility to determine isolation and barriers required, practices required to eliminate and/or reduce dust and debris, air monitoring precautions, negative pressure monitoring (HEPA), patient placement, and clean up.

control risks via the ICRA and attend meetings as needed

• Continue monitoring hospital wide construction activities in conjunction with Plant Operations

• ICRAs reported to ICC and held in separate binders within infection prevention department

G. Active Surveillance Cultures

• MRSA Nasal screening per California Code of Regulations, Title 22, Sections 1255.8 and 1288.55

• Protocols to be developed to obtain ASC for targeted MDROs

• Monitor ASC populations as identified and report appropriately

H. Facilitate/ Participate in HAI case review, or other infection related processes requiring RCA / FMEA/HAC /QAPI and task force review

• Facilitate/participate in review of identified cases of unanticipated deaths or major permanent loss of function and HACs (never events) associated with a healthcare associated infection

• Task force to assess measures and metrics for True North Metrics and PRIME measures

• Review reported/identified cases and compare to CDC and other guidelines. Report results of review as appropriate

• Participate in RCA/FMEA as requested

• Participate in True North Metrics planning and PRIME measures planning

I. Outbreak Management

• An outbreak is described as the sudden occurrence or increase of infectious and non-infectious disease and conditions.

• The Infection Prevention and Control Program investigates potential outbreaks to identify the source and/or likely cause of infections and also investigates patients from who pathogens with high transmission potential have been identified or suspected to assure that control measures appropriate to the pathogen have been instituted.

• A full scale investigation will be conducted in the event of a suspected outbreak using sound epidemiological principles

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• In circumstances where a significant potential for transmission of an infectious pathogen from either a patient or employee has been identified, the Infection Prevention and Control Program works closely with the Employee Health Program to identify both patients and employee who may be at risk for disease acquisition and to intervene as appropriate to the circumstance.

J. Policies and Procedures

• Infection Control policies and procedures are based on recognized guidelines and applicable laws and regulations. The policies address the prevention of infection transmission among patients, employees, visitors, and environmental issues.

• Policies will reflect current accepted and approved Infection Prevention practices based on regulatory recommendations, standards, and guidelines.

• Continue policy and procedure review at least every three years or as needed based on regulatory recommendations, guidelines. However, the Tuberculosis Exposure Control Plan is reviewed annually

• Assist Employee Health

in review of the Bloodborne Pathogen Exposure Control plan annually

• Review Respiratory Protection Plan Annually

• TB Exposure Plan Annually

K. Information

Reporting • Continue participating in public

databases and reporting as indicated

• Continue reporting of Reportable conditions as indicated by law

• NHSN and State initiatives

• Per State Reportable

Conditions

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L. Education

• Infection prevention education is provided to employees at hire and annually as required based on job description.

• Coordinate with Nursing Education for competency fairs, and periodic nursing staff education.

• Additionally education is provided to LIPs, patients, visitors, and families

• Education provided at new staff orientation

• Education to Medical Staff in Department meetings

• On-site education done per schedule

• Individual and unit education done during rounding and at request of management

• Televised public education done as requested

• Patient/Family education done as requested

• Offsite education done as requested

• Annual online modules

M. Communication • Communication regarding the Infection Prevention and Control Program is ongoing

• Communication between local and

regional health care organizations offering opportunities for early identification of infections

• Communicable Disease Reporting

o Prompt reporting of all Title 17 reportable diseases is ongoing to Alameda County Public Health Department.

o Prompt reporting of specific diseases to California Emerging Infections Program (CEIP).

o Prompt follow-up and reporting of communicable disease exposures to first responders (Ryan White Act).

o Reporting to California Department of Public Health as required (e.g., outbreaks, significant exposures).

Hospital Level • Leadership – scheduled

leadership meetings and as requested

• Physicians - Committees, physician newsletter, one on one

• Staff – individual and small groups during rounds, reports to managers to share with their staff

• Students – IC orientation • Volunteers – orientation

Community Level • Between hospitals (referring

hospital will be notified when an infection is identified in transferred patient)

• Health Department meetings

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N. Influx of Patients

• IC participates for disaster planning, pandemic response & preparedness including the management of an influx of infectious patients. The IC team participates in disaster drills and emergency management meetings.

