NOTICE - Kaweah Delta Medical Center · NOTICE . The Board of Directors of the Kaweah Delta Health Care District will meet in an open Board of Directors meeting at 5:30PM on Monday,

400 West Mineral King Avenue · Visalia, CA · (559) 624 2000 · www.kaweahdelta.org

October 20, 2017

NOTICE The Board of Directors of the Kaweah Delta Health Care District will meet in an open Board of Directors meeting at 5:30PM on Monday, October 23, 2017 in the Kaweah Delta Medical Center – Mineral King Wing – Blue Room {400 W. Mineral King, Visalia}.

The Board of Directors of the Kaweah Delta Health Care District will meet in a closed Board of Directors meeting at 5:31PM on Monday, October 23, 2017 in the Kaweah Delta Medical Center Blue Room {400 W. Mineral King, Visalia} pursuant to Government Code 54956.9(d)(1), Government Code 54956.9(d)(2), Health & Safety Code 32155, and Health & Safety Code 1461.

The Board of Directors of the Kaweah Delta Health Care District will meet in an open Board of Directors meeting at 6:00PM on Monday October 23, 2017 in the Kaweah Delta Medical Center – Mineral King Wing – Blue Room {400 W. Mineral King, Visalia}.

The Board of Directors of the Kaweah Delta Health Care District will meet in a closed Board of Directors meeting immediately following the 6:00PM Open Board meeting on Monday, October 23, 2017 in the Kaweah Delta Medical Center –Blue Room {400 W. Mineral King, Visalia} pursuant to Government Code 54957(b)(1) and Health and Safety Code 32106

All Kaweah Delta Health Care District regular board meeting and committee meeting notices and agendas are posted 72 hours prior to meetings (special meetings are posted 24 hour prior to meetings) in the Kaweah Delta Medical Center, Mineral King Wing entry corridor between the Mineral King lobby and the Emergency Department waiting room.

The disclosable public records related to agendas are available for public inspection at the Kaweah Delta Medical Center – Acequia Wing, Executive Offices (Administration Department) {1st floor}, 400 West Mineral King Avenue, Visalia, CA and on the Kaweah Delta Health Care District web page http://www.kaweahdelta.org.

KAWEAH DELTA HEALTH CARE DISTRICT Lynn Havard Mirviss, Secretary/Treasurer

Cindy Moccio Board Clerk & Executive Assistant to CEO

DISTRIBUTION: Governing Board Legal Counsel Executive Team Chief of Staff www.kaweahdelta.org

http://www.kaweahdelta.org/

http://www.kaweahdelta.org/about/agenda.asp

KAWEAH DELTA HEALTH CARE DISTRICT BOARD OF DIRECTORS

Kaweah Delta Medical Center {400 West Mineral King Avenue} Mineral King Wing Basement (Blue Room)

www.KaweahDelta.org

Herb Hawkins – Zone I ⃰⃰ Lynn Havard Mirviss – Zone II ⃰⃰ John Hipskind, MD – Zone III ⃰⃰ Carl Anderson – Zone IV ⃰⃰ Nevin House – Zone V Board Member Secretary/Treasurer Board Member President Board Member

Monday, October 23, 2017

OPEN MEETING AGENDA {5:30PM} Call to order Approve agenda Public / Medical Staff participation – Members of the public or the medical staff may comment on agenda items before action is taken and after the item has been discussed by the Board. Each speaker will be allowed five minutes. Members of the public wishing to address the Board concerning items not on the agenda and within the subject matter jurisdictions of the Board are requested to identify themselves at this time. 1. Approval of Closed Agenda as follows: Closed Meeting Agenda – Kaweah Delta Medical

Center Blue Room – 5:31PM 1.1. Conference with Legal Counsel – Existing Litigation – Pursuant to Government Code

54956.9(d)(1) - Andy Weiss, Legal Counsel & Kassie Waters, Interim Risk Manager 1. Johana Martinez – Case # 266240 2. Judith Pearce – Case#VCU269667 3. Clyborne, Zane – Case # 261675 4. Ferreira, Steven – Case # 16C0328 5. Calvillo, Lindsey – Case# 265986 6. Edison, Marilyn – Case# 265419 7. John Doe – Case # 1:08 8. Esparza, Emma – Case #VCU256571 9. Brito-Mojica, Rosa – Case # VCU265405 10. Delgado, Anabel – Case # 263390 11. Madrigal, Maria – Case # 264562

1.2. Conference with Legal Counsel – Anticipated Litigation – Significant exposure to litigation pursuant to Government Code 54956.9(d)(2) – 9 Cases - Andy Weiss, Legal Counsel & Kassie Waters, Interim Risk Manager

1.3. Credentialing - Medical Executive Committee requests that the appointment, reappointment and other credentialing activity regarding clinical privileges and staff membership recommended by the respective department chiefs, the credentials committee and the Medical Executive Committee be reviewed for approval pursuant to Health and Safety Code 1461 and 32155 – Harry Lively, MD, Chief of Staff

1.4. Approval of closed meeting minutes {09/25/17} Adjourn


Monday, October 23, 2017 Page 2 of 4 Herb Hawkins – Zone I ⃰⃰ Lynn Havard Mirviss – Zone II ⃰⃰ John Hipskind, MD – Zone III ⃰⃰ Carl Anderson – Zone IV ⃰⃰ Nevin House – Zone V Board Member Secretary/Treasurer Board Member President Board Member

CLOSED MEETING AGENDA {5:31PM} Call to order 1. Conference with Legal Counsel – Existing Litigation – Pursuant to Government Code

54956.9(d)(1) - Andy Weiss, Legal Counsel & Kassie Waters, Interim Risk Manager 1. Johana Martinez – Case # 266240 2. Judith Pearce – Case#VCU269667 3. Clyborne, Zane – Case # 261675 4. Ferreira, Steven – Case # 16C0328 5. Calvillo, Lindsey – Case# 265986 6. Edison, Marilyn – Case# 265419 7. John Doe – Case # 1:08 8. Esparza, Emma – Case #VCU256571 9. Brito-Mojica, Rosa – Case # VCU265405 10. Delgado, Anabel – Case # 263390 11. Madrigal, Maria – Case # 264562

2. Conference with Legal Counsel – Anticipated Litigation – Significant exposure to litigation pursuant to Government Code 54956.9(d)(2) – 9 Cases - Andy Weiss, Legal Counsel & Kassie Waters, Interim Risk Manager

3. Credentialing - Medical Executive Committee requests that the appointment, reappointment and other credentialing activity regarding clinical privileges and staff membership recommended by the respective department chiefs, the credentials committee and the Medical Executive Committee be reviewed for approval pursuant to Health and Safety Code 1461 and 32155 – Harry Lively, MD, Chief of Staff

4. Approval of closed meeting minutes {09/25/17}

Action Requested: Approval of the 09/25/17 closed meeting minutes. Adjourn

OPEN MEETING AGENDA {6:00PM} Call to order Approve agenda Public / Medical Staff participation – Members of the public or the medical staff may comment on agenda items before action is taken and after the item has been discussed by the Board. Each speaker will be allowed five minutes. Members of the public wishing to address the Board concerning items not on the agenda and within the subject matter jurisdictions of the Board are requested to identify themselves at this time. Closed Session Action Taken – Report on actions taken in closed session. 1. Recognitions

1.1. Director House presentation of Resolution 1969 to Maile Headrick, Clinical Pharmacist, for the Service Excellence Award – October 2017.

Monday, October 23, 2017 Page 3 of 4 Herb Hawkins – Zone I ⃰⃰ Lynn Havard Mirviss – Zone II ⃰⃰ John Hipskind, MD – Zone III ⃰⃰ Carl Anderson – Zone IV ⃰⃰ Nevin House– Zone V Board Member Secretary/Treasurer Board Member President Board Member

2. Consent Calendar (All matters under the Consent Calendar will be approved by one motion, unless a Board member request separate action on a specific item). Recommended Action: Approve the October 23, 2017 Consent Calendar

3. Press Ganey – Review of the results of the Kaweah Delta employee engagement survey – Lisa Daul, M.B.A, R.D, Advisor, Press Ganey Associates, Inc.

4. Annual Audited Financial Statement – Report to Board from Moss Adams relative to the annual audited financial statement for fiscal year 2016/2017 – Kaweah Delta; Malinda Tupper, Interim Chief Financial Officer and Jennifer Stockton, Director of Finance, Moss Adams; Brian Conner, Partner and Adam Roth, Audit Manager

Recommended Action: Approval of the 2016/2017 Annual Audited Financial Statement.

5. Quality Report – Sepsis Quality Focus Team Report: Review of Key Quality of Care Indicators and Actions for the Sepsis Population – Thomas Gray, M.D., Quality and Patient Safety Medical Director

6. Refinancing of the Siemen’s Lease and a portion of the 2012 Revenue Bonds Preliminary Resolution – Review of preliminary Resolution 1970, as reviewed and recommend for approval by the Finance, Property, Services, and Acquisition Committee (10/19/17) authorizing certain officers of the District to take steps necessary for the potential issuance of revenue refunding bonds. Recommended Action - Approve preliminary Resolution 1970 authorizing the President of the Board, the District’s Chief Executive Officer, its Chief Financial Officer, and/or its Director of Finance to take any and all necessary action needed to prepare for the possible Revenue Refunding Bonds, subject to the Board’s approval of a final authorizing resolution in November 2017.

7. Credentialing – Medical Executive Committee request that the appointment, reappointment and other credentialing activity regarding clinical privileges and staff membership recommended by the respective department chiefs, the credentials committee and the Medical Executive Committee be reviewed for approval – Harry Lively, MD, Chief of Staff Recommended Action: Whereas a thorough review of all required information and supporting documentation necessary for the consideration of initial applications, reappointments, request for additional privileges, advance from provision al status and release from proctoring and resignations (pursuant to the Medical Staff bylaws) has been completed by the Directors of the clinical services, the Credentials Committee, and the Executive Committee of the Medical Staff, for all of the medical staff scheduled for reappointment, Whereas the basis for the recommendations now before the Board of Trustees regarding initial applications, reappointments, request for additional privileges, advance from provision al status and release from proctoring and resignations has been predicated upon the required reviews, including all supporting documentation, Be it therefore resolved that the following medical staff be approved or reappointed (as applicable), as attached, to the organized medical staff of Kaweah Delta Health Care District for a two year period unless otherwise specified, with physician-specific privileges granted as recommended by the Chief of Service, the Credentials Committee, and the Executive Committee of the Medical Staff and as will be documented on each medical staff member’s letter of initial application approval and reappointment from the Board of Trustees and within their individual credentials files.

8. Chief of Staff Report – Update from the Chief of Staff relative to Medical Staff issues - Harry Lively, MD, Chief of Staff

Monday, October 23, 2017 Page 4 of 4 Herb Hawkins – Zone I ⃰⃰ Lynn Havard Mirviss – Zone II ⃰⃰ John Hipskind, MD – Zone III ⃰⃰ Carl Anderson – Zone IV ⃰⃰ Nevin House – Zone V Board Member Secretary/Treasurer Board Member President Board Member

9. Chief Executive Officer Report – Report relative to current events and issues - Gary Herbst, Chief Executive Officer 9.1. Healthgrades recognitions

Kaweah Delta named America’s 50 Best Hospitals for Cardiac Surgery Orthopedic Surgery excellence Pulmonary Care excellence

9.2. Kaweah Delta Center of Excellence – 1st renewal from Surgical Review Corporation Minimally Invasive Gynecological Surgery Center for Excellence in Robotic Surgery

9.3. Foundation giving campaign employee donor BBQ October 31st {Blue Room}, November 1st {Cousteaus}, and November 2nd {South Campus Cafeteria}

9.4. Pink Tea took place Sunday October 22nd 9.5. KDHUB Update 9.6. Community Advisory Committee Update

10. Board President Report – Report from the Board President relative to current events and issues – Carl Anderson, Board President

11. Approval of Closed Agenda as follows: Closed Meeting Agenda – Kaweah Delta Medical Center Blue Room – Immediately following the open session

• CEO Evaluation – Discussion of with the Board and the Chief Executive Officer relative to the evaluation of the Chief Executive Officer pursuant to Government Code 54957(b)(1) – Gary Herbst, Chief Executive Officer, Dennis Lynch, Legal Counsel & Board of Directors

• Report involving trade secrets {Health and Safety Code 32106} – Discussion will concern a proposed new services/programs – estimated date of disclosure is 03/01/18 – Gary Herbst, Chief Executive Officer

Adjourn

CLOSED MEETING AGENDA {immediately following the 6:00PM Open Meeting}

Call to order 1. CEO Evaluation – Discussion of with the Board and the Chief Executive Officer relative to

the evaluation of the Chief Executive Officer pursuant to Government Code 54957(b)(1) – Gary Herbst, Chief Executive Officer, Dennis Lynch, Legal Counsel & Board of Directors

2. Report involving trade secrets {Health and Safety Code 32106} – Discussion will concern a proposed new services/programs – estimated date of disclosure is 03/01/18 – Gary Herbst, Chief Executive Officer

Adjourn In compliance with the Americans with Disabilities Act, if you need special assistance to participate at this meeting, please contact the Board Clerk (559) 624-2330. Notification 48 hours prior to the meeting will enable the District to make reasonable arrangements to ensure accessibility to the Kaweah Delta Health Care District Board of Directors meeting.

BOARD OF DIRECTORS MEETING – CLOSED SESSION

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KAWEAH DELTA HEALTH CARE DISTRICT

BOARD OF DIRECTORS MEETING

MONDAY OCTOBER 23, 2017

CLOSED MEETING SUPPORTING DOCUMENTS

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DIRECTORS: James McNulty / Rheta Sandoval BOARD MEMBER: Nevin House

Service Excellence October 2017 Maile Headrick, Clinical Pharmacist (11 Years)

Nominated By: Rheta Sandoval Comments: This nomination is being submitted on behalf of a number of Pharmacy Team members who are grateful to work with Clinical Pharmacist team member Maile Headrick. We are fortunate that Maile joined our team in August of 2006. Her strong clinical knowledge base and critical care experience positively impacts the quality of care provided to our patients. Maile is an engaged member of the team and on a consistent basis takes the initiative to improve procedures and systems as needs are identified. Examples of this include her work in establishing policy and procedures, order sets and/or institutional guidelines to promote safe and effective use of medications. Whether it is to assure optimal anticoagulation for our patients supported by percutaneous ventricular assist devices, assure appropriate use of antithrombotics in or around neuraxial procedures, collating blood factor product resource information, or guiding the safe use of patient own insulin pumps; if it involves a low volume, high risk, problem prone medication use you can bet that Maile has been involved behind the scenes in a very important way.

Each year at the time of her performance evaluation, her peers provide what I would consider top tier comments that support without question that she is exceeding expectations with respect to the technical and interpersonal aspects of job performance and her efforts to support the Department and organization in meeting our Hospital Cornerstone goals. These top tier comments are typically reserved for those folks that demonstrate consistency in performing at the highest level of professionalism, quality and support of others.

Included in this nomination are a few of the comments provided by her peers during her most recent evaluations that describe how valuable Maile is to our team. Maile is one of the more knowledgeable pharmacists I work with at KDHCD. She's dependable and resourceful in her role as a pharmacist and is very much a team player. Her contributions to the department have made an important impact in progressing the practice of pharmacy and improving patient safety.

It's a joy working with Maile. She is perhaps one of the best pharmacist and colleague that I have had the pleasure to work with. She's always cordial toward everyone who interacts with her. She is also a great resource for clinical knowledge and can always be depended upon to assist her teammates whenever possible. Whenever I have questions regarding critical care or anticoagulation, I can count on Maile to provide a thoughtful and appropriate response.

She often arrives to work early in order to help everyone catch up. She represents the department well and I think we are very lucky to have her on our service. Maile is an excellent pharmacist with great attention to detail. She is very safety minded and communicates well with the team. She also makes herself available to assist with projects or other activities as needed (ie, will go above and beyond).

DIRECTORS: James McNulty / Rheta Sandoval BOARD MEMBER: Nevin House

In addition, she followed up on concerns with how we monitor tirofiban which resulted in order set changes and she noted confusion with use of alteplase for Venous Thromboembolism and is working toward developing an order set to facilitate a safer process. Maile not only notes where we can improve, but takes part in the improvement effort.

Maile is my rock - any time I had a more challenging day, I can always rely on Maile's empathetic and compassionate listening ears. Maile inspires me - every time she calls to discuss a situation, I either learn something new, or look at an old question in a new way, and on rare occasions when I actually know the answer, answering her question reinforces my knowledge.

Maile is highly respected in the department, by nursing staff and by physicians. She was recognized as the Pharmacy Departments first Marlin of the Year for her contributions to medication safety. Her diligence in reporting medication errors and providing input on systems improvements has resulted in better care for our patients. Maile is the pharmacist I would want to take care of myself or my family if admitted to the hospital. She always puts our patients first. She has an incredible work ethic, sharp mind, and is committed to professional development, We are so proud and grateful to be able to call her a colleague.

Consent Calendar – October 23, 2017 Page 1 of 16


BOARD OF DIRECTORS - CONSENT CALENDAR

Kaweah Delta Medical Center {400 West Mineral King Avenue} Mineral King Wing Basement (Blue Room)

www.KaweahDelta.org

Monday, October 23, 2017 – 6:00PM

NOTE: All items listed on the Consent Calendar are considered to be routine by the District Board of Directors, and will be enacted by one motion. There will be no separate discussion of these items unless a Board Member so requests, in which event, the item will be removed from the Consent Calendar and considered in its normal sequence on the regular agenda.

2.1. Reports A. Medical Staff Recruitment B. Risk Management C. Clinical Decision Unit (2S) D. Rural Health Clinics E. Performance Improvement Dashboard F. Investment report G. Finance H. Post-Surgical Care {BP, 3N, 4S}

2.2. Policies: A. ADMINISTRATIVE

1. Access to legal counsel AP57 Revised 2. Travel, Per Diem, and Other Employee Reimbursement AP19 Revised 3. Use of District name and/or Stationery AP27 Reviewed

B. EMERGENCY MANAGEMENT 1. Media Plan DM 2107 Revised 2. Program Management – Emergency Management

Committee DM 2109 Revised 3. Dependent Care Plan DM 2111 Revised 4. Person In Charge DM 2115 Revised 5. Code Blue-Activation Plan DM 2202 Revised 6. Water Systems Failure Disruption DM 2216 Revised 7. Emergency Impact Assessment DM 2104 Reviewed 8. Elevator Use During Emergency Situations DM 2112 Reviewed 9. Reporting for Duty-Building Access DM 2116 Reviewed 10. Application for FEMA Financial Aid DM 2119 Reviewed 11. Post Disaster Recovery-Financial DM 2120 Reviewed 12. Critical Incident Stress management DM 2121 Reviewed 13. Code Triage-Activation Plan DM 2101 Reviewed



14. Code Gray-Activation Plan DM 2203 Reviewed 15. Code Red- Activation Plan DM 2207 Reviewed 16. Code Shelter in Place DM 2209 Reviewed 17. Code Orange-Hazardous Material Spill DM 2210 Reviewed 18. Earthquake Response DM 2212 Reviewed 19. Internal Flood-Activation Plan DM 2215 Reviewed 20. Anhydrous Ammonia Safety Procedures DM 2218 Reviewed 21. Surge Tent Use DM 2226 Reviewed 22. Total Evacuation Plan DM 2810 Reviewed

C. ENVIRONMENT OF CARE 1. Failure of Air Conditioning EOC 1039 Revised 2. Fire Watch EOC 5003 Revised 3. Clinical Engineering management Plan EOC 6001 Revised 4. Environment of Care Communication Flow Chart EOC 1002 Revised 5. Indoor Air Quality EOC 1020 Revised 6. Disruption of Service, Sewage EOC 1037 Reviewed 7. Emergency Generator Testing and Fuel Levels EOC 7403 Reviewed 8. Infection Control Risk Assessment EOC 5021 Reviewed 9. Utilities Management Inventory EOC 7305 Reviewed 10. Compressed Gas and Oxygen Use EOC 4007 Reviewed 11. Department Decorations EOC 5041 Reviewed 12. Disruption of Service, Elevator EOC 1041 Reviewed 13. Ergonomics EOC 1071 Reviewed 14. Failure or Absence of Nurse Call System while Caring for

Patient EOC 1043 Reviewed 15. Formaldehyde Spill EOC 4404 Reviewed 16. Key Control Policy EOC 3010 Reviewed 17. Medical Equipment Hazardous Device and Recall

Notification Policy EOC 6004 Reviewed 18. Storage and Warming of Blankets in Warming Cabinet EOC 6007 Reviewed

D. HEMATOLOGY 1. Quality Control Protocol HE-00097 Revised 2. Alternate Methodology HE-00055 Revised 3. Protocol for Platelet Poor Plasma Validation HE-00072 Revised

E. HOSPICE 1. Initial and Comprehensive Assessments HO2-029 Revised 2. Emergency Management Plan HO6-011 Revised

F. IMAGING & SRCC RADIATION ONCOLOGY SERVICES 1. Substantial Radiation Dose Management for

Fluoroscopically-Guided Procedures IS 5.7 New 2. Communication of Mammography Results to Patients IS 7.02 Revised 3. Mammography Image Release IS 7.3 Revised 4. Mammography Infection Control IS 8.1 Revised


5. Mammographic Localization IS 17.15 Revised 6. Mammography Stereotactic Biopsy IS 17.17 Revised 7. Communication of Critical Findings IS 7.4 Reviewed 8. Radiology T-Tube Cholangiogram-Physician Preference IS 17.22 Reviewed 9. Mammography Ductogram – Physician Preference IS 17.23 Reviewed 10. Radiology Venogram – Physician Preference IS 17.24 Reviewed 11. Radiology Enteroclysis – Physician Preference IS 17.26 Reviewed 12. Radiology Sialogram – Physician Preference IS 17.27 Reviewed 13. Radiology Voiding Cystogram (VCUG) IS 17.30 Reviewed 14. Radiology Porta-cath Check – Physician Preference IS 17.33 Reviewed 15. Contrast/Medication – CT Oral Contrast Administration IS 18.7 Reviewed 16. Pediatric Radiation Safety IS 19.2 Reviewed 17. Routine Pediatric Radiography IS 19.4 Reviewed

G. IMAGING SERVICES 1. Contrast/Medication – Procurement, Storage, Control,

Distribution, Administration and Monitoring of Radiographic Contrast Media IS 18.2 Revised

2. Contrast/Medication–Outpatient Radiology Narcotic Control IS 11.01 Reviewed 3. Pediatric Contrast Dose IS 19.6 Reviewed

H. ISS 1. Restore Testing of Back Ups ISS.004 Revised

I. RENAL SERVICES 1. Hepatitis Testing in Renal Patients for Acute Dialysis RS-L.34 Revised 2. Initiating and Discontinuing Hemodialysis using a Central

Venous Catheter RS-L.10 Revised 3. Patient No Call/No Show: Patient Failure to Attend

Treatment/Appointment RS-E.02 Revised

J. RESPIRATORY CARE – SOUTH CAMPUS 1. Therapeutic Gas, Storage, Handling and Quality Control 2009 Revised 2. Mechanical Ventilation 3001 Revised 3. Bagging 3008 Revised 4. Transport of Ventilator Patients 3009 Revised 5. Aerosol Therapy 4001 Revised 6. Metered Dose Device (Inhaler) 4002 Revised 7. Sputum Induction 4004 Revised 8. Oxygen Therapy 5001 Revised 9. Non-Rebreather Mask 5002 Revised 10. Assuring Oxygen Purity, Availability, and System Integrity 5003 Revised 11. Pulse Oximetry 5004 Revised 12. Oxygen Cylinder Use 5005 Revised 13. Airway Management 6001 Revised 14. Requirements for Initiation Weaning from Continuous

Mechanical Ventilation 6004 Revised


15. Extubation Policy 6005 Revised 16. Peak Flow Determination 6006 Revised 17. Tracheostomy Care – South Campus 6007 Revised 18. Routine Tracheostomy Tube Change 6008 Revised 19. Postural Drainage and Percussion 6009 Revised 20. Suctioning 6011 Revised 21. Use of Passy-Muir Valve (PMV) 6013 Revised 22. Continuous Positive Airway Pressure 3003 Deleted 23. Bilevel Positive Airway Pressure “BIPAP” 3004 Deleted 24. Intermittent Positive Pressure Breathing (IPPB) 3005 Deleted 25. Incentive Spirometry 6010 Deleted

K. RURAL HEALTH CLINICS 1. Medication Storage and Security RCP.68 Revised 2. Kaweah Delta Woodlake Health Clinic Organizational Chart WH.303 Revised 3. Abnormal Results Follow-up RCP.39 Revised 4. Patient Referrals RCP.38 Revised 5. Hazardous Materials and Infectious Waste RCP.61 Revised 6. Gases for Medical Use RCP.62 Revised 7. Clinical Oversight RCP.88 Revised 8. Admission Policy RCP.86 Revised 9. Medication Storage and Security RCP.68 Revised 10. Kaweah Delta Lindsay Health Clinic Organizational Chart LH. 303 Reviewed 11. Suspected Child Abuse Reporting RCP.42 Deleted 12. Recall of Medical Devices or Supplies RCP.70 Deleted 13. Child Abuse/Neglect Reporting MH.13 Deleted

L. CLINICAL LABORATORY 1. Turnaround Time and Frequency for In-house Testing LG-00032 Revised 2. Competency Assessment LG-00014 Revised 3. Novius Lab Computer Backup LC00005 Reviewed 4. Lab Document Control Procedure LG-00019 Reviewed

M. HUMAN RESOURCES 1. District Commitment & Staff Member Relations HR.02 Revised 2. Equal Employment Opportunity HR.12 Revised 3. Reasonable Accommodation & Medical Fitness for Work HR.16 Revised 4. Grievance HR.215 Revised 5. Transfers HR.31 Revised 6. Progressive Discipline HR.216 Revised 7. Separation from Employment HR.220 Revised 8. Employee reduction in force or reassignment resulting in demotion HR.221 Revised 9. Introductory Period HR.37 Revised 10. Staff Member Relations HR.90 Deleted 11. Medical Fitness for Current Employees HR.108 Deleted 12. Involuntary Termination HR.217 Deleted


2.3. Approval of the Board of Directors meeting open meeting minutes – 09/25/17.

2.4. Approve the recommendations from the Medical Executive Committee October 2017. A. Medical Staff Policies

1. MS.43 Informed Consent for Surgical, Diagnostic, or Therapeutic Procedure (Revised)

2. MS 31 Chain of Command (Delete) B. Pharmacy Manual

1. RX 4.30.0 Infection Control (Revised) C. Order Sets (New/Revised)

1. ANES PACU Opioid Pain Control Medications – Normal Renal Function (New-Cerner)

2. ANES PACU Opioid Pain Control Medications – Renal Patients (New-Cerner) 3. Antibiotic POST-Op CABG, Other Cardiac (New-Cerner) 4. Antibiotic POST-Op Colon/Abdomen (NON-Gynecological) (New-Cerner) 5. Antibiotic POST-Op Head/Neck (New-Cerner) 6. Antibiotic POST-Op Neuro/Ortho/Vasc/Podiatry (New-Cerner) 7. Antibiotic POST-Op Ortho (Open Fracture) (New-Cerner) 8. Antibiotic PRE-Op CABG/Other Cardiac (New-Cerner) 9. Antibiotic PRE-Op Colon/Abdomen (NON-Gynecological) (New-Cerner) 10. Antibiotic PRE-Op Head/Neck (New-Cerner) 11. Antibiotic PRE-Op Neuro/Ortho/Vasc/Podiatry (New-Cerner) 12. Antibiotic PRE-Op Urology (NON-Penile Prosthesis) (New-Cerner) 13. Antibiotic PRE-Op Urology (Penile Prosthesis) (New-Cerner) 14. CC Electrolyte Protocol (New-Cerner) 15. CC General ICU Admission (New-Cerner) 16. ED Pneumonia Suspected (New-Cerner) 17. ED Seizure (New-Cerner) 18. ED Trauma Major Alert (New-Cerner) 19. ED Trauma Moderate Alert (New-Cerner) 20. MED POST PICC/Midline Insertion (New-Cerner) 21. NICU Discharge (New-Cerner) 22. NICU Fentanyl Continuous Infusion (New-Cerner) 23. NICU HIV Exposed Newborn (New-Cerner) 24. NICU to Mother Baby Unit (New-Cerner) 25. PED Cellulitis (New-Cerner) 26. PED Constipation and Bowel Cleanout Admission (New-Cerner) 27. PED Discharge (New-Cerner) 28. PED Kawasaki Disease Admission (New-Cerner) 29. PED Pneumonia Admission (New-Cerner) 30. PED POST NICU Observation (New-Cerner) 31. SURG General Surgery Outpatient (New-Cerner) 32. SURG General Surgery PERI-Op (New-Cerner) 33. VASC Discharge (New-Cerner) 34. VTE Critical Care Patients (New-Cerner)


35. VTE Elective Total Hip Patients (New-Cerner) 36. VTE Elective Total Knee Patients (New-Cerner) 37. VTE General Surgery (New-Cerner) 38. VTE Gynecological Extensive Surgery for Malignancy or Additional Risk (New-

Cerner) 39. VTE Gynecological Lap with Additional Risk or Major Surgery (New-Cerner) 40. VTE Hip Fracture Surgery Patients (New-Cerner) 41. VTE Intracranial Neurosurgery Patients (New-Cerner) 42. VTE Medical Patients (New-Cerner) 43. VTE Spinal Neurosurgery Patients (New-Cerner) 44. VTE Trauma Patients (New-Cerner) 45. VTE Urologic Surgery Patients (New-Cerner) 46. VTE Venous Thromboembolism Prophylaxis (New-Cerner) 47. ANES Adult Inpatient (New-Cerner) 48. ANES Adult Outpatient (New-Cerner) 49. ANES Pediatric Inpatient (New-Cerner) 50. ANES Pediatric Outpatient (New-Cerner) 51. ANES Open Heart Surgery POST-Op (New-Cerner) 52. NICU Dobutamine (New-Cerner) 53. Electrolyte Replacement Protocol (Update) (Revised - Sorian & Paper) 54. POST PICC Insertion Care (Update) (Revised - Sorian) 55. Comfort Care Order Set (Update) (Revised - Sorian) 56. Post Intervention Cardiac Cath Order Set (Update) (Revised - Sorian) 57. Oxytocin Change (Emergent Update) (Revised - Sorian)

D. Order Sets (Annual Review – CPOE) 1. Acute Hemodialysis Order Set (Reviewed) 2. Administration of Labetalol for Severe Hypertension in Pregnancy (Reviewed) 3. ADMISSION Order Set - ACS_NSTEMI (NEW) (Reviewed) 4. ADMISSION Order Set - ACS_NSTEMI (old) (Reviewed) 5. ADMISSION Order Set - Active GI Bleed (Reviewed) 6. ADMISSION Order Set - Heart Failure (Reviewed) 7. ADMISSION Order Set - Pneumonia (Adult) (Reviewed) 8. ADMISSION Order Set - Standard (Universal) (Reviewed) 9. Admit to CDU- Chest Pain_ACS Observation (Reviewed) 10. Admit to CDU- General Admission Orderset (Reviewed) 11. ADMIT to Critical Care (Reviewed) 12. ADULT Analgesia and Sedation Orders (for ICU or ICCU_ED on Vent) (Reviewed) 13. Adult Organ Donor Order Set (Reviewed) 14. Antepartum Admit Order Set (Reviewed) 15. Argatroban Inpatient Order Set (ADULT) (Reviewed) 16. Bilateral Tubal Ligation POST-OP (Reviewed) 17. Bilateral Tubal Ligation PRE-OP (Reviewed) 18. Cardiac Cath Lab Post Interventional Order Set (Reviewed) 19. Cardiothoracic Surgery Addendum Orders for Transfer (Reviewed)


20. Cardiothoracic Surgery Pre Op Order Set (Reviewed) 21. Cervical Ripening Orders (Reviewed) 22. Cesarean Section Postoperative Orders (Reviewed) 23. Cesarean Section Preoperative Orders (Reviewed) 24. Chronic Obstructive Pulmonary Disease Acute Exacerbation Orders (Reviewed) 25. Cisatracurium (NIMBEX) IV Infusion Order Set (Reviewed) 26. CIWA-Ar Orders for MILD TO MODERATE Alcohol Withdrawal Syndrome

(Reviewed) 27. Comfort Care Order Set - INPATIENT (Reviewed) 28. Cosyntropin (CORTROSYN) Stimulation test Tomorrow at 6-00am (Reviewed) 29. Critical Care Orders, COMMON (Reviewed) 30. Critical Care Trauma Order Set (Reviewed) 31. CRRT_SLED Order Set (Reviewed) 32. CVICU Cardiac Surgery Post Op Order Set (Reviewed) 33. CVICU General Thoracic Surgery Post Op Order Set (Reviewed) 34. Cytotoxic Drug Extravasation Management (Reviewed) 35. Elective Total HIP Post Operative Order Set (Reviewed) 36. Elective Total KNEE Post Operative Order Set (Reviewed) 37. Electrolyte Common Orders for MED_SURG Units (Reviewed) 38. Empiric INITIAL Inpatient Antimicrobial Order Set (Adult) (Reviewed) 39. Epidural or Intrathecal Analgesic Orders (Reviewed) 40. Fractured HIP Post Operative Order Set (Reviewed) 41. General Surgery Post Op OUTPATIENT Order Set (Reviewed) 42. General Surgery Post Op Admission Orders (Reviewed) 43. General Surgery Pre Op Orders (Reviewed) 44. Glucommander Diabetic Ketoacidosis (DKA) Order Set. (Reviewed) 45. Glucommander INITIAL - SubQ Insulin Order Set (ADULT) (Reviewed) 46. Glucommander INITIAL SubQ CUSTOM Orders (ADULT) (Reviewed) 47. Glucommander IV Insulin Infusion Order Set (ADULT) (Reviewed) 48. Glucommander SubQ Insulin Order Set - RENAL_LOW STARTING DOSE

(Reviewed) 49. Glucommander Transition from IV to SubQ Glucommander (Reviewed) 50. Glucommander- Post Cardiac Surgery Order Set (Reviewed) 51. Glucommander- INTRAPARTUM IV Insulin Infusion Order Set (Reviewed) 52. Gynecology POST-OP Orders (Reviewed) 53. Gynecology Elective Surgery PRE-OP Orders (Reviewed) 54. Gynecology Post-Op OUTPATIENT Order Set (Reviewed) 55. Hand Post-Op Admission Order Set (Reviewed) 56. Hand Post-Op Outpatient Order Set (Reviewed) 57. Hand Post-Op Wound Care Orders (Reviewed) 58. Heparin IV Infusion for AMI and_or ACS. (Reviewed) 59. Heparin IV Infusion for PE and_or DVT. (Reviewed) 60. Hip Fracture Admission Orders (Reviewed) 61. HIV Exposed Newborn Infant (Reviewed)


62. Humidified Isolette Order Set (Reviewed) 63. Hydromorphone (DILAUDID) PCA Orders (NEW) (Reviewed) 64. Impella Ventricular Assist Device Order Set (Reviewed) 65. Inpatient Stroke Alert Order Set (Reviewed) 66. Insert Rectal Tube (Reviewed) 67. KD Acute Rehabilitation Unit Admission Orders (Reviewed) 68. Ketamine Infusion - Adult Analgesia Order Set- ED_ICU_CVICU_ICCU (Reviewed) 69. Labor Orders (Reviewed) 70. Lidocaine - Perioperative Analgesia for Colon Surgery (Reviewed) 71. Local Infusion Pain Mgmt System (ON-Q ELASTOMERIC PUMP) Orders

(Reviewed) 72. Med_Surg Admission Orders (Reviewed) 73. Med_Surg Trauma Admission Orders (Reviewed) 74. Mental Health Hospital Admission Orders (Reviewed) 75. Mental Health Hospital Alcohol_Sedative Withdrawal Orders(CIWA). (Reviewed) 76. Midazolam (VERSED) For Sedation Order Set (Reviewed) 77. Moisture Friction Wounds Treatment Order Set (Reviewed) 78. Morphine PCA Order Set (NEW) (Reviewed) 79. Neurosurgery Postoperative PACU Order Set (Reviewed) 80. Neurosurgery- Cranium Postoperative Order Set (Reviewed) 81. Neurosurgery- Intracranial Hypertension Order Set, ADULT (Reviewed) 82. Neurosurgery- Spinal Postoperative Order Set (Reviewed) 83. NeuroSurgical Anesthesia Pre-Op Orders (Reviewed) 84. NICU Admission Order Set - Intensive Care (Reviewed) 85. NICU Admission Order Set - Intermediate Care (Reviewed) 86. NICU Admission Orders - Late Preterm Infant (LPI) (Reviewed) 87. NICU Caffeine Citrate (CAFCIT) Order Set (Reviewed) 88. NICU Continuing Care Order Set (Reviewed) 89. NICU DOBUTamine Order Set (Reviewed) 90. NICU DOPamine Order Set (Reviewed) 91. NICU Fentanyl (SUBLIMAZE) Continuous Infusion Order Set (Reviewed) 92. NICU Ferrous Sulfate Order Set (Reviewed) 93. NICU Hyaluronidase Order Set (Reviewed) 94. NICU Immunizations- 2 Month Order Set (Reviewed) 95. NICU Midazolam (VERSED) Continuous Infusion Order Set (Reviewed) 96. NICU Morphine (DURAMORPH) Order Set (Reviewed) 97. NICU Observation Order Set (Reviewed) 98. NICU PICC Placement Orders (Neonatologist_Pediatric Hospitalist) (Reviewed) 99. NICU Prostaglandin E1 (Alprostadil) Order Set (Reviewed) 100. NICU to Mother Baby Unit Transfer Orders (Reviewed) 101. NICU to Pediatrics Couplet Care Order Set (Reviewed) 102. NICU Vasoactive IV Drip Medications (Reviewed) 103. Nursing Communication for Acute Renal Dialysis (DRHI) Protocol (Reviewed) 104. Nursing Communication Order for Electrolyte Replacement ProtocoL (Reviewed)


105. Nursing Standardize Procedure - Treatment of Hypoglycemia (Reviewed) 106. Nursing Standardize Procedure- NICU Hyaluronidase (Reviewed) 107. Nursing Standardize Procedure- NICU Phentolamine (Reviewed) 108. Obstetrical Triage_Outpatient Orders for GTE 37 Weeks Gestation (Reviewed) 109. Oncology Admission Orders (Reviewed) 110. Open Heart Surgery POST-OP Anesthesia Orders (Reviewed) 111. Open Heart Surgery PRE-OP ANESTHESIA Orders (Part 1 of 2) (Reviewed) 112. Open Heart Surgery PRE-OP ANESTHESIA Orders (Part 2 of 2) (Reviewed) 113. Opthalmology Post-Operative Order Set (Reviewed) 114. Opthalmology Pre-Operative Order Set (Reviewed) 115. Orthopedic Admission Orders (Reviewed) 116. Oxytocin (PITOCIN) Induction_Augmentation Orders (Reviewed) 117. Patients Own SubQ Insulin Pump Orders (Reviewed) 118. Pediatric Admission Order Set (Reviewed) 119. Pediatric Adolescent (14 to 18 years of age) Admission Order Set (Reviewed) 120. Pediatric Aminophylline Order Set (Reviewed) 121. Pediatric Asthma Order Set (Reviewed) 122. Pediatric Bronchiolitis Order Set (Reviewed) 123. Pediatric Gastroenteritis Order Set (Reviewed) 124. Pediatric Indomethacin (INDOCIN) Order Set (Reviewed) 125. Pediatric Lidocaine_Prilocaine 2.5% (EMLA) Cream Order Set (Reviewed) 126. Pediatric Pneumonia Admission Order Set (Reviewed) 127. Pediatric Possible Sepsis Order Set (Reviewed) 128. Peritoneal Dialysis Related Peritontiis Order Set (Reviewed) 129. Post Appendectomy Admit Orders (PEDIATRIC) (Reviewed) 130. Post Appendectomy Orders (ADULT) (Reviewed) 131. Post Cardiovascular (Cathlab) Diagnostic Order Set (Reviewed) 132. Post Chemo Embolization Order Set (Reviewed) 133. Post Interventional Radiology Order Set (Reviewed) 134. Post NICU Observation Order Set (Reviewed) 135. Post Op Anesthesia Orders (Reviewed) 136. Post Operative Order Set - Orthopedic (Reviewed) 137. POST Procedure Device Order Set (Reviewed) 138. Post-Op Outpatient Orders - Orthopedic (Reviewed) 139. Postoperative Cholecystectomy (Reviewed) 140. POSTPARTUM Magnesium Sulfate Orders (Reviewed) 141. Post-Splenectomy Vaccination Order Set (Reviewed) 142. Pre Op Anesthesia Orders (Reviewed) 143. PRE Procedure Device Order Set (Reviewed) 144. PRE-ECLAMPSIA Magnesium Sulfate Orders (Reviewed) 145. Pregnancy Induced Hypertension Order Set (Reviewed) 146. Preoperative Appendicitis Admission Orders (ADULT) (Reviewed) 147. Preoperative Cholecystitis Admission Orders (Reviewed) 148. Preoperative Surgery Order Set - Orthopedic (Reviewed)