• Refer to Facility Emergency Management Plan

O. Data Analysis • Case definitions for healthcare associated infections shall be those developed and published by the National Healthcare Safety Network (NHSN), and CDC guidelines if it’s a measure that is not being followed by NHSN.

• Continue to work through processes with Cerner to collect the most accurate data.

• All data collected for infection control should be presented in a rate-based format for clarity and comparison purposes

• For data in the NHSN system,

a standardized infection ratio (SIR), shall be used for national benchmark comparisons

P. Cleaning of medical equipment, supplies and devices

• The Infection Preventionist collaborates with hospital departments and the Environment of Care/Safety Committee to assure that a system for the cleaning of medical equipment, devices, supplies and supply rooms is implemented.

• Manufacturer’s recommendations will be adhered to

• Reprocessed single use items are done with the selected vendor – the items will be placed in the appropriately labeled containers provided by the company

• A monitoring system will be implemented to assure compliance with cleaning of medical equipment, devices and supplies. (CDC Level II) Compliance will be reported in IPC committee.

• UV Disinfectant machine(s) are being used to augment chemical and mechanical cleaning.

o This is a joint project between IPC and EVS.

• Reassess systematic designation for clean vs dirty medical equipment, to include cleaning schedule, who and when an item is to be cleaned.

• The IPC in conjunction with the Environment of Care committee to review and assess compliance during EOC rounds.

• Germicidal sanicloths and disinfectant will be made available in patient care areas

• Before the technology is

utilized, a full program will be implemented to guide its usage

Q. BHC, Rehab,

and the Wound Center

• The Infection Preventionist will coordinate with leaders from these facilities to ensure elements from this Plan are implemented in these offsite arenas.

• As appropriate, infection control indicators will be reported to the committee

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R. Presence in facilities

• IPC staff members attend multiple meetings in the hospital providing a constant presence and reminder about the importance of infection prevention.

These include, but are not limited to: • Infection Prevention and

Control Committee • Policy and Procedures

Committees (Clinical Practice Council and Committee on Interdisciplinary Practice)

• Medical Executive Committee

• Antimicrobial Stewardship Committee

• Nurse Leadership Council • EOC Committee • Quality Council • Nurse Staffing Committee • Construction Strategic pre-

planning sessions • Value Analysis Team (VAT)

Meeting • Fairmont quality Council • OR Executive Committee • Emergency Management

Committee • Critical Care committee

S. SSI reduction efforts

1. Safe OR Practices 2. Screen3.

–for MRSA Shower – with CHG pre-procedure

4. Skin prep – Alcohol based saniziters 5. Solution

Implement measures recommended by CDC, APIC, IHI, SHEA, AORN, AAMI and other organizations with SSI prevention strategies – CHG irrigant

T. Zika Virus: Per the CDC, Zika virus is transmitted to humans primarily through the bite of an infected Aedes species mosquito. The mosquito vectors typically breed in domestic water-holding containers; they are aggressive daytime biters and feed both indoors and outdoors near dwellings. Nonhuman and human primates are likely the main reservoirs of the virus, and anthroponotic (human-to-vector-to-human) transmission occurs during outbreaks. Perinatal, in utero, and possible sexual and transfusion transmission events have also been reported.

Infection Control will follow developments related to Zika Virus and follow CDC recommendations for our patients and community.

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APPENDIX A: Employee Health Influenza Vaccination Compliance Grid, 2015-2016 Season

HCP Categories Employee HCP

Non-employee HCP

Employees (on facility payroll)

Licensed independent practitioners; physicians, and physician assistants/Contractors

Students, & volunteers

# HCP who worked at this healthcare facility for at least 30 days between October 1, 2015 and March 31, 2016

2217 64 49

# HCP who received influenza vaccination at this healthcare facility since influenza vaccine became available this season

1234 37 16

# HPC who provided a written report or documentation of influenza vaccination outside of TMC since influenza vaccine became available this season