149. PRE-Procedure Angiography Order Set (Reviewed) 150. Pre-Procedure Cardiovascular Services Order Set (Reviewed) 151. PRE-Procedure Chemo Embolization_TIPS Order Set (Reviewed) 152. PRE-Procedure Drainage Order Set (Reviewed) 153. PRE-Procedure Vascular Access Order Set (Reviewed) 154. Pressure Ulcer Stage 1 Treatment (Reviewed) 155. Pressure Ulcer Stage II Treatment (Reviewed) 156. Pressure Ulcer Stage III_IV Treatment Order Set (Reviewed) 157. Pressure Ulcer Suspected Deep Tissue Injury Tx Order Set (Reviewed) 158. Pre-Term Labor (Labor Triage) Order Set (Reviewed) 159. Routine Post Partum Orders (Reviewed) 160. Severe Sepsis Orders (Reviewed) 161. Short Stay Rehabilitation Admission Orders (Reviewed) 162. Skilled Nursing Facility Admission Order Set (Reviewed) 163. Skin Tear Treatment Order Set (Reviewed) 164. Smoking and Tobacco Cessation Order Set (Reviewed) 165. Sodium Chloride 3% For Treatment of Hyponatremia (Reviewed) 166. Standardized Procedure- Lidocaine for PICC Insertion (Reviewed) 167. Standardized Procedure-IV Therapy- Care of Implanted Port, ADULT (Reviewed) 168. STROKE_TIA- (Non-Alteplase) Admission Orders Med_Surg (Reviewed) 169. STROKE- (Non-Alteplase) Admission Orders ICU_ICCU (Reviewed) 170. STROKE- Alteplase Admission Order Set ICU (Reviewed) 171. STROKE- Alteplase CC Infusion Order Set (Reviewed) 172. STROKE- Intracranial Hemorrhage Admission Orders ICU_ICCU (Reviewed) 173. STROKE- Nursing Protocol Order (Reviewed) 174. Subcutaneous Insulin Order Set - ADULT (Reviewed) 175. SURGICAL POST-OP ANTIBIOTIC PROPHYLAXIS ORDERS (ADULT) (Reviewed) 176. SURGICAL PRE-OP ANTIBIOTIC PROPHYLAXIS ORDERS (ADULT) (Reviewed) 177. Syncope not due to TIA_CVA Order Set (Reviewed) 178. Transient Ischemic Attack (TIA) Observation Orders (Reviewed) 179. UNSTAGABLE- Pressure Ulcer Treatment (Reviewed) 180. Urology Admission Order Set (Reviewed) 181. Urology General Post-Op Inpatient Order Set (Reviewed) 182. Urology Post-Op OUTPATIENT Order Set (Reviewed) 183. Urology Pre-Op Order Set (Reviewed) 184. Vascular Alteplase Thrombolysis Order Set (Reviewed) 185. Vascular Post-Op Order Set (Reviewed) 186. Vascular Post-Op Outpatient Orders (Reviewed) 187. Vascular Pre-Op _ Admit Orders (Reviewed) 188. Vasoactive IV TITRATING Drip Medications (Reviewed) 189. Venous ThromboEmbolism (VTE) Prophylaxis Order Set (NEW) (Reviewed) 190. Obstetric Insulin SubQ Order Set (OB PATIENTS ONLY) (Reviewed)

E. Order Sets (Annual Review – Paper) 1. Acetylcysteine (Acetadote) IV - Adult (Reviewed)


2. Adult ParenteralNutritionOrderSet (Reviewed) 3. Aerosol Protocol (Reviewed) 4. Albumin Institutional Guidelines (Reviewed) 5. Alteplase Thrombolysis Protocol Radiology (Reviewed) 6. Antibiotic Order Set (Adult) (Reviewed) 7. Ambulatory Surgery Center Pre Admit Order Set (Reviewed) 8. Amiodarone Infusion Protocol (Reviewed) 9. Anesthesia Epidural Intrathecal Analgesic (Reviewed) 10. Anesthesia Orders - Post Op (Reviewed) 11. Anesthesia Orders - Pre Op (Reviewed) 12. Argatroban Inpatient Order Set (Adult) (Reviewed) 13. Argatroban protocol for dialysis (Reviewed) 14. Bilateral Tubal Ligation (Reviewed) 15. Bowel Management Program (Reviewed) 16. Cardiac Rehab Out Patient Chest Pain Protocol (Reviewed) 17. Cisatracurium Nimbex Cont IV (Reviewed) 18. Cisplatin Orders (Reviewed) 19. CIWA mild mod ETOH Orders (Reviewed) 20. Critical Trauma Protocol (Reviewed) 21. Diabetes Outpatient Education Order (Reviewed) 22. Discharge Instructions - Lumbar Laminectomies (Reviewed) 23. Discharge Instructions - Mastectomy (Reviewed) 24. Discharge Instructions - Neurostimulator (Reviewed) 25. Discharge Instructions - Orthopaedic Surgery (Reviewed) 26. Discharge Instructions - Surgery (Reviewed) 27. Discharge Instructions - TAH (Reviewed) 28. Discharge Instructions - Total Hip (Reviewed) 29. Discharge Instructions - Total Knee (Reviewed) 30. Discharge Instructions - TVH (Reviewed) 31. Empiric Antimicrobial Order Set (Adult) (Reviewed) 32. Endoscopy Dalal Orderset (Reviewed) 33. Endoscopy Outpatient Physician Order Set (Reviewed) 34. Entereg Communication Form (Reviewed) 35. Entereg Initiation Protocol (Reviewed) 36. Factor VIIa Guidelines (Reviewed) 37. Febrile Neutropenia Order Set (Reviewed) 38. Fourth Degree Perineal Laceration FHCN (Reviewed) 39. Glucommander Adult IV Infusion Insulin (Reviewed) 40. Glucommander INITIAL SubQ Insulin Order Set-Adult (Reviewed) 41. Glucommander INITIAL SubQ Insulin Order Set-Obstetric (Reviewed) 42. Glucommander INITIAL SubQ Insulin Order Set-Renal/Low Dose (Reviewed) 43. Glucommander Intrapartum IV Insulin Infusion (Reviewed) 44. Glucommander Post Cardiac Surgery Order Set (Reviewed) 45. Glucommander DKA (Reviewed)


46. Glucommander Transition from IV to SubQ Glucommander (Reviewed) 47. Hand Post-Op Wound Care Orders (Reviewed) 48. Heart Failure Discharge Pt Ed Handout (Reviewed) 49. Heparin IV for AMI_ACS (Reviewed) 50. Heparin IV for PE_DVT (Reviewed) 51. HIV Exposed Newborn Infant (Reviewed) 52. HIV Patient in Labor (Reviewed) 53. Home Health Admission Orders (Reviewed) 54. Hospice Order Set (Reviewed) 55. Hospice Wound Care Orders (Reviewed) 56. Hoyt Thomas Cerv Lam PO DC-Spanish (Reviewed) 57. ICU - Post OHS Weaning-Extubation Protocol (Reviewed) 58. ICU ICCU Daily Lab Xray Protocol Thresholds (Reviewed) 59. ICU ICCU Electrolyte Replacement Protocol (Reviewed) 60. ICU ICCU Enteral Nutrition Support Protocol (Reviewed) 61. ICU ICCU Epoprostenol Admin Nebulizer comm (Reviewed) 62. ICU ICCU Epoprostenol Admin Nebulizer Protocol (Reviewed) 63. ICU ICCU Hypocalcemia comm (Reviewed) 64. ICU ICCU Hypokalemia comm (Reviewed) 65. ICU ICCU Hypomagnesemia comm (Reviewed) 66. ICU ICCU Hypophosphatemia comm (Reviewed) 67. ICU ICCU Hypotension Protocol Comm (Reviewed) 68. ICU ICCU Hypotension Protocol (Reviewed) 69. ICU ICCU Hypothermia Protocol Comm (Reviewed) 70. ICU ICCU Kinetic Protocol (Reviewed) 71. ICU ICCU STAT Lab XRay Unstable Pts Protocol (Reviewed) 72. ICU ICCU Therapeutic Hypothermia CA (Reviewed) 73. ICU ICCU Weaning Protocol (Reviewed) 74. Infusion Center Orders (Reviewed) 75. Infusion Center Patient Discharge Instructions (Reviewed) 76. Iodine - 131 Admission Orders (Reviewed) 77. Iodine - 131 Patient Instructions Discharge (Reviewed) 78. Iron Administration IV (Adult) Order Set (Reviewed) 79. KCentra Institutional Guidelines (Reviewed) 80. Ketamine - Adult Analgesia Order Set (Reviewed) 81. Labor Triage-Pre Term Labor Order Set (Reviewed) 82. Lidocaine Peri-Op Analgesia Colon Surgery (Reviewed) 83. MentalHealthTherapueticHold (Reviewed) 84. MI Acute-IV Alteplase (Reviewed) 85. MidazolamSedationOrderMechVentPts ICU CVICU ED (Reviewed) 86. Moderate Trauma Protocol (Reviewed) 87. (Reviewed) 88. Nesiritide Protocol (Reviewed) 89. Newborn Admission Medication Orders (Reviewed)


90. Newborn Admission Orders (Reviewed) 91. NICU Admission Orders (Reviewed) 92. NICU Caffeine Citrate Orders (Reviewed) 93. NICU Dobutamine Orders (Reviewed) 94. NICU Dopamine Orders (Reviewed) 95. NICU Fentanyl (Sublimaze) Cont Inf Order Set (Reviewed) 96. NICU Ferrous Sulfate (Reviewed) 97. NICU Humidified Isolette Protocol (Reviewed) 98. NICU Hyaluronidase Protocol (Reviewed) 99. NICU Immunization Orders 2-Month (Reviewed) 100. NICU Intermediate Infant Admission Orders (Reviewed) 101. NICU Intubation Pre Med Orderset (Reviewed) 102. NICU Late Preterm Infant Admit (Reviewed) 103. NICU Midazolam (Reviewed) 104. NICU Morphine Orders (Reviewed) 105. NICU Neonatal TPN Orders (Central) (Reviewed) 106. NICU Neonatal TPN Orders (Peripheral) (Reviewed) 107. NICU Observation Orders (Reviewed) 108. NICU Peripherally Inserted PICC Orders (Reviewed) 109. NICU Placenta cultures and path (Reviewed) 110. NICU Post NICU Observation Orders (Reviewed) 111. NICU Prostaglandin E1 (Reviewed) 112. NICU ROP Eye Exam Protocol (Reviewed) 113. NICU Respiratory Management Order Set (Reviewed) 114. OB triage OP orders for (Reviewed) 115. Oncology Admission Orders (Reviewed) 116. Oral Contrast Protocol - Radiology Dept (Reviewed) 117. Orthopaedic Post Operative Order Set (Reviewed) 118. OP Iron Administration IV (Adult) Orders (Reviewed) 119. Outpatient Blood Transfusion Orders (Reviewed) 120. Outpatient Hospice Palliative Care Serv (Reviewed) 121. Outpatient Therapy Skin and Wound Medications (Reviewed) 122. Oxygen Protocol (Reviewed) 123. Oxytocin (Pitocin) Induction Orders (Reviewed) 124. PCA Infuser System-HYDROmorphone (Dilaudid) (Reviewed) 125. PCA Infuser System-Morphine Sulfate (Reviewed) 126. Pediatric Adolescent Admission (Reviewed) 127. Pediatric Asthma MD DC Order (Reviewed) 128. Pediatric Asthma Orders (Reviewed) 129. Pediatric Bronchiolitis Order (Reviewed) 130. Pediatric EMLA Cream Top Anesthetic (Reviewed) 131. Pediatric Endoscopy (Reviewed) 132. Pediatric Hospitalist Aminophylline (Reviewed) 133. Pediatric Hospitalist Gastroenteritis (Reviewed)


134. Pediatric Hospitalist Indocin (Reviewed) 135. Pediatric Hospitalist Order Pneumonia (Reviewed) 136. Pediatric Hospitalist Order Rule Out Sepsis (Reviewed) 137. Penicillin Desensitization (Reviewed) 138. Post Angiographic Orders (Reviewed) 139. Post Bronchoscopy Orders (Reviewed) 140. Post Interventional Radiology Orders (Reviewed) 141. Post Op BB Protocol Communication Form (Reviewed) 142. Post Op BB Protocol (Reviewed) 143. Post Op Elective Total Knee/Hip Order Set (Reviewed) 144. ProgMobility AlgorithmNO Set (Reviewed) 145. Radiology Orders Post Intereventional (Reviewed) 146. Post Pacemaker Discharge Instructions (Reviewed) 147. Post Radical Prostatectomy Surgery (Reviewed) 148. Post Transfusion Discharge Instructions (Reviewed) 149. Radiology Department Post Biopsy Order (Reviewed) 150. Radiology Order Pre-Interventional (Reviewed) 151. Ramsinghani Veena (Reviewed) 152. Remicade Adult (Reviewed) 153. Remicaide Pediatric (Reviewed) 154. Renal Access Coord Access eval (Reviewed) 155. Renal Access Coord Inpatient Dialysis Protocol (Reviewed) 156. Renal Access Coord Intervention (Reviewed) 157. Renal Access Coord Clotted/Malf Fistula Graft Prot (Reviewed) 158. Renal Access Coord Renal Surg Access (Reviewed) 159. Renal Access Coord Renal Surg Interv (Reviewed) 160. Renal Access Coord Tunneled-non CVAD (Reviewed) 161. Renal Services Abx Admin for Cath Repair (Reviewed) 162. Renal services CAPD Initial Peritonitis Order Set (Reviewed) 163. Renal Services CAPD Related Gram Negative Org Peritonitis (Reviewed) 164. Renal Services CAPD Related Gram Positive Organism Perito (Reviewed) 165. Renal Services CAPD Related Peritonitis Exit Site Infection (Reviewed) 166. Renal Services CAPD Related Peritonitis with Negative Culture (Reviewed) 167. Renal Services CAPD Related Yeast Peritonitis Order Set (Reviewed) 168. Renal Services CAPD Thrombolytic Instillation For Occluded (Reviewed) 169. Renal Services CAPD/CCPD Order Set (Reviewed) 170. Renal Continuous Renal Replacement Therapy (Reviewed) 171. Renal Hypoglycemia Adult Admin of Dextrose in CD (Reviewed) 172. Renal OP CAPD/CCPD Protocol Iron Therapy (Reviewed) 173. Renal Services OP Hepatitis Immuno Control (Reviewed) 174. Renal Services OP Nutrition QI Lab (Reviewed) 175. Renal Prophylactic ABX for Cath Repair Protocol CD (Reviewed) 176. Renal Services OP CD Admission Orders (Reviewed) 177. Renal Services OP HD Anemia Manage Protocol (Reviewed)


178. Renal Services OP CAPD/CCPD Anemia Manage Protocol (Reviewed) 179. Renal Services OP CAPD/CCPD Orders (Reviewed) 180. Renal Services Dialysate Potassium Adjustment (Reviewed) 181. Renal Services Doxercalciferol Injection (Reviewed) 182. Renal Services Doxercalciferol Oral (Reviewed) 183. Renal Services OP HD IV Iron Mgmt Protocol (Reviewed) 184. Renal Services OP HD Lab Monitoring Protocol (Reviewed) 185. Renal Edema-free Weight Adjustment Protocol (Reviewed) 186. Renal Services OP PD Lab Monitoring Protocol (Reviewed) 187. Renal Services Peritoneal Hypoglycemia Proto (Reviewed) 188. Renal Services Sodium Variation Protocol (Reviewed) 189. Renal Services Temp Variation Protocol (Reviewed) 190. Renal Services UF Profiling Protocol (Reviewed) 191. Renal Service Prophylactic ABX Admin for Cath Repair (Reviewed) 192. Renal Services Acute DRHI Protocol (Reviewed) 193. Renal Services Acute DRHI Protocol COMM (Reviewed) 194. Renal Services Chronic DRHI Protocol (Reviewed) 195. Renal Services Hepatitis Immuno Acute (Reviewed) 196. Renal Services Flush Protocol (Reviewed) 197. Renal Services OP CD Malfunctioning Tunn CV Cath (Reviewed) 198. Renal Thrombolytic Infusion (Reviewed) 199. Restraint Protocol - Destructive Behavior (Reviewed) 200. Restraint Protocol - Invasive Devices (Reviewed) 201. Rituxan Order Set (Reviewed) 202. Roto Rest Bed Orders (Reviewed) 203. Severe Sepsis and Septic Shock Protocol (Reviewed) 204. Severe Sepsis Protocol Initiation Comm Form (Reviewed) 205. Skilled Nursing Facility Admission Order Set (Reviewed) 206. (Reviewed) 207. Sodium Chloride 3 percent Trmt of Hyponatremia (Reviewed) 208. Special Services - Bladder Surg DC Instructns (Reviewed) 209. Special Services - Cast Care Instructions (Reviewed) 210. Special Services - Cystoscopy Discharge (Reviewed) 211. Special Services - D C Discharge Instructions (Reviewed) 212. Special Services - Discharge Instructions (Reviewed) 213. SS - Cardiac Cath Angiogram Discharge (Reviewed) 214. SS - Circumcision Discharge Instructions (Reviewed) 215. SS - Dialysis Graft Declot Discharge (Reviewed) 216. SS - Epidural Facet Injection Discharge (Reviewed) 217. SS - ESWL Discharge Instructions (Reviewed) 218. SS - Extremity Surgery Discharge (Reviewed) 219. SS - Foley Cath and Leg Bag Care (Reviewed) 220. SS - Inguinal Hernia Repair Discharge (Reviewed) 221. SS - Lap Chole Discharge Instructions (Reviewed)


222. SS - Laparoscopic BTL Discharge (Reviewed) 223. SS - Laser Turp Discharge Instructions (Reviewed) 224. SS - Orchiectomy Discharge Instructions (Reviewed) 225. SS - Prostate Needle Biopsy DC (Reviewed) 226. STROKE Alteplase Administration (Reviewed) 227. STROKE - Alteplase Inclusion Exclusion for AIS (Reviewed) 228. Subacute - Restorative Nursing Order Set (Reviewed) 229. Subacute Admission Orders (Reviewed) 230. Subacute- Renewal Order Set (Reviewed) 231. Subacute Nursing order renewals (Reviewed) 232. Suspected Infection Protocol for Subacute (Reviewed) 233. Taxol Routine Orders (Reviewed) 234. Tikosyn Protocol (Reviewed) 235. Tube Feeding Gastric (Reviewed) 236. Tube Feeding Small Bowel (Reviewed) 237. Vascular Alteplase Thrombolysis Order Set (Reviewed) 238. VBAC in Labor (Reviewed) 239. Vent Protocol - ARDS Low Volume Vent (Reviewed) 240. Vent Protocol - High Frequency Oscillating (Reviewed) 241. Vent Protocol-Special Mechanical Orders (Reviewed) 242. Vent Protocol - Spont. Breathing Trial (Reviewed) 243. Ventilator Protocol - NIPPV (Reviewed) 244. Ventilator Orders-Mechanical (Reviewed) 245. VTE Order Set (Reviewed) 246. Wound Packing Communication Form (Reviewed) 247. Wound VAC Therapy Order (Reviewed) 248. Patient Controlled Epidural Analgesia for Laboring Patients (Reviewed) 249. Wound Full Thickness Order Set (Reviewed) 250. Wound Moisture Associated Skin Damage Order Set (Reviewed) 251. OB Insulin SubQ Order Set (Reviewed) 252. One Time Acute Hemodialysis Order (Reviewed) 253. OP Peritoneal Dialysis Clinic Lab Protocol (Reviewed) 254. Wound Partial Thickness Order Set (Reviewed) 255. Wound Pressure Injury Order Set (Reviewed) 256. Wouldn Pressure Ulcer Prevention Nurse Order (Reviewed) 257. Renal Services OP Suture Removal Protocol (Reviewed) 258. Wound Skin Tear Treatment OS (Reviewed) 259. SubQ Insulin Adult Non-Glucomm Inpatient/Skilled Nurs (Reviewed) 260. Vaprisol Order Set (Reviewed)

F. Anesthesia Privileges G. Cardiovascular Medicine Privileges

Request for appointment to the Kaweah Delta Health Care, Inc. Board effective November 1, 2017: 11/01/17 – 10/31/20 Craig Calloway, M.D. and Gary Herbst

Adult Primary Care 1 Intensivists 2Dermatology 1Gastroenterology 3Orthopedic Surgery 1 General Surgery (Colorectal or other subspecialty) 1Pediatrics 1

Sequoia Radiation Oncology Medical AssociatesRadiation Oncologist 1

Adult Primary Care 1OB/Gyn 1 Valley Children's Health CarePediatrics 1 Maternal Fetal Medicine 2

Pediatric Hospitalist 3

Family Medicine Core Faculty 1 Valley Hospitalist Medical GroupHospitalist 4

Cardiac & Thoracic Surgery 1 Other RecruitmentPalliative Medicine 1

CEP - Family Medicine Clinic

Golden State Cardiac & Thoracic Surgery

Horizon Critical Care

IQ Surgical Associates

Kaweah Delta Physician Recruitment

Prepared by: Brittany Taylor, Physician/Leadership Recruiter [email protected] - (559)624-2899Date prepared: 10/9/2017

Kaweah Delta Medical Foundation

Kaweah Exeter Medical Group

Open Position Snapshop - October 2017

1

Specialty Group Last Name First Name Availability Board Certification Miscellaneous Current Status

Adult Primary Care - Family Medicine

Kaweah Delta Medical Foundation & Valley Hospitalist Group.

Howard, M.D. Ryan 07/18American Board of Family Medicine, Eligible

No CA License; Completing residency in AZ; also considering Hospitalist position; Candidate reached out directly on 7/10/17.

Site visit: 11/3/17


Open Tahir, M.D. Sadaf 07/18American Board of Family Medicine, Eligible

No CA License; Completing residency in FL; Presented on 8/14/17 by Physician Empire.

Site visit: 10/27/17



Chan, M.D. Roy 02/18American Board of Family Medicine, Certified

CA Licensed; Candidate reached out directly on 5/25/17.

Site visit: 8/9/17; Offer accepted; Anticipated start date: 2/1/2018

Adult Primary Care - Internal Medicine


Atchabahian, M.D. Lara 10/17American Board of Internal Medicine, Eligible

CA Licensed; Spouse, Dr. Edward Samourjian, Vascular Surgeon, joining Visalia group. Candidate reached out directly on 4/4/17.

Site visit: 4/24/17; Offer Accepted. Start Date: 10/02/2017

Cardiology, Invasive/Non-Interventional


Said, M.D. Sarmad 08/18

American Board of Internal Medicine, Certified; American Board of Internal Medicine - Cardiovascular Disease, Eligible

CA Licensed; Presented on 7/13/17 by Physician Empire.

Site visit: 9/22/17; Offer accepted.

EndocrinologyKaweah Delta Medical Foundation

Saif, M.D. NomanTBD - pending

CA License

American Board of Internal Medicine, Certified; American Board of Internal Medicine - Endocrinology, Certified

CA license in process; Currently practicing in Longview, TX; Brother is moving to Fresno. Presented by Cejka on 2/1/17.

Site Visit: 3/9/17; Offer accepted

GastroenterologyKaweah Delta Medical Foundation

Hsueh, M.D. William 08/19American Board of Internal Medicine, Certified

No CA license; Presented by Fidelis Partners on 7/25/17.

Site visit: 11/10/17


Singh, M.D. Sital 08/18American Board of Internal Medicine, Certified

CA Licensed; Presented by Physician Empire on 8/2/17.

Site visit: 9/20/17; Offer extended

Candidate Activity

2



Theethira, M.D. Thimmaiah G. 08/17American Board of Internal Medicine, Certified

CA Licensed; Completing fellowship at UCSF, Fresno; Met at CareerMD Career Fair on 7/20/17, CV received 8/7/17.

Site visit: 9/18/17; Offer pending


Pua, M.D. Shirley 01/18

American Board of Internal Medicine, Diplomate; American Board of Internal Medicine – Gastroenterology, Certified

CA licensed; presented by Integro Healthcare on 4/19/17.

Currently under review. Met at conference 5/8/17. Site visit: 7/11/17. Offer accepted

Gastroenterology (Hospitalist) IQ Surgical Associates Al-Khedr, M.D. Hany 07/18American Board of Internal Medicine, Certified

No CA license. Completing Gastroenterology & Hepatology fellowship 6/2017. Presented by Physician Empire on 5/11/17.

Phone Interview: 6/22/17; F/up scheduled for 1/2017

General Surgery (Trauma/Surgical Critical Care)

Open Jeffcoach, M.D. David 08/18American Board of Surgery - General Surgery, Eligible

Visalia native interested in returning after fellowship. Wife is a PA. Trauma/Surgical Critical Care Fellowship in Fresno, completion date - 7/2017. CV rec'd directly from Dr. Jeffcoach on 7/17/15.

Site Visit: 7/21/2016; Dinner with Dr. Sebastiano Cassaro on 4/24/17 at 6PM. 10/9/17- Reached back out to f/up.

GME Family Medicine Faculty (full-time)

CEP Parungao, M.D. Jodi 09/18American Board of Family Medicine, Eligible

No CA license; Candidate information rec'd on 9/11/17.

Site visit: 9/19/17; Offer accepted; tentative start date: 8/2018

GME Family Medicine Faculty (full-time)

CEP Ramirez, M.D. Magda 10/17American Board of Family Medicine, Eligible

Completing residency in NM; Presented through CEP recruitment team 1/3/17.

Site Visit: 1/25/17; Offer accepted. Anticipated start date: 10/2017

HospitalistValley Hospitalist Group

Elahi, M.D. Asim TBDAmerican Board of Internal Medicine, Certified

CA Licensed; Friends in Fresno, CA; Presented by Puzzle Piece Solutions on 9/7/17.

Currently under review

3



Guo, M.D. Chao 08/18American Board of Internal Medicine, Eligible

No CA License; Presented by Physician Empire on 9/20/17.



Kanji, M.D. Rehan Amin 01/18American Board of Family Medicine, Eligible

CA Licensed; Spouse is employed by KDHCD. Candidate reached out directly on 9/13/17.

Site Visit: 10/31/17


Legesse, M.D. Ashenafi 01/18American Board of Internal Medicine, Eligible

CA Licensed; Candidate is currently practicing in Fresno; Candidate reached out directly on 9/18/17.



Manalac, M.D. Janet 08/18American Board of Internal Medicine, Eligible




Singh, M.B.B.S. Nirmal 08/18American Board of Internal Medicine, Eligible




Win, M.D. Shine 08/18American Board of Internal Medicine, Eligible

Family lives in CA; Presented by Physician Empire on 6/30/17

Site visit: 12/4/17


Gumaste, M.D. Purva 09/19American Board of Internal Medicine, Eligible

No CA license; Husband is joining local Nephrology group; Candidate reached out directly on 7/6/17.

Site visit: 9/11/17; Offer accepted.

Intensivist Horizon Critical Care Bean, D.O. Matthew 08/18

American Board of Anesthesia, Certified; Critical Care Medicine, Eligible

No CA license; Completing critical care fellowship at Duke University Medical Center; Presented by Medical Puzzle Piece Solutions on 8/3/17.


Intensivist Horizon Critical Care Moore, M.D. JustinTBD - pending

CA License

American Board of Internal Medicine, Eligible; Critical Care Medicine, Eligible; Sleep Medicine, Eligible

No CA license; Presented by Medical Puzzle Piece Solutions on 7/27/17.

Site visit: 9/15/17

4


Intensivist Horizon Critical Care Psihos, D.O. Peter John 08/18

American Osteopathic Board of Internal Medicine, Certified; Critical Care Medicine, Eligible (2018); Pulmonary Medicine, Eligible (2017)

No CA License; Presented by Medical Puzzle Piece Solutions on 7/14/17.

Site visit: 8/11/17

Intensivist Horizon Critical Care Speredelozzi, M.D. Daniel 08/18

American Board of Internal Medicine, Eligible; Critical Care Medicine, Eligible

No CA License; Presented by Medical Puzzle Piece Solutions on 8/16/17.

Site visit: 9/16/17

NeonatologyValley Children's Healthcare

Dosado, M.D. Jose 07/17

American Board of Pediatrics, Certified; American Board of Pediatrics - Neonatal-Perinatal, Certified.

No CA license; Currently practicing in IA. CV presented by Children's on 1/20/17.

Site Visit - 1/24/17; Offer accepted; start date - 9/18/17

NeonatologyValley Children's Healthcare

Younis, M.D. Usama Mohamed 07/17

American Board of Pediatrics, Certified; American Board of Pediatrics - Neonatal-Perinatal, Certified.

No CA license; Currently practicing in SD. CV presented by Children's on 1/20/17.

Site Visit - 1/23/17; Offer accepted; start date - 9/25/2017

NeurologyKaweah Delta Medical Foundation

Joshi, M.D. Rohini ASAPAmerican Board of Internal Medicine, Certified

CA Licensed; Current VMC Independent Contractor interested in Full-Time.

Offer accepted. Start date for full-time status: 12/01/2017

Orthopedic Surgeon, Hand & Upper Extremity

Orthopaedic & Associates

Kolahi, M.D. Kourosh Michael 07/18American Board of Orthopedic Surgery, Eligible

CA Licensed; Currently completing Hand & Upper Extremity Surgery fellowship in New Mexico 7/2017-6/2018. Referred by Dr. Bruce Le on 1/25/17.

Site Visit: 4/7/17; Offer extended

Pediatric HospitalistValley Children's Hospital

Burger, M.D. CraigTBD - pending

CA LicenseAmerican Board of Pediatrics, Certified

No CA license; Currently practicing in Fort Lewis, WA; Presented by VCH on 7/3/17.

Site Visit: 7/27/17; Offer extended

Radiation Oncology

UrologyKaweah Delta Medical Foundation

Ford, M.D. Joseph 07/18

No CA License; Completing Oncology fellowship 2017-2018; Presented by Fidelis Partners on 6/14/17.

Site Visit: 7/7/17; Offer accepted

Dr. Youssef Hanalla, Sequoia Radiation Oncology Medical Associates, will met 6 candidates at ASTRO conference in San Diego (9/24-9/26/17).

Risk Management Report – Open 3rd Quarter 2017 October 23, 2017

Kassie Waters Interim Director of Risk Management

Risk Management Goals

1. Reduce frequency and severity of harm (patient and non-patient). Zero incidents of “never events”

2. Reduce frequency and severity of claims. 3. Promote a safety culture as a proactive risk reduction

strategy.

Total of 1084 Risk Events for 3rd Qtr 2017

Successes & Reductions

• Reduced – Radiology events – Acute Mental Health patient prohibited

items – Number of non-utilized blood transfusions

• Improved code blue/rapid response physician paging system by implementing new application on Intensivists cell phones.

• Work Place Violence Committee

Claims Frequency CY 2015 – 2017 Average of Claims/Year = 14-15

15

5

3 3 3

54

3

0

2

4

6

8

10

12

14

16

2015 1 Q 2016 2 Q 2016 3 Q 2016 4 Q 2016 1 Q 2017 2 Q 2017 3 Q 2017

Annual Insurance Premiums

538,733582,473

527,754587,452

185,244 189,563 189,563 187,749

40,865 39,284 50,953 50,953

0

100000

200000

300000

400000

500000

600000

700000

2014-2015 2015-2016 2016-2017 2017-2018General Liability Insurance Premium

Professional Liability Insurance Premium Auto Liability Insurance Premium

# Complaints & Grievances Filed by Quarter

7985

63 60

68

8185

128

138

152

131

0

20

40

60

80

100

120

140

160

1 Q 2015 2 Q 2015 3 Q 2015 4 Q 2015 1 Q 2016 2 Q 2016 3 Q 2016 4 Q 2016 1 Q 2017 2 Q 2017 3 Q 2017

Trends: Ineffective

physician/staff communication

Quality of Care Excessive wait

times – ED

Reducing Complaints & Grievances

• Assigned full time positon in the Patient Relations Department to respond to all complaints and grievance (Spanish speaking) & implemented new workflow.

• Established lost & found workgroup • Availability and utilization of Interpretive Services

presentation provided to medical staff. • Empowering front line staff to resolve complaints in

real-time.

Complaints & Grievances Workflow Risk Management (RM) - Scope

• High Risk Complaints (regulatory related, external agencies, surveys, etc.)

• High Risk Grievances • Oversee Risk Management-

MIDAS occurrences • Consult PX Dept • Back up for PX Dept

Patient Experience (PX) - Scope

• Complaints: Refer to Point of Service (Supervisor/Manager/Director)

• Low Risk Grievances • Oversee Patient Relations-

MIDAS occurrences • Consult RM Dept.

• Resource for patients, visitors, staff, and leaders RM & PX - Shared Scope

fi

Clinical Decision Unit Daniel L. Allain, MSN, FNP-C, NE-BC, Assistant Chief Nursing Officer, x2536; Wally Huynh, MD, Medical Director Beth Nelson, BSN, RN Director House Supervision April Matthews, BSN, RN, Nurse Manager 2-South Nicole Seitz, MSN, RN, Director Care Management September 2017

Summary Issue/Service Considered

The CDU has been in place on 2-South for the past 3-years and remains an open unit for all physicians wishing to admit and manager their patient’s.

The CDU is for those patients who are seen in the ED and are not responding to intervention and may benefit from an extended observation period.

2-South is a 29-bed unit with 14-17 beds designated as observation (OBS) beds, the remainder of the unit houses the 3 couplet rooms for mother baby and 12-beds temporarily allocated for the Ambulatory Surgical Center (ASC) starting on June 30, 2016.

The 12-beds used by ASC will be released on January 1, 2018 when the remodeled ASC unit opens and will then become overflow medical surgical beds for inpatient admissions.

Patients must be admitted by a physician. Once admitted, primary provider coverage is accomplished with certified nurse practitioners staffing 24-hours a day Monday through Friday and 20 hours a day Saturday, Sunday and holidays. These nurse practitioners collaborate with the adult hospitalist as well as any other physician who wish to utilize the unit and the NP’s.

Patients admitted to the CDU are managed following the observation unit guidelines, order sets and within the established timelines. Admission orders are written within 2-hours of admission, follow-up to diagnostic results as well as condition changes occur within 1-hour or less.

Patients stay a minimum of 8-hours and generally the discharge should occur within 24-hours.

Most top performing CDU’s are discharging patients within 15-hours.

These patients are considered outpatients and as such receive an hourly charge as well as procedure and diagnostic charges along with medication and IV fluid charges.

The unit is staffed with dedicated RNs who are trained in the management of outpatients focused on high quality expeditious care.

Types of patients cared for on the CDU: o Chest pain TIMI score < 5 or similar symptoms o Syncope/Vertigo

Kaweah Delta Health Care District Clinical Decision Unit (CDU) 2-South Annual Report to the Board of Directors

o TIA with an NIH score of 0, no restrictions based on ABCD² score o Shortness of Breath - Chronic Obstructive Pulmonary Disease (COPD)

Exacerbation, Asthma o Dehydration o Hypoglycemia o Renal Calculi, Pyelonephritis

Quality/Performance Improvement Data

Throughput Overall observation admissions to the District have remained relatively flat with a noted spike in May 2017. The observation cases admitted to 2-South have been showing a decline on average of 50 admissions to most notably beginning June 2016 with average admission of 206 per month which dropped off to an average of 159 for the past 14-monhts. This drop correlates with the move of ACS to 2-South.

Length of Stay (LOS) for admissions on 2-South have not met the 24-hour benchmark since opening the unit. Top performing hospitals are discharging patients within 15-hours.

JULY2016

AUG2016

SEPT2016

OCT2016

NOV2016

DEC2016

JAN2017

FEB2017

MAR2017

APR2017

MAY2017

JUNE2017

JULY2017

AUG2017

CDU OBS Cases 2 South 144 138 130 145 168 162 152 168 164 140 191 177 165 183

Obs Cases Other Units 242 236 197 200 212 216 239 191 236 247 312 262 329 336

Total Obs Cases 386 374 327 345 380 378 391 359 400 387 503 439 494 519

CDU Obs Cases 2 South % of Total 37% 37% 40% 42% 44% 43% 39% 47% 41% 36% 38% 40% 33% 35%

100150200250300350400450500550

2016-2017 OBSERVATION ADMISSIONS

JUL2016

AUG2016

SEPT2106

OCT2016

NOV2016

DEC2016

JAN2107

FEB2017

MAR2017

APR2017

MAY2017

JUN2017

JUL2017

AUG2017

Adult Patients 31 36 34 43 34 35 29 29 32 35 34 38 32 32

Adult Patients-2S 30 36 31 29 28 30 33 31 31 32 29 28 34 29

TARGET ≤ 24 HRS 24 24 24 24 24 24 24 24 24 24 24 24 24 24

TOP PERFORMING HOSPITALS ≤15 HRS

15 15 15 15 15 15 15 15 15 15 15 15 15 15

1015202530354045

2016-2017 OBSERVATION LOS HOURS (AVERAGE)

Clinical Related Outcomes: The percent of discharges from the CDU is trending at 93% well above our internal benchmark of 80%. This performance would support that the patients are appropriately being admitted to the CDU. The remaining 5-7% of the patients where appropriately transitioned to inpatient status for more extensive diagnostics and management.

The 30-day CDU inpatients re-admit internal benchmark is < 1.5%. These represent any re-admission to the hospital and may not be directly related to the initial CDU admission.

JULY2016

AUG2016

SEPT2016

OCT2016

NOV2016

DEC2016

JAN2017

FEB2017

MAR2017

APR2017

MAY2017

JUNE2017

JULY2017

AUG2017

% Discharged from CDU 93% 96% 92% 92% 95% 92% 87% 93% 95% 95% 93% 95% 95% 92%

Benchmark 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80%

70%

75%

80%

85%

90%

95%

100%

2016-2017 % OF PATIENT'S DISCHARGED FROM THE CDU

JULY2016

AUG2016

SEPT2016

OCT2016

NOV2016

DEC2016

JAN2017

FEB2017

MAR2017

APR2017

MAY2017

JUNE2017

JULY2017

AUG2017

30-DAY INPATIENT RE-ADMITS % 1.4% 0.7% 0.8% 0.7% 1.8% 0.6% 2.6% 0.0% 1.2% 0.0% 1.6% 1.7% 1.2% 0.5%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

2016-2017 CDU 30-DAY INPATIENT RE-ADMITS %

The re-admission rates to the ED are tracked for 7-days as well as 30-days. The internal benchmark for the 7-day re-admission rate was set at < 8% and is trending below 6% over the past 3-months. The 30-day re-admission internal benchmark is set at <25%. This 30-day readmission may have been for other illnesses and injuries not specifically related to the reason for the CDU admission.

JULY2016

AUG2016

SEPT2016

OCT2016

NOV2016

DEC2016

JAN2017

FEB2017

MAR2017

APR2017

MAY2017

JUNE2017

JULY2017

AUG2017

7-Day ED RE-ADMIT % 8% 10% 5% 4% 5% 6% 8% 8% 9% 6% 8% 3% 6% 4%

0%

2%

4%

6%

8%

10%

12%2016-2017 CDU 7-DAY ED RE-ADMITS %

JULY2016

AUG2016

SEPT2016

OCT2016

NOV2016

DEC2016

JAN2017

FEB2017

MAR2017

APR2017

MAY2017

JUNE2017

JULY2017

AUG2017

30-Day ED RE-ADMITS % 35% 25% 21% 18% 19% 20% 34% 30% 41% 19% 32% 22% 26% 22%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45% 2016-2017 CDU 30-Day ED RE-ADMITS %

Recommendations/Next Steps

Conclusions: The CDU is fully staffed by NPs on the day and swing shifts with coverage on the night shift being provided by one full time NP. To facilitate the throughput for low risk chest pain admissions the NPs are being credentialed to perform the tread mill stress tests. Order sets have been developed for the more frequently admitted patients such as chest pain, transient ischemic attacks (TIAs), syncope, exacerbation of chronic obstructive lung disease and asthma, dehydration, kidney stones, and kidney infections. CDU’s continue to be an effective strategy for patients who are initially seen in the Emergency Department when discharge is not a good option and the patient does not meet criteria for inpatient admission. The target groups are those patients for whom an extended observation period (generally less than 24-hours) will be of benefit. If the patient progresses in the disease process while in observation, the patient is then considered for admission to an inpatient status and transferred off the CDU. To further support the throughput efforts, the NPs offer to collaborate with all admitting physicians to manage the patient’s stay while allowing the admitting physician to document the admission history and physical along with the discharge summary. Following the treatment plan set forth by the admitting physician, the NPs will review diagnostics and order other appropriate tests/diagnostics while also keeping the physician informed of the patient progression through the treatment plan. We are currently collaborating with the Finance Decision Support team to further analyze the impact the NPs have on our throughput process and to differentiate those patients who are managed by NPs compared to those managed only by physicians. Our throughput process improvement goal is to bring our LOS to 15 hours, in alignment with other top performing hospitals, while providing quality patient care through early recognition of those patients who do not meet inpatient hospitalization criteria but may need further interventions and diagnostics prior to discharge.