675 9 33

# HCP who declined influenza vaccine 202 Unknown Unknown

# HCP Noncompliant 106 33 Unknown

Bloodborne Pathogen Exposures in 2016 (HGH, JGH, Fairmont, Wellness Clinics)

Injuries by type of Exposure Total # 86 % of the all incidents

Splashes 14 16%

Needlestick Injuries 52 60%

Lacerations/Punctures 19 22% Other/bite 1 1%

Injuries by Job Classification RN 29 34% Residents/Medical Students 29 34% Physicians 15 17% Other (RT, PT, EVS etc) 13 15%

Injuries by Location OR 25 29% Podiatry/Dental Clinic 18 21% ED 13 15% Other (Lab, JGH, FMT, NUCL Med, Vas Clinic, Parking lot) 9 10%

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Med/Surg 8 9% L&D 6 7% ICU 3 3% Peds/NICU 2 2% Wellness Clinics 2 2%

Mechanism of Injury by ranking Carelessness 1 Stuck while disposing needle 2 Patient’s sudden movement 3 Stuck during procedure 4

Bloodborne Pathogen Plan Annual Review Statement The existing Blood borne Pathogen Plan was reviewed and compared to OSHA standards. It was revised by Employee Health with IPC staff serving as a resource. The document was presented and approved by the Infection Prevention and Control Committee, Environment of Care Committee. APPENDIX B: TB Exposure Control Plan

Incidence of TB 2016 2015 2014 Community Rate/100,000 residents 9.1 9.5 7.4 State Rate/100,000 residents 5.3 5.5 5.6 National Rate100,000 residents 2.9 3.0 2.9 # Suspected 39 38 28 # Confirmed 29 23 17 Cluster of MTb None None None Employee Conversion Rates 0 0 0 Any group/trend with increased rate None None None Risk Classification # of Cases diagnosed in Alameda Co.

136 139 108

Risk Assigned High High High Screening of HCW for mTb infection (Annual TST screening of staff and LIPs) Baseline – 2 step TST On Hire and/or last TST >1 year Frequency of TST Annually Records maintained 30 years Who maintains records Employee Health TB Infection Control Program Written Aerosol Transmissible Disease Exposure control Plan

Yes

Effective /Original Date 6/2010 Reviewed/Updated 10/2017 Infection Control Committee Yes Implementation of TB Control Plan Ongoing education provided? Yes

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Person responsible for program TB infection prevention RN Lab Processing: Blood Culture Contamination Rate Laboratory started reporting Blood culture Contamination rates January 2017 and forward.

Environmental Controls AIIR Rooms: 42 Negative pressure isolation or procedure rooms Routinely checked Engineering and Nursing Room directional flow checked daily when in use Process in place for annual assessment of negative pressures and air changes per hour for AIIR

Respiratory Protection Program What type of mask is used? N95 Is Initial Fit test completed? Yes Annual fit testing program in place Yes

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APPENDIX C: Infection Control Risk Assessment 2017 Background: As part of its commitment to quality care and service, AHS conducts a periodic assessment of the risk(s) for transmission and acquisition of infectious agents. This risk assessment incorporates an analysis of the following: 1. The geographic location and community environment of the organization, the programs and services provided, and the characteristics of the

population served. 2. The results of the organization’s surveillance, prevention, and control data. 3. The care, treatment, and services provided. The risk assessment is conducted at least annually and whenever there is a significant change in any of the above factors. Risk Assessment Findings: The risks for the transmission and acquisition of infectious agents have been identified and weighted using a hazard probability format. Each IC issue is ranked numerically according to probability, risk and preparedness. Highest scoring issues will receive the highest priority for surveillance and process improvement. In addition, AHS must also comply with California State law surveillance and reporting requirements as well as requirements set forth by The Joint Commission, OSHA and CMS. The risk level scores are achieved by addition the scores for each event. The risk level scores are a range of 3 – 12, with 3 being the lowest score and 12 the highest score. The ranking is 1 thru 31 in chronological order.

Event

How likely is our facility to have a problem with _________________?

If this were to happen, to what degree would it affect patients,

staff, or organization?