CHESTPAIN

SYNCOPECOLLAPSE

TRANSCEREBRALISCHEMIA

ACUTEAPPYUNSP

COPDHEART

DISEASEDIZZINESS

/GIDDY

AVE OBS HRS 31 29 29 24 50 56 29

MED OBS HRS 24 21 12 27 22 65 19

0

10

20

30

40

50

60

70

CDU OBSERVATION HOURS SUMMARY BY PRIMARY DIAGNOSIS

DATA REPRESENTS 67% OF TOTAL PATIENTS ADMITTED SEPT 2016-AUG 2017

c Kaweah Delta Health Clinics David Garrett, Director of Outpatient Health Clinics, 559.592.7395 Dr. William Roach, Rural Clinic Medical Director Dr. Dan Brown, Family Medicine Center Medical Director October 03, 2017 Summary Issue/Service Considered Kaweah Delta Health Clinics, located in the Tulare County cities of Visalia, Exeter, Lindsay, Woodlake and Dinuba, offer primary and specialty care services emphasizing prevention, wellness, individual dignity and cultural sensitivity. Services offered at the rural clinics include Family Medicine, Pediatrics, Women’s Health, Mental Health, Health Education, Nutrition Education, Rheumatology, Adult Infectious Disease, Hand Surgery, Pulmonology, Nephrology, Neurology, Endocrinology, Dermatology, Podiatry, Adult Cardiology, and Pediatric Cardiology. The above service lines currently include a total of 47 (part-time and full-time) physicians and advanced practice providers, 19 family medicine residents, nine psychiatry residents, and 10 GME faculty members. New Providers: The clinics have expanded services in Psychiatry, Family Medicine, OB/GYN, Interventional Cardiology, and Therapy to meet the needs of the underserved communities: • Psychiatry—three new psychiatry residents (Jose Feliberti MD, Patrick

McLaughlin DO, and Latika Phillips MD) • Family Medicine—one family medicine faculty (Julius Metts MD); seven family

medicine residents (Aashini Shah MD, Gursharn Kaur MD, Jasneet Dhaliwal MD, Lea Macias MD, Marina Nemetalla MD, Matthew Kim MD, and Sara Bansal MD)

• Other Providers—Juan Sabogal MD, OBGYN; Ankur Gupta MD, Interventional Cardiology; LaMar Mack MD, Vascular Surgery; Sandy Badger-Jones LCSW; and Lauren Diaz LCSW.

RHC and Residency Clinic Accomplishments: Four significant projects were accomplished by clinic staff and management since last year: executing the remodel of three clinics in Dinuba, Lindsay, and Exeter; developing the transition to Cerner electronic medical record; graduating the second family medicine residency class; and implementing the Public Hospital

Kaweah Delta Health Care District Annual Report to the Board of Directors

Redesign and Incentives in Medi-Cal (PRIME) ambulatory program. A brief description and accounting of each item is given below. • Remodel of the Dinuba, Lindsay, and Exeter Clinics.

1. Dinuba Clinic - due to the growth of primary care visits and the interests of multiple specialists wanting to work in Dinuba, the clinic has undergone an expansion of 1,715 sq. ft., adding six exam rooms, a provider office, nurses’ station, storage, and a lab draw station for future development. After state licensing performs its review, the expansion will be available for patient care.

2. Lindsay Clinic - Tulare Local Health Care District vacated its Lindsay clinic in Dec 2016. This 5,000 sq. ft. clinic is west of the Kaweah Delta Lindsay Clinic. With assistance from the city of Lindsay and the Lindsay Hospital District Board, the adjacent space is now considered part of the KD Lindsay Health Clinic, under the same rural clinic license. This clinic addition will allow the services occupying the current Lindsay Clinic to move to a larger clinic and expand our primary care and specialty services. The current Lindsay clinic space will be dedicated to outpatient mental health services provided by the psychiatry residency program.

3. Exeter Clinic – The construction began in December 2016 with the expected completion in December 2017. The project’s goal is to maximize the clinical space and to consolidate non-clinical areas to meet the growing primary care needs of the surrounding communities. The plan also includes improvements to existing buildings’ exterior, to save water through water conscious landscaping and to improve clinic parking. The project includes erecting two new structures and demolishing one structure in a phased process. The project has completed the first of two phases by erecting and occupying the new administration building and demolishing the old administration building. Phase Two includes erecting the Women’s Health clinic, expanding on-site parking, and improving the campus landscape.

• Second class of the family medicine residency graduated. The Family Medicine Residency Program successfully graduated another six family medicine residents from the program. These six residents all passed there Board exams with high marks. A major portion of the residents’ work occurs in the Family Medicine Center outpatient clinic with each resident seeing over 1,650 continuity patients during the three-year training period. All met their minimum volume without delays.

• Developing the Cerner Electronic Medical Record Infrastructure. A significant portion of the clinic’s management and staff have been dedicated to develop and learn about the Cerner outpatient electronic health record. Though there have been delays in go-live, the clinic staff and management continue to be engaged in this development process. This delay has allowed management to gain a better understanding of system functionality and reporting. The clinic

management, with the support of ISS, is developing more training tools and work instructions for the staff to have them better prepared for go-live.

• Approval of the Ambulatory Redesign Project in PRIME. The clinics’ portion of

the PRIME incentives will bring an additional $2 million per year to the District to support the ever-growing needs of the Medi-Cal population. The data from the clinics was successfully submitted on September 30, 2017. The focus now is on the improvement of the PRIME Metrics and identifying disparities of care in vulnerable populations as defined by race, ethnicity, language, sexual orientation, or gender identification.

Clinic Operations: • Clinic Volumes. The Kaweah Delta Clinics have reached a new patient-care

milestone with over 117,400 visits in a single year. Each service within the clinics continues to match previous year’s performance. The area of biggest growth has been psychiatry due to the majority of psychiatry residency program outpatient work being conducted at Exeter. Also, Family Medicine, Pediatrics, and Adult Specialty services continue to increase in volume. Reputation and word-of-mouth efforts are the source of most clinic referrals. In addition, marketing efforts continue to promote the primary care community events and the work of the residency program.

• Second year contracting with Kaweah Exeter Medical Group. Clinic management and the medical group have a favorable working relationship in the second year of a three-year contract. Group physicians and management are developing coordination of care teams in order to reduce the number of admissions to the hospital, to improve patient outcomes, to improve patient experience, and to improve access to outpatient care. Drs. Edgar Castillo (psychiatry) and Rocio Medina (internal medicine) now are president and vice-president of the group, respectively.

• Submitted for National Committee for Quality Assurance (NCQA) Patient-

centered Medical Home (PCMH) recognition for the rural health clinics. The project has been submitted for approval to the NCQA. The primary care providers have supported and adapted the PCMH changes of clinical practice. Management expects to achieve PCMH recognition Level 2 for all rural clinics in fall of 2017. The clinics’ transformation will follow the PCMH model requirements as outlined by the NCQA. As of the writing of this report, one clinic has been recognized as Level Two PCMH and the other three are under review. Final determination for all rural clinics should be given before the end of the year.

Financial Status:

The rural health clinics and FMC continue to be a profitable service line for Kaweah Delta. For FY 2017, the clinics experienced a 5% growth in patient volume over FY 2016. The clinic network remains profitable for the District with a consolidated contribution margin of $5.1 million, operating nearly $1 million favorable to the FY17 budget (see accompanying financial report). Quality/Performance Improvement Data Management continues to focus its efforts on maintaining service delivery, improving employee morale, and following the fiscal budget during the past year. The clinics continue to submit Meaningful Use data, to enhance medication reconciliation, to improve utilization of immunizations/preventative health medicine measures (HEDIS), to monitor patient-centered medical home (PCMH) metrics, and to submit base-line metrics for the PRIME project (i.e. Alcohol and Drug Misuse (SBIRT); CG-CAHPS: Provider Rating; Colorectal Cancer Screening; Comprehensive Diabetes Care: HbA1c Poor Control (>9.0); Controlling Blood Pressure; Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic; Prevention Quality Overall Composite #90; Screening for Clinical Depression and follow-up; and, Tobacco Assessment and Counseling). The clinics perform quality assurance and performance improvement projects as required by the District (QAPI, now PROSTAFF): depression screening utilization, diabetes management, positive first impression, use of EHR prescription writing, and same day appointment utilization.. In addition, through the FOCUS-PDCA method, the clinic staff and physicians have monitored timely completion and sign-off of progress notes, patient satisfaction, flu shot compliance, and diabetes management. Recommendations/Next Steps • Submit two semi-annual PRIME reports that demonstrate achieving patient

outcome goals and obtaining maximum financial incentive for the District.

• Implement the Chronic Care Management (CCM) and Transitional Care Management (TCM) programs for primary care patients. Demonstrate an improvement in care with these two programs

• Plan and implement the transition of the electronic medical record from

eClinicalWorks to CERNER.

• Expand primary care and specialty services in each of the three remodeled clinics to maximize space, efficiency, and service.

Approvals/Conclusions No additional approvals needed at this time. The Kaweah Delta health clinics service line continues to be a highly successful service line for the District; providing outstanding primary and specialty care services to the community it serves. It continues to make improvements in achieving outstanding health outcomes, providing excellent service, offering an ideal work environment, and maintaining financial strength. Efforts are made to recruit and retain appropriate providers and staff, with a greater emphasis on primary care, supplemented by specialty care.

Kaweah Delta Health Care DistrictAnnual Report to the Board of Directors

Financial & Statistical Information

Kaweah Delta Health Clinics

Dave Garrett, Director

October 2, 2017

Service Line Report Data: Fiscal Year 2017

Patient Net Pat Direct ContributionService Visits Revenue per case Expenses per case Margin per case

KD Exeter Health Clinic 80,279 15,300,681$ $190.59 10,932,638$ 136.18$ 4,368,043$ 54.41$ KD Lindsay Health Clinic 8,105 1,666,708 $205.64 774,479 95.56$ 892,229 110.08$ KD Woodlake Health Clinic 9,506 1,913,628 $201.31 1,124,981 118.34$ 788,647 82.96$ KD Dinuba Health Clinic 8,418 1,554,903 $184.71 1,184,512 140.71$ 370,391 44.00$

Rural Clinics Subtotal 106,308 20,435,920 $192.23 14,016,610 131.85$ 6,419,310 60.38$

KD Family Medicine Center 11,100 520,384 $46.88 1,817,220 163.71$ (1,296,836) (116.83)$ -

Grand Total - Actual 117,408 20,956,304$ $178.49 15,833,830$ 134.86$ 5,122,474$ 43.63$

COMBINED BUDGET FY2017 123,863 20,374,600 164.49$ 16,243,827 131.14$ 4,130,773 33.35$

Variance from Budget (6,455) 581,704$ 14.00$ (409,997)$ 3.72$ 991,701$ 10.28$

Service Line Report Data: Fiscal Year 2016

Patient Net Pat Direct ContributionService Visits Revenue Expenses Margin

KD Exeter Health Clinic 79,227 14,463,754$ $182.56 10,104,831$ 127.54$ 4,358,923$ 55.02$ KD Lindsay Health Clinic 6,931 1,395,239 $201.30 716,774 103.42$ 678,465 97.89$ KD Woodlake Health Clinic 9,986 1,844,985 $184.76 1,089,057 109.06$ 755,928 75.70$ KD Dinuba Health Clinic 6,152 1,144,901 $186.10 880,865 143.18$ 264,036 42.92$

Rural Clinics Subtotal 102,296 18,848,879 $184.26 12,791,527 125.04$ 6,057,352 59.21$

KD Family Medicine Center 9,846 696,230 $70.71 1,473,656 149.67$ (777,426) (78.96)$

Grand Total - Actual 112,142 19,545,109$ $174.29 14,265,183$ 127.21$ 5,279,926$ 47.08$

Two Year Comparison 5,266 1,411,195$ 1,568,647$ (157,452)$


$120 $125 $130 $135 $140

Last Year

This Year

Direct Cost Per Unit of Service

$40 $42 $44 $46 $48 $50

Last Year

This Year

Contribution Margin Per Unit of Service

$170 $172 $174 $176 $178 $180

Last Year

This Year

Net Revenue Per Unit of Service


Measure

CMS Benchmark / *TJC National

Rate

Trends (Red Line =

Benchmark)

Last Data Point (green = benchmark

achieved)Compl

Due Date

PCM-01 Early Elective Deliveries - down trend positive (Clinical Staff Sponsor - Tracie Plunkett)

*2.42% 0%July 2017

Jan 2016

ED Patient Throughput (Quarterly Report) October 2014 - July 2017 (Dan Allain)

Benchmark (Hospital Compare

Average)

Trends (Red Line =

Benchmark)

Last Data Point (green =

benchmark achieved)

Compl Due Date

1) Median ED Arrival time to ED Departure Time for In-patients {minutes} - (down Trend Positive)

423 Minutes 443

July 2017Aug2017

A) Inpatient (Ed Largoza):Benchmark

(Internal)

Trends (Red Line =

Benchmark)


achieved)Compl

Due Date

1

Comments / Actions

No Fallouts - Benchmark Maintained

Value Based Purchasing (VBP) Measures

3rd Quarter 2017Board of Directors PI Dashboard

Emergency Department (Core Measure)

Patient Satisfaction

Jun2017

Comments / Actions

Comments / Actions

10/09/2017, The ED LOS for Door to admission (departure time) based on 100% sampling is reflecting performance times better than the benchmark with June at 388, July at 407 and August at 417. The PI reported data based on the sampling methodology has June reported at 398 and July at 443. Plan to continue the same process with notifying the physician when all diagnostics are back asking for the disposition to be entered, admission versus discharge. Continue with the process to call report and if not available give the verbal report at bedside.

Benchmark Maintained 1) Inpatient Satisfaction - HCAHPS Performance data (up trend positive)

74.5% 74.6%July 2017

B) ED (Dan Allain / Ed Largoza):

Benchmark (Internal)

Trends (Red Line =

Benchmark)


achieved)Compl

Due Date

1) ED Patient Satisfaction - not included in HCAHPS (mean score - up trend positive)

50th Percentile 2nd

percentile Aug 2017

Sep2017

C) Physician Satisfaction (every 2 years, due 2011; up trend positive)

75th Percentile 46 percentile

2009; 37 in 2007

n/a

D) Employee Satisfaction 2005 - 2015 (every 2 years - due 2017; up tend positive)

N/A 74.1 2015 n/a

A) Employee Turnover 3rd qtr 2014 - 2nd qtr 2017 (Dianne Cox) (reported quarterly):

Benchmark (CHA - changes

quarterly)

Trends (Red Line =

Benchmark)


achieved)Compl

Due Date

1) All Employees Turnover (down trend positive) 2.7% 3.4%

2nd qtr 20173rd qtr2017

2) RN Turnover (down trend positive) 3.1% 3.1%

2nd qtr 20172nd qtr 2017

B) Contracted / Traveler Staff - September 2017: 35 out of 4533 total staff (down trend positive)

0.33%(internal

benchmark) 0.77%

Sep 2017Oct

2017

2

Comments / Actions

KDHCD's current RN vacancy rate is statistically much lower than the CHA. With our recent hiring event on June 1, 2017 we offered over 50 RN's a position and have 47 staff RN positions open as of 9/30/2017..

10/9/2017, Provider at Triage (PAT) will be begin on October 10th from 0800 to 2400 daily. The focus and goal is getting to the patients at the earliest opportunity to begin the evaluation and then hand off the patient to the intake team, or the respective zone in the department. Internal holding areas will be set up to keep oversight of the patients pending CT scans and other imaging studies as well as labs. In addition the provider in the triage area will be monitoring and acting on the negative results of imaging studies to facilitate discharges without requiring the patient to wait for an ED treatment space.

Comments / Actions

Oct update: 35 travelers used in September; goal is to reduce the number of travelers to 15.

Await 2017 results

Pending data update

Human Resources

A) Capital Structure (Gary Herbst) (up trend positive):

Benchmark (Budget FY 2017)

Trends (Red Line =

Benchmark)


achieved)

Compl Due Date

1) Maximum Annual Debt Service Coverage: net income available to cover debt payments

3.7 3.7Aug 2017

Jun 2017

B) Liquidity:

1) Days Cash on Hand: number of days operating expenses covered by cash 150 155.1

Aug 2017Jun

2017

2) Net Days in Accounts Receivable: average number of days to collect a patient account (down trend positive)

55 64.1Aug 2017

Sep2017

C) Profitability (up trend positive):

1) Operating Margin: profit from core-business revenue and expenses 2.6% 3.9%

Aug 2017Feb 2017

2) Operating Cash Flow Margin: cash flow available to pay debt & purchase capital assets

8.1% 8.3%Aug 2017

Jun 2017

AbbreviationsCMS = Centers for Medicare & Medicaid Services

CHA = California Hospital Association

PSAT = Patient Satisfaction Action Tool

TJC = The Joint Commission

3

Comments / Actions

>10% From Benchmark

Benchmark Achieved

Benchmark achieved

Color Code

Within 10% of Benchmark

Benchmark achieved

Benchmark achieved

Benchmark was not met due to delayed claim submissions as a result of staffing shortages as well as a software upgrade. This issue should be resolved within the next six weeks.

Benchmark maintained

Finance

KAWEAH DELTA HEALTH CARE DISTRICT FINANCE DIVISION MEMORANDUM TO: Finance Committee, Board of Directors, Chief Executive Officer and Executive Team FROM: Malinda Tupper, Interim Chief Financial Officer (ext. #4065) and Jennifer Stockton,

Director of Finance (ext. #5536) DATE: October 12, 2017 SUBJECT: Semi-annual Investment Report Each month the Board of Directors receives an investment report depicting the specific investments held by the District including the nature, amount, maturity, yield, and investing institution. On a semi-annual basis, the District’s Chief Financial Officer is required to review the District’s investment policy with the Board, to discuss our compliance with that policy, to review the purpose of our various investment funds and to report on the performance, quality and risk profile of our current portfolio. At the Board’s request, fulfillment of this requirement is hereby made by means of this written report and accompanying schedules. The purpose of this report is to assure the Board that the following primary objectives have been satisfied with respect to its fiduciary responsibility for the sound and prudent management of the District’s monetary assets: 1) The Board of Directors understands and approves of the District’s investment policy and is confident that management has effectively complied with this policy. 2) Management has effectively established appropriate funds and managed investments in a manner that safeguards the District’s assets, meets the ongoing liquidity needs of the District and provides necessary funds for the various projects and budgets approved and adopted by the Board. 3) Within the constraints of the investment policy and the funding needs of the District, management effectively maximizes its return on investments to meet the income expectations adopted by the Board as part of the annual budget. 4) The acceptance/approval of this report includes the semi-annual review and approval of the investment policy (and any changes proposed) as well as the delegation of authority contained within the policy. For the purpose of assessing performance relative to each of these objectives, this written report describes and evaluates each of the following documents accompanying this report and demonstrates achievement of the stated objectives.

General Deposit and Investment Policy Included in this packet is a copy of the current investment, with no changes proposed. The District’s current investment policy reflects strict compliance with the California Government Code (Code) sections 53600 through 53686 which govern the investment of surplus funds by governmental entities of the State of California, including political subdivisions thereof. At June 30, 2017 the District’s investment portfolio complies with all reporting and investment provisions of this policy. Statement of Purpose Guidelines District Funds This document describes the various funds established by the District for the purpose of setting aside cash and investments for specific uses. The establishment of these funds (other than revenue or general obligation bond proceeds) is entirely at the discretion of the Board and are not mandated or controlled by any third-party or regulatory agency. Summary of Investment Funds This document depicts the carrying value, equal to amortized cost, of investments held at June 30, 2017 in each of the various funds established by the District. As indicated in this report, the District’s total adjusted surplus funds at June 30, 2017 are $281.0 million. The following table depicts the District’s adjusted surplus funds over the past three and one half years; the number of days cash on hand, a measure of liquidity; and the District’s average daily operating expenses (excluding depreciation expense), the denominator used in the calculation of the liquidity measure; and the percent increase in each year over the prior year: June 30,

2017 December 31,

2016 December 31,

2015

December 31, 2014

Adjusted Surplus Funds $280,988,000 $262,399,000 $237,459,000 $233,171,000Days Cash on Hand 169.2 159.2 167.6 190.2 Average Daily Operating Expenses (excluding depreciation expense)

$1,661,000 $1,648,000

$1,417,000 $1,226,000Percent Increase in Daily Expenses 0.8% 16.3% 15.6% 5.1% Days Cash on Hand Benchmarks: Moody’s “A” Rated Hospitals 215.5 Days Revenue Bond Covenants 90 Days As illustrated in the above table, the District’s liquidity ratio (days cash on hand) exceeds the covenant amount required by the District’s revenue bond indentures. Total surplus funds have experienced a 20.5% increase from December 31, 2014 to June 30, 2017, but the number of days cash on hand has decreased 11.0% from 2014. The increase in total surplus funds of $47.8 million from 2014 to 2017 is mainly attributable to four factors:

1) The District generated cumulative net income of $58.3 million for the period.

2) Charitable contributions restricted for capital purchases of $3.3 million which are not included in net income but provide cash for use of specific projects as determined by the donor.

3) Cumulative debt payments of $18.2 million for the period. 4) Purchases of property, plant and equipment of $62.7 million of property, offset by cumulative

depreciation expense of $56.0 million that is included in net income above. The total purchases amount does not include the amount funded from revenue bonds, general obligation bonds, or capital leases.

Given the District’s current average daily operating expense total of $1,661,000, achievement of the Moody’s “A”-rated hospitals’ days cash on hand benchmark of 215.5 would require approximately $76.9 million of additional cash resources. The District’s surplus funds investment portfolio is separated into three different categories including short-term funds, medium-term funds and long-term funds. For the year ended June 30, 2017 the District experienced a total return of 0.71% on funds invested short-term including mainly its investment in the Local Agency Investment Fund (LAIF). The average return for LAIF for the year ended June 30, 2017 was 0.75%. The District’s total return of 0.21% for the same twelve-month period for medium-term investments includes funds held with CalTrust. The CalTrust investment exceeded its benchmark, the ML 1-3 Corp & Government, which was 0.15% for the same period. The CalTrust yields at a higher rate than the LAIF portfolio due to its longer term nature, but the total return was impacted by unrealized losses during the period. The District’s long-term portfolio is managed by PFM Asset Management (PFM) and Wells Capital Management (Wells Cap). The twelve-month total return of the portfolio managed by PFM was 0.00% (net of fees), while the twelve-month total return of the portfolio managed by Wells Cap was 0.15% (net of fees). Both the Wells Cap portfolio and the PFM portfolio performance exceeded the benchmark of (0.08%) for the period. The Wells Cap portfolio outperformed the PFM portfolio for the period mainly due to its larger allocation to asset backed, municipal securities and corporate securities. The benchmark for the managed portfolios is a custom index including 70% of the Merrill Lynch 1-5 year US Treasury Index and 30% of the Merrill Lynch 1-5 year A-AAA Corporate Index. The benchmark does include security types that the District is not allowed to purchase and that because of their nature tend to carry higher yields. These include foreign issuers, foreign agencies, and private placement securities. As of June 30, 2017, the District’s investment portfolio had a weighted average prospective yield of 1.51%. The District’s targeted rate of return of 1.51% was used to project interest income in the District’s Annual Budget for the fiscal year. Both the prospective yield and the targeted rate of return exclude market value fluctuations that are included in the total return figures noted above. Investment Summary by Institution This document depicts the amount of District investments held by various financial institutions as of June 30, 2017. In each case, the financial institution may be the issuer of an investment security, the custodian of securities, or the investment advisor managing the securities.

Investment Summary of Surplus Funds by Type This document depicts the amount of District funds invested into the various categories of investments permitted by the District’s investment policy and the Code, as well as the percentage of total surplus funds invested in each category and the corresponding limitation established by the Code for compliance measurement. Investment Summary of Surplus Funds by Maturity This document depicts the amount of District funds maturing each year over the five-year investment time horizon permitted by the District’s investment policy. The measurement period for each year commences on July 1 and runs to June 30. The purpose of this schedule is to assess the overall liquidity of the District’s portfolio, which has a weighted average maturity of 2.59 years at June 30, 2017. Investment Summary of Surplus Fund’s Unrealized Gains and Losses All investment summaries referenced above include the amortized cost of investments and do not reflect current market values. This document depicts the status of securities with respect to unrealized gains and losses at June 30, 2017. The District measures and records an adjustment to reflect the current fair market value of its total investment portfolio each quarter. The unrealized loss on the District’s surplus fund portfolio at June 30, 2017 was $471,000.

Kaweah Delta Health Care District General Deposit and Investment Policy

Scope

This policy sets forth the deposit and investment policy governing all District funds and related transactions and investment activity. This policy does not apply to the Employer Retirement Plan Trust. Bond proceeds shall be invested in securities permitted by the applicable bond documents. If the bond documents are silent as to the permitted investments, bond proceeds will be invested in the securities permitted by this Policy. Notwithstanding the other provisions of this Policy, the limitations (credit quality, percentage holdings, etc.) listed elsewhere in this Policy do not apply to bond proceeds. With the exception of permitted investment requirements, all other provisions of this policy will apply to the investment of bond proceeds to the degree they do not conflict with the requirements of the applicable bond documents.

Goals and Objectives Legal Compliance: All District deposits and investments shall be in compliance with sections 53600 through 53686 of the California Government Code (Code) for local agencies. This policy sets forth certain additional restrictions which may exceed those imposed by the Code. Prudence: The District Board of Directors (Board) and any persons authorized to make investment decisions on behalf of the District are trustees and therefore fiduciaries subject to the prudent investor standard. When managing District investment activities, a trustee shalt act with care, skill, prudence and diligence under the circumstances then prevailing, including, but not limited to, the general economic conditions and the anticipated needs of the District, that a prudent person acting in a like capacity and familiarity with those matters would use in the conduct of funds of like character and with like aims, to safeguard the principal and maintain the liquidity needs of the District. Goals: In order of priority, trustee goals shall be: 1) Safety - The principal of the portfolio will be preserved by investing in high quality

securities and by maintaining diversification of securities to include various types, issuers and maturities. Investments will be limited to those allowed by the Code as outlined in the permitted investments section below. Due to the complexity of various investment options and the volatility of market conditions, the trustee may seek professional advice in making decisions in order to optimize investment selections.

The trustee will also monitor the ongoing credit rating of selected investments by reference to monthly investment statements and council with investment advisors.

2) Liquidity - The portfolio will be managed to ensure sufficient liquidity to meet routine

and non-routine budgeted cash flow requirements as well as provide for unanticipated cash needs. Based upon these needs, investments with appropriate maturity dates will be selected. Generally, these investments will be held to maturity once purchased unless called by the issuer. Securities may be sold prior to maturity under the following circumstances: 1) A security with declining credit may be sold early to minimize loss of principal. 2) A security trade would improve the quality, yield, or target duration in the portfolio. 3) Liquidity needs of the portfolio require that the security be sold.

3) Rate of Return - The investment portfolio shall be designed with the objective of

attaining a market rate of return throughout budgetary and economic cycles, taking into account the investment risk constraints and liquidity needs. Performance will be measured by the ability to meet the targeted rate of return, which will equal or exceed the average return earned on the District's investment in the State of California Local Agency Investment Funds.

Safekeeping

District investments not purchased directly from the issuer shall be purchased either from an institution licensed by the State as a broker-dealer or from a member of a federally-regulated securities exchange, a national or state-chartered bank, a federal or state association or from a brokerage firm designated as a primary government dealer by the Federal Reserve Bank. Investments purchased in a negotiable, bearer, registered or nonregistered format shall be delivered to the District by book entry, physical delivery or third party custodial agreement. The transfer of securities to the counterparty bank's customer book entry account may be used for book entry delivery. A counterparty bank's trust or separate safekeeping department may be used for the physical delivery of the security if the security is held in the District's name. Authorized Financial Dealers and Institutions: If the District utilizes an external investment adviser, the adviser may be authorized to transact with its own Approved Broker/Dealer List on behalf of the District. In the event that the investment advisor utilizes its own Broker/Dealer List, the advisor will perform due diligence for the brokers/dealers on its Approved List.

Internal Controls: The Chief Financial Officer is responsible for establishing and maintaining an internal control structure designed to ensure that the assets of the District are protected from loss, theft or misuse. The internal control structure shall be designed to provide reasonable assurance that these objectives are met. The concept of reasonable assurance recognizes that (1) the cost of a control should not exceed the benefits likely to be derived and (2) the valuation of costs and benefits requires estimates and judgments by management. Delivery vs. Payment: All trades where applicable will be executed by delivery vs. payment (DVP) to ensure that securities are deposited in an eligible financial institution prior to the release of funds. Securities will be held by a third-party custodian as evidenced by safekeeping receipts.

Ethics and Conflicts of Interest

Officers and employees involved in the investment process shall refrain from personal business activity that could conflict with the proper execution and management of the investment program, or that could impair their ability to make impartial decisions. Employees and investment officials shall disclose any material interests in financial institutions with which they conduct business. They shall further disclose any personal financial/investment positions that could be related to the performance of the investment portfolio. Employees and officers shall refrain from undertaking personal investment transactions with the same individual with whom business is conducted on behalf of the District.

Delegation of Authority

The Board hereby delegates its authority to invest District funds, or to sell or exchange purchased securities, to the Treasurer for a one-year period, who shall thereafter assume full responsibility for those transactions until the delegation of authority is revoked or expires. The Board may renew the delegation of authority each year. The responsibility for day-to-day management (including the investment of funds, and selling or exchanging of purchases securities) of District investments is hereby delegated by the Board,and the Treasurer, to the Chief Financial Officer (CFO).and/or their designee subject to compliance with all reporting requirements and the prudent investor standard. The District may engage the services of one or more external investment managers to assist in the management of the investment portfolio in a manner consistent with the Districts’ objectives. Such external managers will be granted the discretion to purchase and sell investment securities in accordance with the Investment Policy.

Reporting The Treasurer or CFO shall annually submit a statement of investment policy to the Board summarizing the District’s investment activities and demonstrating compliance with this policy and the Code. The Treasurer or CFO shall submit monthly reports to the Board detailing each investment by amount, type, issuer, maturity date, and rate of return, and reporting any other information requested by the Board. The monthly reports shall also summarize all material non-routine investment transactions and demonstrate compliance of the portfolio with this policy and the Code, or delineate the manner in which the portfolio is not in compliance. Any concerns regarding the District’s ability to maintain sufficient liquidity to meet current obligations shall be disclosed in the monthly reports. Performance Standards: The investment portfolio will be managed in accordance with the parameters specified within this policy. The portfolio should obtain a market average rate of return during a market/economic environment of stable interest rates. A series of appropriate benchmarks shall be established against which portfolio performance shall be compared on a regular basis.

Deposits All District deposits shall be maintained in banks having full-service operations in the State of California. Deposits are defined as working funds needed for immediate necessities of the District. Deposits in any depository bank shall not exceed the shareholders' equity of that bank. The Treasurer shall be responsible for the safekeeping of District funds and shall enter into a contract with any qualified depository making the depository responsible for securing the funds deposited. All District deposits shall be secured by eligible securities as defined by section 53651 of the Code and shall have a market value of at least 10 percent in excess of the total amount deposited. The Treasurer may waive security for the portion of any deposits insured pursuant to federal law and any interest which subsequently accrues on federally-insured deposits.

Permitted Investments Sinking funds or surplus funds not required for immediate needs of the District shall be invested in authorized investments as defined in Code section 53601 and may be further limited by this policy. No investment shall be made in any security having a term remaining to maturity exceeding five years at the time of investment unless the Board has granted express authority to make the investment no less than three months prior to the investment. Certain investments are limited by the Code and this policy as to the

percent of surplus funds which may be invested. Investments not expressly limited by the Code or this policy may be made in a manner which maintains reasonable balance between investments in the portfolio. Authorized investments are limited to the following:

(a) Investment in the State of California Local Agency Investment Fund up to the maximum investment allowed by the State.

(b) United States Treasury notes, bonds, bills or certificates of indebtedness, or

those for which the faith and credit of the United States are pledged for the payment of principal and interest.

(c) Registered State warrants or treasury notes or bonds of this State, including

bonds payable solely out of the revenues from a revenue-producing property owned, controlled or operated by the State or a department, board, agency or authority of the State.

(d) Federal agency or United States government-sponsored enterprise obligations,

participations, or other instruments, including those issued by or fully guaranteed as to principal and interest by federal agencies or United States government-sponsored enterprises.

(e) Bills of exchange or time drafts drawn on and accepted by a commercial bank,

otherwise known as bankers' acceptances. Purchases of bankers' acceptances may not exceed 180 days maturity or 40 percent of surplus funds. However, no more than 30 percent of surplus funds may be invested in bankers' acceptances of any one commercial bank.

(f) Commercial paper of prime quality of the highest ranking or of the highest letter

and numerical rating as provided for by a nationally recognized statistical rating organization (NRSRO).. Eligible paper is further limited to issuing corporations organized and operating within the United States and having total assets exceeding five hundred million dollars ($500,000,000) and having an ”A” or higher rating for the issuer's debt, other than commercial paper, if any, as provided for by an NRSRO. Purchases of eligible commercial paper may not exceed 270 days maturity nor represent more than 10 percent of the outstanding paper of an issuing corporation. Purchases of commercial paper may not exceed 25 percent of surplus funds.

(g) Negotiable certificates of deposit issued by a nationally or state-chartered bank, a savings association or a federal association, a state or federal credit union, or by a federally licensed or state-licensed branch of a foreign bank. For purposes of this section, negotiable certificates of deposit do not come within Article 2 (commencing with Section 53630), except that the amount so invested shall be subject to the limitations of Section 53638. The legislative body of a local agency and the treasurer or other official of the local agency having legal custody of the moneys are prohibited from investing local agency funds, or funds in the custody of the local agency, in negotiable certificates of deposit issued by a state or federal credit union if a member of the legislative body of the local agency, or a person with investment decision making authority in the administrative office manager’s office, budget office, auditor-controller’s office, or treasurer’s office of the local agency also serves on the board of directors, or any committee appointed by the board of directors, or the credit committee or the supervisory committee of the state or federal credit union issuing the negotiable certificates of deposit. Purchases of all types of certificates of deposit may not exceed 30 percent of surplus funds.

(h) Investments in repurchase agreements or reverse repurchase agreements of any

securities authorized by this policy when the term of the agreement does not exceed one year. The market value of securities underlying a repurchase agreement shall be valued at 102 percent or greater of the funds borrowed against those securities and the value shall be adjusted no less than quarterly. Reverse repurchase agreements shall meet all conditions and requirements set forth in Code section 53601.

(i) Medium-term notes, defined as all corporate and depository institution debt

securities with a maximum of five years maturity, issued by corporations organized and operating within the United States or by depository institutions licensed by the United States or any state and operating within the United States. Notes eligible for investment shall be rated “A” or its equivalent or better by an NRSRO. Purchases of medium-term notes may not exceed 30 percent of surplus funds.

(j) Any mortgage passthrough security, collateralized mortgage obligation,

mortgage- backed or other pay-through bond, equipment lease-backed certificate, consumer receivable passthrough certificate, or consumer receivable-backed bond of a maximum of five years' maturity issued by an issuer having an “A” or higher rating for the issuer's debt as provided by a nationally-recognized rating service and rated "AA” or its equivalent or better by an NRSRO.

Purchases of collateralized mortgage obligations may not exceed 20 percent of surplus funds.

(k) Shares of beneficial interest issued by diversified management companies that

invest in securities and obligations as authorized by section 53601 or that are money market funds registered with the Securities and Exchange Commission under the Investment Act of 1940, and that have attained the highest ranking or the highest letter and numerical rating provided by not less than two NRSROs. Purchases of shares of beneficial interest may not exceed 20 percent of surplus funds, and no more than 10 percent of surplus funds may be invested in shares of beneficial interest of any one mutual fund.

(I) Bonds issued by Kaweah Delta Health Care District, including bonds payable

solely out of the revenues from a revenue-producing property owned, controlled, or operated by Kaweah Delta Health Care District.

(m) Bonds, notes. warrants, or other evidences of indebtedness of any local agency

within this state, including bonds payable solely out of the revenues from a revenue- producing property owned, controlled, or operated by the local agency, or by a department, board, agency, or authority of the local agency.

(n) Registered treasury notes or bonds of any of the other forty-nine United States in

addition to California, including bonds payable solely out of the revenues from a revenue-producing property owned, controlled, or operated by a state or by a department, board, agency, or authority of any of the other forty-nine United States, in addition to California.

(p) Shares of beneficial interest issued by a joint powers authority (JPA) organized

pursuant to Section 6509.7 that invests in the securities and obligations authorized under Section 53601 subdivisions (a) to (q), inclusive. Each share shall represent an equal proportional interest in the underlying pool of securities owned by the JPA. The JPA issuing the shares shall have retained an investment adviser registered or exempt from registration with the Securities and Exchange Commission, with not less than five years of experience investing in the authorized securities, and having assets under management in excess of five hundred million dollars.

(q) United States dollar denominated senior unsecured unsubordinated obligations

issued or unconditionally guaranteed by the International Bank for

Reconstruction and Development, International Finance Corporation, or Inter-American Development Bank, with a maximum remaining maturity of five years or less, and eligible for purchase and sale within the United States. Investments under this subdivision shall be rated “AA” or better by an NRSRO and shall not exceed 30 percent of surplus funds.

Policy Considerations

This policy shall be reviewed on an annual basis. Any changes must be approved by the Chief Financial Officer and any other appropriate authority, as well as the individual(s) charged with maintaining internal controls.

Kaweah Delta Health Care District STATEMENT OF PURPOSE GUIDELINES

DISTRICT FUNDS Operating Accounts: General operating funds to meet current and future operating obligations. Self-Insurance Trust Fund: Self-insurance fund established for potential settlement of general, professional and public liability claims. All earnings remain in the fund. Disbursements are allowed for payment of claims, legal fees, or by approval of the Board of Directors. Whenever possible, District operating funds or other funds will be used to meet such liabilities. 2006 Revenue Bond Fund: The purpose of this fund is to hold and disburse the District’s 2006 Revenue Bond proceeds for various projects and to hold principal and interest payments made by the District pending disbursement by the trustee bank. 2011 Revenue Bond Fund: The purpose of this fund is to hold and disburse the District’s 2011 Revenue Bond proceeds for various projects and to hold principal and interest payments made by the District pending disbursement by the trustee bank. 2012 Revenue Bond Fund: The purpose of this fund is to hold and disburse the District’s 2012 Revenue Bond proceeds for various projects and to hold principal and interest payments made by the District pending disbursement by the trustee bank. 2015A Revenue Bond Fund: The purpose of this fund is to hold and disburse the District’s 2015A Revenue Bond principal and interest payments made by the District pending disbursement by the trustee bank. 2015B Revenue Bond Fund: The purpose of this fund is to hold and disburse the District’s 2015B Revenue Bond proceeds for various projects and to hold principal and interest payments made by the District pending disbursement by the trustee bank. 2017 Revenue Bond Fund: The purpose of this fund is to hold and disburse the District’s 2017 Revenue Bond principal and interest payments made by the District pending disbursement by the trustee bank. 2014 General Obligation Bond Fund: The purpose of this fund is to hold and disburse the District’s 2014 General Obligation Bond principal and interest payments made by the District pending disbursement by the trustee bank. Plant Fund: The primary purpose of this fund is to retain investments for funded depreciation. In addition, funds for special capital projects and Board-designated projects which may include real property, unbudgeted capital equipment, etc. are retained in the fund. Disbursements are made for such special capital projects and for replacement capital items at the Board’s discretion. Cost Report Settlement Fund: Account established to set aside sufficient funds to settle Federal and State cost reports due to the substantial nature of potential settlements. Development Fund: Accumulated reserves set aside from special projects, activities and memorials to be used as seed money for research, community service, or service development at the specific direction of the Board.

Workers’ Compensation Liability Fund: Funds available for possible settlement or payment of employee work-related medical claims, suits or judgments, or legal fees. Whenever possible, District operating funds or other funds will be used to meet such liabilities. General Obligation Bond Reserve Fund: The purpose of this fund is to hold funds set aside to establish a reserve account in the amount recommended by the County of Tulare.