How effective are our Current Procedures

Risk Level (ICP only)

Rank High Med Low None

Catastrophic Loss of life/limb/

function

Temp loss of Function

Or Legal

Prolonged Length of

Stay

Moderate (Clinical or Financial)

Minimal (Clinical

or Financial)

Poor Fair Good

Score: 4 3 2 1 5 4 3 2 1 3 2 1

POTENTIAL INFECTIONS

Multidrug-Resistant Organisms (MDRO) to include MRSA, ESBL, VRE, and CRE

4 4 1 9 5

C. difficile 3 4 1 8 7

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Event








function


Or Legal

Prolonged Length of

Stay


Minimal (Clinical

or Financial)

Poor Fair Good

Score: 4 3 2 1 5 4 3 2 1 3 2 1

Facility Acquired Procedure-Related Wound Infections

1 4 2 7 8

Other

DEVICE RELATED INFECTIONS

Catheter Associated Urinary Tract Infections (CAUTI)

3 2 2 7 9

Central Line Associated Blood Stream Infection (CLABSI)

2 3 1 6 19

SURGICAL SITE INFECTION

Knee Prosthesis

2 5 3 2 12 1

Hip Prosthesis 2 5 2 9 5

Gastrointestinal 3 5 2 10 4

C- Section 3 2 1 6 20 FX Open Reduction of Fracture 4 5 2 11 2 Other

EXPOSURE-RELATED

Unusually Large Influx of Infectious Patients 2 2 1 5 26

Bloodborne Pathogen Exposures 3 1 1 5 23 Influenza 2 2 1 5 28 Tuberculosis 2 1 1 5 29

Lack of Communication of Isolation Necessity of Patients Moving Between Units

3 1 1 5 22

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Event








function


Or Legal

Prolonged Length of

Stay


Minimal (Clinical

or Financial)

Poor Fair Good

Score: 4 3 2 1 5 4 3 2 1 3 2 1

Other

PEOPLE

Hand Hygiene Compliance 4 2 1 7 10

Compliance with Isolation precautions/PPE 4 2 1 7 11

Inadequate Staff education and training in infection control practices

3 2 2 7 13

Inadequate Patient/Family Education about CLABSI, CAUTI, MDRO, and SSI Prevention

3 1 2 6 14

Other

ENVIRONMENT

Inadequate disease/ dust mitigation practices for Construction Activities

4 1 1 6 16

Inadequate Cleaning of Environment 3 2 1 6 18

Inadequate Temperature / Humidity 3 1 2 6 15

Incorrect air flow of rooms. 2 1 1 4 27

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Event








function


Or Legal

Prolonged Length of

Stay


Minimal (Clinical

or Financial)

Poor Fair Good

Score: 4 3 2 1 5 4 3 2 1 3 2 1

Other

SUPPLIES/EQUIPMENT

Inadequate Cleaning, High Level Disinfection, or Sterilization of supplies and equipment

4 1 2 7 12

Frequent Immediate Use Sterilization of Instruments

2 1 2 5 24

Transport of supplies 2 3 1 6 17

Torn Furniture 3 1 2

RISK OF MDRO OR OTHER INFECTION FOR POPULATION SERVED

ICU 4 5 2 11 3

Pediatrics 2 1 1 4 30

Skilled Nursing Facility Patients 2 2 1 5 25

Oncology 2 4 1 7 13

Dialysis Patients 3 4 2 9 6

Inpatient Psychiatric Patients 2 1 1 4 31

Other

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IMPORTANT: This tool is used for IC program planning & goal setting to determine priorities for IC surveillance activities for 2017 -2018. However, regulatory and accreditation requirements must be considered in combination with IC staffing to determine IC’s annual surveillance priorities. * Issue or event is required by California State Law and is publically reported through NHSN. Approvals

Departmental Date: 10/2017 Infection Control Committee Date: 10/2017 Quality and Safety Committee Date: 11/2017 Medical Executive Committee Date: 11/2017 Board of Trustees Date:

Documents

Executive Summary for MEC - Highland Hospital · Patients with >28 weeks estimated gestational age should have Category I fetal heart rate tracing or a reactive NST medically indicated