Kaweah Delta Health Care DistrictSUMMARY OF INVESTMENT FUNDSJune 30, 2017

June 30, December 31, December 31, December 31,2017 2016 2015 2014

Total Surplus Funds $259,430,000 $243,467,000 $218,223,000 $216,537,000

Add: Kaweah Delta Medical Foundation 2,766,000 1,972,000 4,078,000 0Sequoia Regional Cancer Ctr. 54,000 40,000 447,000 566,000KDH Foundation 16,275,000 15,696,000 13,501,000 13,031,000Adjustment to record fair market value (FMV) 1,596,000 463,000 540,000 2,471,000Accrued Investment Earnings 867,000 761,000 670,000 566,000

Adjusted Surplus Funds $280,988,000 $262,399,000 $237,459,000 $233,171,000

Daily Operating Expenses (excludingdepreciation expense ) $1,661,000 $1,648,000 $1,417,000 $1,226,000

Percent Increase 0.8% 16.3% 15.6% -25.6%

Days Cash on Hand (Actual - consolidated financial statements) 169.2 159.2 167.6 190.2

Benchmark:Moody's "A" Rated Hospitals (2016) 215.5Cash spread to "A" rating $76,890,000

Surplus portfolio return (includes FMV adjustment) :12-Months Ended :

Short-Term (LAIF/Operations/CD) 0.71% 0.54% 0.31% 0.22%LAIF 0.75% 0.58% 0.31% 0.25%

Medium-Term (Cal Trust) 0.21% 1.08% 0.59% 0.42%ML 1-3 Corp & Govt (A rated) 0.15% 0.58% 0.31% 0.25%

Long-Term (PFM - net of fees) 0.00% 1.28% 1.10% 1.36%Long-Term (WC - net of fees) 0.15% 1.49% 1.20% 1.59%Benchmark (70% ML 1-5 Treasury, 30% ML US Corp A-AAA) -0.08% 1.42% 1.14% 1.50%

Prospective Yield of Portfolio (No FMV) 1.51% 1.38% 1.32% 1.18%

Fiscal Year Budget (No FMV) 1.51% 1.51% 1.25% 0.92%

Note: All investment balances included in the attached investment summaries are stated at the amortizedcost value and do not reflect current fair market values. Please refer to the Investment Summary of Unrealized Gains and Losses for current market values.

Kaweah Delta Health Care DistrictSUMMARY OF INVESTMENT FUNDSJune 30, 2017

Investment Amount (Cost)December 31,

2016

Trust Accounts

Self-Insurance Trust Fund 6,381,000$ 6,797,000$

2006 Revenue Bond Fund - 109,000

2011 Revenue Bond Fund - 17,000

2012 Revenue Bond Fund 3,983,000 9,670,000

2014 General Obligation Bond Fund 3,252,000 2,943,000

2015A Revenue Bond Fund 96,000 592,000

2015B Revenue Bond Fund 78,382,000 87,216,000

2017 Revenue Bond Fund 103,000 -

Operating Accounts 723,000 3,157,000

Board Designated Funds

Plant FundCommitted for Capital Expenditure $20,200,000Committed for Other Expenditure $3,424,000Uncommitted 208,669,000 232,293,000 212,732,000

General Obligation Bond Reserve 1,947,000 1,762,000

Cost Report Settlement Fund 3,448,000 3,448,000

Development Fund 116,000 127,000

Workers' Compensation Liability Fund 20,903,000 22,241,000

Total Board Designated Funds 258,707,000 240,310,000

Total Investments 351,627,000$ $350,811,000

Kaweah Delta Medical Foundation Funds $2,766,000 $1,972,000

Sequoia Regional Cancer Center Funds $54,000 $40,000

Kaweah Delta Hospital Foundation $16,275,000 $15,696,000

June 30,2017

Kaweah Delta Health Care DistrictINVESTMENT SUMMARY BY INSTITUTIONJune 30, 2017

Investment Amount (Cost)June 30, December 31,

2017 2016

US Bank (Bond Trustee) 82,564,000$ 97,604,000$

Union Bank (Workers Compensation) 162,000 98,000

Local Agency Investment Fund (LAIF) 64,536,000 57,322,000

PFM Asset Management (Manager) - US Bank Custodian 92,082,000 91,380,000

Wells Capital Management (Manager) - US Bank Custodian 81,563,000 70,892,000

Wells Capital Management (SITF) 6,381,000 6,797,000

Cal Trust (Managed by Blackrock) 20,720,000 20,597,000

Bancorp (FSA) 32,000 23,000

West America Bank (Pledged CD) 56,000 55,000

Torrey Pines CD (CD Placement GO Refinance) 3,002,000 3,007,000

Wells Fargo Bank (Operating accounts) 529,000 3,036,000

Total Investments 351,627,000 350,811,000

Less Trust Accounts (92,197,000) (107,344,000)

Total Surplus Funds $259,430,000 $243,467,000


Wells Fargo Bank $2,766,000 $1,972,000

Sequoia Regional Cancer Center

Wells Fargo Bank $54,000 $40,000

Kaweah Delta Hospital Foundation

Central Valley Community Bank $433,000 $1,130,000

Various Short-Term and Long-Term Investments 15,842,000 14,566,000

$16,275,000 $15,696,000

Kaweah Delta Health Care DistrictINVESTMENT SUMMARY OF SURPLUS FUNDS BY TYPEJune 30, 2017

InvestmentAmount $ or %(Cost) % Limit

Certificates of Deposit $19,083,000 7.4% 30.0%

Checking Accounts 723,000 0.3%

Local Agency Investment Fund (LAIF) 61,284,000 23.6% $65 mm

Cal Trust 20,720,000 8.0%

Medium-Term Notes (Corporate) 42,299,000 16.3% 30.0%

U.S. Treasury and Government Agency 88,473,000 34.1%

Municipal Securities 8,800,000 3.4%

Money Market Accounts 804,000 0.3% 20.0%

Commercial Paper 0 0.0% 25.0%

Asset Backed Securities 17,244,000 6.6% 20.0%

Total Surplus Funds $259,430,000 100.0%

Kaweah Delta Health Care DistrictINVESTMENT SUMMARY OF SURPLUS FUNDS BY MATURITYJune 30, 2017

InvestmentAmount(Cost) %

1 Year $95,549,000 36.8%

2 Years 35,094,000 13.5%

3 Years 45,893,000 17.6%

4 Years 46,410,000 17.9%

5 Years 36,484,000 14.1%

Total Surplus Fund Investments 259,430,000$ 100.0%

Weighted Average Maturity 2.59 Years

Kaweah Delta Health Care DistrictINVESTMENT SUMMARY OF SURPLUS FUND'S UNREALIZED GAINS AND LOSSESJune 30, 2017

Description Maturity Par Value Amort Cost Market Value Unrealized

Gain (Loss)

Negotiable Certificate of Deposits:

SKANDIN ENS BANKEN 11/16/2017 2,000,000 2,000,000 1,999,900 (100) HSBC BANK USA NA 11/17/2017 2,000,000 2,000,000 2,001,460 1,460 ROYAL BANK OF CANADA NY 03/09/2018 1,800,000 1,800,000 1,803,276 3,276 CANADIAN IMPERIAL BK 11/30/2018 1,800,000 1,798,999 1,807,542 8,543 NORDEA BANK FINLAND NY 11/30/2018 1,800,000 1,800,000 1,807,542 7,542 SVENSKA HANDELBANKEN NY 01/10/2019 1,800,000 1,800,000 1,795,104 (4,896) BANK OF MONTREAL CHICAGO 02/07/2019 1,200,000 1,200,000 1,206,972 6,972 BANK OF NOVA SCOTIA 04/05/2019 2,000,000 2,000,000 1,998,820 (1,180) SUMITO MTSU BKG CO 05/03/2019 1,625,000 1,625,000 1,625,000 -

16,025,000 16,023,999 16,045,616 21,617

Medium-Term Notes (Corporate):

CREDIT SUISSE NEW YORK 04/27/2018 500,000 499,849 499,965 116 CHARLES SCHWAB CORP 07/25/2018 340,000 339,981 341,744 1,763 HSBC USA INC 09/24/2018 500,000 499,788 504,800 5,012 CITIGROUP INC 09/26/2018 250,000 250,575 251,695 1,120 CITIGROUP INC 12/07/2018 500,000 499,967 500,745 778 JOHN DEERE CAPITAL CORP 01/08/2019 390,000 389,988 391,541 1,552 TOYOTA MOTOR CREDIT CORP 02/19/2019 900,000 899,941 901,071 1,130 AMERICAN HONDA FINANCE 02/22/2019 500,000 499,945 500,560 615 CISCO SYSTEMS INC 03/01/2019 435,000 434,897 438,528 3,631 NBCUNIVERSAL ENTERPRISE 04/15/2019 400,000 399,330 401,396 2,066 RELIANCE STAND LIFE II 04/24/2019 450,000 449,620 452,997 3,377 UNION BANK NA 05/06/2019 500,000 499,593 502,065 2,472 IBM CORP 05/17/2019 875,000 874,792 877,048 2,255 NEW YORK LIFE GLOBAL FDG 06/18/2019 500,000 499,778 502,890 3,112 TOYOTA MOTOR CREDIT CORP 07/18/2019 500,000 499,442 503,470 4,028 MANUF TRADERS TRUST CO 07/25/2019 650,000 649,850 654,401 4,550 AMERICAN HONDA FINANCE 08/15/2019 1,725,000 1,723,627 1,739,645 16,018 PACCAR FINANCIAL CORP 09/15/2019 600,000 599,849 604,110 4,261 BURLINGTON NORTH SANTA FE 10/01/2019 425,000 454,998 451,830 (3,168) PNC BANK NA 10/18/2019 575,000 577,013 580,411 3,398 US BANK NA CINCINNATI 10/28/2019 575,000 576,520 579,278 2,758 GENERAL ELEC CAP CORP 12/11/2019 1,200,000 1,207,562 1,209,516 1,954 GOLDMAN SACHS GROUP INC 12/13/2019 900,000 899,450 902,457 3,007 GENERAL ELEC CAP CORP 01/08/2020 500,000 541,137 544,625 3,488 WELLS FARGO COMPANY 01/30/2020 850,000 853,078 852,185 (894) TOYOTA MOTOR CREDIT CORP 03/12/2020 550,000 552,655 553,146 491 E I DU PONT DE NEMOURS 05/01/2020 500,000 499,480 502,715 3,235 QUALCOMM INC 05/20/2020 150,000 149,991 150,686 694 HOME DEPOT INC 06/05/2020 425,000 424,759 425,196 436 JOHN DEERE CAPITAL CORP 06/22/2020 200,000 199,879 200,522 643 JPMORGAN CHASE CO 06/23/2020 1,000,000 1,003,049 1,016,710 13,661 BB T CORPORATION 06/29/2020 1,280,000 1,278,871 1,301,734 22,863 WELLS FARGO COMPANY 07/22/2020 1,150,000 1,154,042 1,166,215 12,173 STATE STREET CORP 08/18/2020 830,000 828,815 845,587 16,772 AUTOMATIC DATA PROCESSNG 09/15/2020 800,000 799,548 809,896 10,348 GOLDMAN SACHS GROUP INC 09/15/2020 350,000 350,775 354,218 3,443 VISA INC 12/14/2020 700,000 702,663 705,852 3,189 APPLE INC 02/23/2021 615,000 621,834 619,077 (2,757) TEXAS INSTRUMENTS INC 03/12/2021 630,000 643,754 643,123 (631) TEXAS INSTRUMENTS INC 03/12/2021 180,000 183,930 183,749 (180) BANK OF NY MELLON CORP 04/15/2021 900,000 915,904 907,146 (8,758) BANK OF AMERICA CORP 04/19/2021 435,000 434,974 436,927 1,953 MORGAN STANLEY 04/21/2021 750,000 748,967 749,423 456 MORGAN STANLEY 04/21/2021 450,000 452,215 449,654 (2,562) PNC BANK NA 04/29/2021 400,000 395,102 397,544 2,442 AMERICAN EXPRESS CREDIT 05/05/2021 450,000 451,894 449,303 (2,591) BB T CORPORATION 05/10/2021 450,000 449,770 446,490 (3,280) STATE STREET CORP 05/19/2021 245,000 244,189 241,906 (2,284) JPMORGAN CHASE CO 06/07/2021 910,000 908,864 908,280 (583) FIFTH THIRD BANK 06/14/2021 800,000 799,526 797,664 (1,862) RYDER SYSTEM INC 09/01/2021 420,000 419,247 414,645 (4,602) ORACLE CORP 09/15/2021 900,000 899,328 892,089 (7,239) CISCO SYSTEMS INC 09/20/2021 800,000 787,846 790,136 2,290 PEPSICO INC 10/06/2021 1,320,000 1,307,787 1,292,122 (15,665) BOEING CO 10/30/2021 1,000,000 1,001,208 1,007,190 5,982 COMCAST CORP 01/15/2022 450,000 430,561 437,540 6,979



Gain (Loss) BANK OF NY MELLON CORP 02/07/2022 1,000,000 998,031 1,006,990 8,959 MICROSOFT CORP 02/12/2022 450,000 451,976 453,303 1,327 JOHNSON JOHNSON 03/03/2022 500,000 498,730 502,655 3,925 WALT DISNEY COMPANY 03/04/2022 375,000 375,114 377,869 2,755 PNC FUNDING CORP 03/08/2022 494,000 513,268 512,125 (1,143) CITIGROUP INC 04/25/2022 1,000,000 1,004,991 998,420 (6,571) NATIONAL RURAL UTIL COOP 04/25/2022 950,000 949,744 954,437 4,693 UNITED PARCEL SERVICE 05/16/2022 450,000 454,853 451,490 (3,363) COSTCO WHOLESALE CORP 05/18/2022 1,000,000 996,341 997,870 1,529 COCA COLA CO 05/25/2022 500,000 499,030 499,505 475

42,299,000 42,404,075 42,540,116 136,041

Municipal Securities:

RIVERSIDE CNTY CA 09/01/2017 900,000 900,000 901,395 1,395 UNIV OF CALIFORNIA CA 05/15/2018 1,180,000 1,180,000 1,186,537 6,537 SAN DIEGO CNTY CA 07/01/2018 425,000 425,000 426,330 1,330 SAN FRANCISCO CITY CNTY CA 08/01/2018 900,000 900,000 904,041 4,041 INLAND VLY CA 09/01/2018 750,000 750,000 760,538 10,538 OAKLAND CA 09/01/2018 650,000 650,000 655,577 5,577 LOS ANGELES CA 11/01/2018 520,000 520,000 524,878 4,878 NEW JERSEY ECONOMIC 02/15/2019 725,000 685,841 698,973 13,131 CONNECTICUT ST 03/15/2019 500,000 500,602 498,790 (1,812) UNIV OF CALIFORNIA CA 07/01/2019 1,000,000 1,003,239 1,003,650 411 CALIFORNIA ST 04/01/2021 1,250,000 1,268,199 1,268,750 551

8,800,000 8,782,882 8,829,458 46,576

U.S. Treasury and Government Agency:

F N M A 07/20/2018 1,500,000 1,501,440 1,496,970 (4,470) U S TREASURY NOTE 11/15/2018 850,000 850,015 848,938 (1,078) F N M A DEB 11/27/2018 500,000 500,628 501,710 1,082 FEDERAL FARM CREDIT BKS 12/14/2018 700,000 699,817 699,370 (447) U S TREASURY NOTE 01/31/2019 1,100,000 1,098,057 1,096,007 (2,050) U S TREASURY NOTE 01/31/2019 190,000 190,691 190,386 (306) FEDERAL HOME LOAN BKS 03/08/2019 800,000 801,763 800,984 (779) FEDERAL HOME LOAN BKS 03/08/2019 495,000 501,050 498,802 (2,248) U S TREASURY NOTE 04/15/2019 1,535,000 1,534,899 1,521,569 (13,330) U S TREASURY NOTE 05/31/2019 625,000 622,207 626,394 4,187 U S TREASURY NOTE 05/31/2019 1,610,000 1,623,264 1,613,590 (9,674) FEDERAL FARM CREDIT BKS 06/12/2019 750,000 749,167 749,595 428 U S TREASURY NOTE 06/15/2019 2,000,000 2,006,146 1,980,460 (25,686) U S TREASURY NOTE 07/31/2019 300,000 294,376 296,814 2,438 F N M A 08/02/2019 2,250,000 2,247,370 2,222,955 (24,415) FEDERAL HOME LOAN BKS 08/05/2019 2,250,000 2,246,985 2,222,505 (24,480) F N M A 08/28/2019 1,650,000 1,648,139 1,633,880 (14,260) U S TREASURY NOTE 09/15/2019 825,000 825,072 815,298 (9,774) U S TREASURY NOTE 09/30/2019 1,950,000 1,958,824 1,964,021 5,197 FEDERAL HOME LOAN BKS 11/15/2019 1,440,000 1,439,737 1,435,579 (4,158) F N M A 11/26/2019 750,000 752,335 754,155 1,820 U S TREASURY NOTE 11/30/2019 800,000 791,728 791,560 (168) U S TREASURY NOTE 12/31/2019 1,000,000 995,560 991,760 (3,800) U S TREASURY NOTE 01/31/2020 900,000 897,427 894,483 (2,944) U S TREASURY NOTE 02/29/2020 2,325,000 2,307,023 2,309,934 2,911 U S TREASURY NOTE 02/29/2020 945,000 942,430 941,674 (757) U S TREASURY NOTE 03/15/2020 4,000,000 3,997,410 4,012,640 15,230 U S TREASURY NOTE 03/31/2020 700,000 701,429 697,403 (4,026) U S TREASURY NOTE 03/31/2020 998,000 1,006,672 994,297 (12,375) FEDERAL FARM CREDIT BKS 05/08/2020 1,050,000 1,050,112 1,047,039 (3,073) U S TREASURY NOTE 05/31/2020 1,650,000 1,642,485 1,647,558 5,073 U S TREASURY NOTE 06/15/2020 1,000,000 999,180 998,590 (590) U S TREASURY NOTE 07/31/2020 1,375,000 1,392,173 1,392,023 (150) U S TREASURY NOTE 08/31/2020 1,055,000 1,051,380 1,047,583 (3,797) U S TREASURY NOTE 08/31/2020 3,500,000 3,541,076 3,556,315 15,239 U S TREASURY NOTE 09/30/2020 1,900,000 1,900,236 1,885,902 (14,334) U S TREASURY NOTE 10/31/2020 400,000 396,355 396,720 365 U S TREASURY NOTE 10/31/2020 2,875,000 2,912,435 2,887,133 (25,302) U S TREASURY NOTE 11/15/2020 2,655,000 2,777,773 2,740,252 (37,521) U S TREASURY NOTE 11/30/2020 150,000 149,834 149,924 90 U S TREASURY NOTE 11/30/2020 1,950,000 1,990,122 1,972,932 (17,190) U S TREASURY NOTE 12/31/2020 600,000 606,261 601,710 (4,551)



Gain (Loss) U S TREASURY NOTE 12/31/2020 1,525,000 1,581,441 1,561,936 (19,505) FEDERAL HOME LOAN BKS 02/18/2021 980,000 978,409 969,445 (8,964) U S TREASURY NOTE 02/28/2021 700,000 691,495 685,783 (5,712) U S TREASURY NOTE 03/31/2021 935,000 933,474 919,516 (13,958) U S TREASURY NOTE 04/30/2021 875,000 875,874 863,826 (12,048) F N M A 05/06/2021 700,000 697,173 687,645 (9,528) F N M A 05/06/2021 3,650,000 3,660,419 3,585,578 (74,841) U S TREASURY NOTE 05/31/2021 1,750,000 1,801,925 1,767,780 (34,145) U S TREASURY NOTE 06/30/2021 400,000 401,562 390,392 (11,170) FEDERAL HOME LOAN BKS 07/14/2021 1,775,000 1,766,282 1,729,507 (36,775) F N M A 08/17/2021 2,900,000 2,893,468 2,834,866 (58,602) U S TREASURY NOTE 08/31/2021 8,000,000 8,089,546 8,070,320 (19,226) U S TREASURY NOTE 10/31/2021 290,000 279,707 283,272 3,565 U S TREASURY NOTE 11/30/2021 1,160,000 1,152,267 1,156,961 4,693 U S TREASURY NOTE 12/31/2021 1,225,000 1,227,824 1,233,857 6,033 U S TREASURY NOTE 12/31/2021 3,600,000 3,663,587 3,646,260 (17,327) U S TREASURY NOTE 02/28/2022 390,000 388,542 390,472 1,930 F N M A 04/05/2022 920,000 916,055 917,111 1,056 U S TREASURY NOTE 04/30/2022 800,000 802,246 799,848 (2,398)

88,473,000 88,942,379 88,421,785 (520,594)

Asset-backed Securities:

F N M A GTD R E M I C PASS THRU 02/25/2018 203,446 203,879 203,354 (525) F N M A GTD R E M I C PASS THRU 04/25/2018 376,586 377,614 376,183 (1,431) F H L M C MULTICLASS MTG PARTN 07/25/2018 192,440 193,178 192,474 (703) F N M A GTD R E M I C PASS THRU 01/25/2019 425,000 427,114 425,225 (1,889) TOYOTA AUTO RECEIVABLES OWNER TRUS 05/15/2019 586,569 586,562 586,135 (427) CARMAX AUTO OWNER TRUST 08/15/2019 485,890 485,871 485,268 (603) F N M A GTD R E M I C PASS THRU 09/25/2019 820,519 825,216 820,347 (4,869) NISSAN AUTO RECEIVABLES OWNER TRUST10/15/2019 343,383 343,365 342,789 (575) FORD CREDIT AUTO OWNER TRUST 11/15/2019 288,201 288,194 287,803 (390) FORD CREDIT AUTO OWNER TRUST 02/15/2020 492,267 492,233 492,055 (178) NISSAN AUTO RECEIVABLES OWNER TRUST03/16/2020 580,000 579,984 579,200 (785) CHASE ISSUANCE TRUST 04/15/2020 1,100,000 1,099,998 1,099,054 (944) MERCEDES BENZ AUTO LEASE TRUST 04/15/2020 1,200,000 1,199,974 1,201,272 1,298 JOHN DEERE OWNER TRUST 06/15/2020 195,000 194,992 194,132 (860) ALLY AUTO RECEIVABLES TRUST 08/17/2020 320,000 319,983 319,645 (338) HYUNDAI AUTO RECEIVABLES TRUST 09/15/2020 175,000 174,982 174,934 (49) TOYOTA AUTO RECEIVABLES OWNER TRUS 10/15/2020 650,000 649,945 645,827 (4,118) BMW VEHICLE OWNER TRUST 11/25/2020 980,000 979,997 973,522 (6,475) HONDA AUTO RECEIVABLES OWNER TRUST12/18/2020 720,000 719,967 714,161 (5,806) HARLEY DAVIDSON MOTORCYCLE TRUST 01/15/2021 1,100,000 1,099,952 1,094,599 (5,353) TOYOTA AUTO RECEIVABLES OWNER 02/16/2021 225,000 224,977 225,288 311 SMART TRUST 03/15/2021 1,150,000 1,149,800 1,135,931 (13,869) HYUNDAI AUTO RECEIVABLES TRUST 04/15/2021 465,000 464,957 461,145 (3,812) FORD CREDIT AUTO OWNER TRUST 06/15/2021 355,000 354,999 354,737 (262) HONDA AUTO RECEIVABLES OWNER 08/15/2021 900,000 899,922 898,632 (1,290) HYUNDAI AUTO RECEIVABLES TRUST 08/16/2021 430,000 429,969 430,099 130 NISSAN AUTO RECEIVABLES OWNER 08/16/2021 1,050,000 1,049,901 1,051,092 1,191 F H L M C MULTICLASS MTG PARTN 09/15/2021 4,702 4,708 4,937 229 CITIBANK CREDIT CARD ISSUANCE TRUST 11/19/2021 1,100,000 1,099,973 1,099,021 (952) AMERICAN EXPRESS CREDIT ACCOUNT 12/15/2021 330,000 329,961 329,739 (222)

17,244,003 17,252,169 17,198,602 (53,567)

Shares of beneficial interest issued by JPA:

CAL TRUST N/A 20,719,917 20,719,917 20,618,813 (101,104)

Kaweah Delta Health Care DistrictCONSOLIDATED INCOME STATEMENT SUMMARYFiscal Year 2018

Income Statement

Average Equiv Net Mgmt Other Mgmt Daily OP Patient Services Operating Contract Employee Depreciation Interest Services

Census Census Revenue Revenue Revenue Payroll Labor Benefits Expense Expense Expense

July 2017 419 12,156 48,230,073$ 2,211,182$ 4,670,590$ 22,049,818$ 575,620$ 4,914,452$ 1,997,288$ 405,981$ 2,142,677$

August 413 12,720 48,238,183$ 2,569,270$ 5,057,986$ 21,311,920$ 579,900$ 5,657,463$ 1,973,972$ 405,516$ 2,558,509$

September

October

November

December

January

February

March

April

May

June 2018

Year-to-date 416 24,876 96,468,256 4,780,452 9,728,576 43,361,738 1,155,521 10,571,915 3,971,261 811,497 4,701,186

Budget 431 24,771 100,411,293 4,967,304 10,851,359 44,649,173 574,137 12,110,384 5,399,266 980,449 4,875,578

Variance (15) 105 (3,943,037)$ (186,852)$ (1,122,783)$ (1,287,434)$ 581,384$ (1,538,468)$ (1,428,005)$ (168,952)$ (174,392)$

Current month 413 12,720 48,238,183$ 2,569,270$ 5,057,986$ 21,311,920$ 579,900$ 5,657,463$ 1,973,972$ 405,516$ 2,558,509$

Budget 431 12,385 50,205,647 2,483,652 5,425,679 22,324,586 287,068 6,055,192 2,699,633 490,225 2,437,789

Variance (18) 335 (1,967,464)$ 85,618$ (367,694)$ (1,012,666)$ 292,832$ (397,729)$ (725,660)$ (84,708)$ 120,720$


July 2017

August

September

October

November

December

January

February

March

April

May

June 2018

Year-to-date

Budget

Variance

Current month

Budget

Variance

Income Statement

Chargeable Nonchargeable Other TotalPharmacy Supplies Supplies Operating Operating Operating Investment Net Income w/o Net GOBExpense Expense Expense Expense Expense Income Income** GOB, PF & IC Revenue Net Income

2,312,503$ 2,033,632$ 4,013,490$ 11,961,191$ 52,406,654$ 2,705,191$ 406,281$ 3,111,472$ 85,796$ 3,197,268$

2,250,857$ 2,483,328$ 4,170,744$ 12,804,515$ 54,196,725$ 1,668,713$ 372,435$ 2,041,148$ 89,831$ 2,130,979$

4,563,360 4,516,960 8,184,234 24,765,707 106,603,379 4,373,904 778,716 5,152,620 175,627 5,328,247

5,200,356 4,109,156 7,450,532 27,812,351 113,161,381 3,068,575 744,510 3,813,085 178,989 3,992,073

(636,996)$ 407,804$ 733,702$ (3,046,644)$ (6,558,002)$ 1,305,329$ 34,206$ 1,339,535$ (3,361)$ 1,336,174$

2,250,857$ 2,483,328$ 4,170,744$ 12,804,515$ 54,196,725$ 1,668,713$ 372,435$ 2,041,148$ 89,831$ 2,130,979$

2,600,178 2,054,578 3,725,266 13,906,175 56,580,690 1,534,288 372,255 1,906,542 89,494 1,996,037

(349,321)$ 428,750$ 445,478$ (1,101,660)$ (2,383,965)$ 134,425$ 180$ 134,605$ 337$ 134,942$


July 2017

August

September

October

November

December

January

February

March

April

May

June 2018

Year-to-date

Budget

Variance

Current month

Budget

Variance

Payroll Net Patient Net Patient & Contract

Net Revenue Revenue Labor as aOperating Income Gross Deductions Per Cost Per Per Cost Per % of Net pat I/P

Margin w/o GOB Patient from DFR & Adjusted Adjusted Adjusted Adjusted and Other Op I/P Revenue% % Revenue Revenue Bad Debt % Discharge Discharge Patient Day Patient Day Revenue Revenue %

4.9% 5.6% 167,760,145$ 119,530,072$ 71.3% 9,510$ 10,334$ 1,918$ 2,084$ 42.8% 86,669,968$ 51.7%

3.0% 3.6% 174,792,902$ 126,554,719$ 72.4% 8,512$ 9,564$ 1,891$ 2,125$ 41.1% 87,628,074$ 50.1%

3.9% 4.6% 342,553,047 246,084,791 71.8% 8,984 9,927 1,904 2,104 41.9% 174,298,043$ 50.9%

2.6% 3.3% 340,257,019 239,845,726 70.5% 9,842 11,091 1,950 2,198 40.6% 176,536,082 51.9%

2,296,028$ 6,239,065$ 1.3% (858)$ (1,164)$ (46)$ (94)$ 1.3% (2,238,040)$ -1.0%

3.0% 3.6% 174,792,902$ 126,554,719$ 72.4% 8,512$ 9,564$ 1,891$ 2,125$ 41.1% 87,628,074$ 50.1%

2.6% 2.8% 170,128,510 119,922,863 70.5% 9,842 11,091 1,950 2,198 40.3% 88,268,041 51.9%

4,664,392$ 6,631,856$ 1.9% (1,330)$ (1,528)$ (59)$ (74)$ 0.8% (639,967)$ -1.8%


July 2017

August

September

October

November

December

January

February

March

April

May

June 2018

Year-to-date

Budget

Variance

Current month

Budget

Variance

Average FTEs perO/P Daily Adjusted

O/P Revenue I/P Occupied Acute Days in Days in Days Cash Total Revenue % Revenue Bed ALOS A/R (Net) A/R (Gross) on Hand Surplus Cash

81,090,177$ 48.3% 6,671$ 4.77 4.82 60.01 57.35 164.41 267,353,335$

87,164,827$ 49.9% 6,852$ 4.61 4.53 64.26 59.84 155.09 256,733,495$

168,255,005$ 49.1% 6,761$ 4.69 4.67

163,720,937 48.1% 6,610

4,534,068$ 1.0% 151$

87,164,827$ 49.9%

81,860,468 48.1%

5,304,359$ 1.8%

Supplemental Information for the Income StatementFor the fiscal year ending June 30, 2018

July August TotalIncreases to Net Revenue:

Intergovernmental TransfersMedi-Cal FFS 608,333$ 608,333$ 1,216,667$ Medi-Cal Managed Care 383,333 383,333 766,667

Medi-Cal Quality Assurance Funds 1,116,667 1,116,667 2,233,333

Medi-Cal DSH Funds 547,500 547,500 1,095,000

Medi-Cal Outpatient Supplemental Funds 108,990 62,282 171,272

Medi-Cal SNF Supplemental Funds - - -

Incentive Payment for Medi-Cal Program - - -

Total Increases 2,764,823 2,718,115 5,482,939

Decreases to Net Revenue:Value Based Purchasing Adjustment (9,564) (10,891) (20,455)

Medicare Readmission Adjustment - - -

Medicare DSH cuts effective 10/1/2013 42,364 23,972 66,336

Changes in RAC Allowance (76,359) 21,088 (55,271)

Total Decreases (43,560) 34,169 (9,390)


July August TotalNet impact on net revenue 2,721,264$ 2,752,285$ 5,473,548$

RAC Receivable BalanceBeginning Receivable Balance 12,819,841$ 4,511,781$

Additional RAC Denials (8,308,060) (6,873) 4,511,781 4,504,908

Beginning Allowance 4,126,937 4,050,578 Increases/Decreases to allowance (76,359) 21,088

4,050,578 4,071,666

Ending Receivable Balance (net of allowance) 461,203$ 433,242$

Acute Inpatient Payor MixMedicare 36.6% 39.8% 39.4%Medicare Managed Care 8.8% 7.2% 7.9%Medi-Cal FFS 8.8% 9.2% 8.7%Medi-Cal Managed Care 29.9% 27.3% 27.9%Charity 0.0% 0.3% 0.2%Indemnity 1.4% 2.5% 2.0%Managed 13.5% 13.3% 13.3%Other 0.9% 0.3% 0.5%

100% 100% 100.0%

Surgical Cases Inpatient 296 335 631 Outpatient 409 544 953 Cardiac 39 39 78


July August Total Robotic 25 14 39

769 932 1,701

Cardiac Cath Volumes Inpatient 539 589 1,129 Outpatient 463 735 1,197

1,002 1,324 2,326

ED Visits 7,531 7,536 15,067

Urgent Care and Sequoia Prompt Care Visits 6,797 7,528 14,325

Rural Health Clinic Visits 11,346 9,825 21,171

OB Deliveries 425 432 857

Percentage of Gross Revenue Inpatient 53.2% 51.7% Outpatient 46.8% 48.3%


STATEMENT OF REVENUE AND EXPENSESFISCAL YEAR 2018

August Year To DateFY18 FY17 $ Change % Change FY18 FY17 $ Change % Change

OPERATING REVENUE:Net patient service revenue 48,238,183$ 45,380,939$ 2,857,244$ 6.3% 96,468,256$ 90,139,892$ 6,328,363$ 7.0%Other operating revenue 7,627,255 5,880,100 1,747,155 29.7% 14,509,028 12,900,494 1,608,534 12.5%

Total operating revenue 55,865,438 51,261,038 4,604,399 9.0% 110,977,283 103,040,386 7,936,897 7.7%

OPERATING EXPENSES:Salaries and wages 21,311,920 21,096,561 215,359 1.0% 43,361,738 42,412,029 949,709 2.2%Employee benefits 5,657,463 6,752,475 (1,095,012) -16.2% 10,571,915 11,519,531 (947,615) -8.2%

Total employment expenses 26,969,383 27,849,036 (879,653) -3.2% 53,933,654 53,931,560 2,094 0.0%

Medical and other supplies 8,904,929 7,921,443 983,486 12.4% 17,264,554 15,958,271 1,306,282 8.2%Medical and other fees 6,468,011 6,368,778 99,233 1.6% 12,403,976 12,308,321 95,654 0.8%Purchased services 3,068,395 2,222,846 845,549 38.0% 5,799,210 4,946,195 853,015 17.2%Repairs and maintenance 1,831,262 1,879,526 (48,264) -2.6% 3,835,268 4,092,233 (256,965) -6.3%Utilities 513,388 502,831 10,557 2.1% 1,038,207 1,006,616 31,592 3.1%Rents and leases 487,145 427,335 59,810 14.0% 938,715 855,818 82,897 9.7%Depreciation and amortization 1,973,972 1,878,556 95,417 5.1% 3,971,261 3,777,449 193,812 5.1%Interest Expense 405,516 456,908 (51,391) -11.2% 811,497 908,338 (96,840) -10.7%Other Expenses 1,016,214 1,082,717 (66,503) -6.1% 1,905,852 2,275,370 (369,518) -16.2%Management Services Expenses 2,558,509 2,264,506 294,003 13.0% 4,701,186 4,125,068 576,118 14.0%

Total operating expenses 54,196,725 52,854,482 1,342,243 2.5% 106,603,379 104,185,239 2,418,140 2.3%

OPERATING MARGIN 1,668,713 (1,593,443) 3,262,156 -204.7% 4,373,904 (1,144,853) 5,518,757 -482.0%

NONOPERATING REVENUE:Incentive Compensation - - - - - Provider Fee Revenue - Investment Income 372,435 425,722 (53,287) -12.5% 778,716 727,609 51,107 7.0%Net GOB Revenue 89,831 84,747 5,084 6.0% 175,627 165,794 9,833 5.9%

Total nonoperating revenue 462,266 510,469 (48,203) -9.4% 954,343 893,403 60,940 6.8%

EXCESS MARGIN 2,130,979$ (1,082,974)$ 3,213,953$ -296.8% 5,328,247$ (251,449)$ 5,579,697$ -2219.0%

Kaweah Delta Health Care DistrictKaweah Delta Health Care District

(3.0%)(2.0%)(1.0%)

0.0%1.0%2.0%

3.0%4.0%5.0%6.0%7.0%8.0%

9.0% EXCESS MARGIN

FY 2018 FY 2017 Budget Benchmark FY 2018 YTD Avg

(4.0%)(3.0%)(2.0%)(1.0%)

0.0%1.0%2.0%3.0%4.0%5.0%6.0%7.0%8.0%9.0%

10.0%OPERATING MARGIN


340

350

360

370

380

390

400

410

420

430

440

450

AVERAGE DAILY CENSUS

FY 2018 FY 2017 Budget FY 2018 YTD Avg

Kaweah Delta Health Care District

$1,700

$1,800

$1,900

$2,000

$2,100

$2,200

$2,300

$2,400

$2,500NET PATIENT REVENUE PER ADJ PATIENT DAY


$1,700

$1,800

$1,900

$2,000

$2,100

$2,200

$2,300

$2,400

$2,500

$2,600 COST PER ADJUSTED PATIENT DAY


4.3

4.4

4.5

4.6

4.7

4.8

4.9

5.0

5.1

5.2

5.3 FTEs PER ADJUSTED OCCUPIED BED




1.20

1.25

1.30

1.35

1.40

1.45

1.50

1.55

1.60CASE-MIX INDEX WITHOUT NORMAL NEWBORNS

FY 2018 FY 2017 FY 2018 YTD Avg

35.00

40.00

45.00

50.00

55.00

60.00

65.00

70.00

75.00 NET DAYS IN ACCOUNTS RECEIVABLE

FY 2018 FY 2017 Benchmark FY 2018 YTD Avg

130.00140.00150.00160.00170.00180.00190.00200.00210.00220.00230.00240.00 DAYS CASH ON HAND



0.0%5.0%

10.0%

15.0%20.0%

25.0%30.0%

35.0%40.0%

45.0%50.0%

55.0%

60.0%

Current 31 - 60 61 - 90 91 - 120 121 - 150 151 +

GROSS ACCOUNTS RECEIVABLE AGING

30-Sep 31-Dec 31-Mar 30-Jun

1,600,0001,650,0001,700,0001,750,0001,800,0001,850,0001,900,0001,950,0002,000,0002,050,0002,100,0002,150,0002,200,0002,250,0002,300,0002,350,0002,400,0002,450,0002,500,000

AVERAGE DAILY COLLECTIONS

FY 2018 FY 2017 FY 2018 YTD Avg

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

105.00%

110.00%

115.00%

120.00%

125.00%

CASH TO NET REVENUE REALIZATION

FY 2018 FY 2017 FY 2018 YTD Avg


13.00%

14.00%

15.00%

16.00%

17.00%

18.00%

19.00%

20.00%

21.00%

22.00%SUPPLIES COST AS A PERCENTAGE OF OPERATING REVENUE


35.00%

40.00%

45.00%

50.00%

55.00%

60.00%

65.00%

SALARIES & CONTRACT LABOR AS A % OF TOTAL OPERATING REVENUE


KAWEAH DELTA HEALTH CARE DISTRICTRATIO ANALYSIS REPORT

AUGUST 31, 2017

June 30,Current Prior 2017 2016 Moody'sMonth Month Unaudited Median BenchmarkValue Value Value Aa A Baa

LIQUIDITY RATIOS

Current Ratio (x) 2.4 2.2 2.1 1.5 2.0 2.3

Accounts Receivable (days) 64.1 60.0 59.4 49.6 48.1 44.3

Cash On Hand (days) 155.1 164.4 158.8 264.6 215.5 157.6

Cushion Ratio (x) 17.1 17.7 17.4 32.4 22.2 13.4

Average Payment Period (days) 46.2 45.4 46.7 76.7 61.2 59.5

CAPITAL STRUCTURE RATIOS

Cash-to-Debt 107.0% 111.3% 109.6% 225.6% 160.6% 112.1%

Debt-To-Capitalization 35.3% 35.4% 35.6% 27.6% 33.9% 43.5%

Debt-to-Cash Flow (x) 4.1 3.7 5.3 2.3 2.7 3.6

Debt Service Coverage 3.7 4.1 2.8 7.1 5.5 3.3

Maximum Annual Debt Service Coverage (x) 3.6 4.0 2.8 6.4 5.0 3.5

Age Of Plant (years) 13.7 13.5 13.5 10.1 11.4 11.8

PROFITABILITY RATIOS

Operating Margin 3.9% 4.9% 2.3% 4.0% 3.2% 1.1%

Excess Margin 4.6% 5.6% 2.6% 7.5% 6.1% 3.4%

Operating Cash Flow Margin 8.3% 9.3% 6.7% 9.7% 10.0% 7.8%

Return on Assets 3.6% 4.4% 2.1% 5.4% 4.6% 2.8%

*For Moody's Reporting Purposes, bad debt is reflected as an operating expense

KAWEAH DELTA HEALTH CARE DISTRICTBALANCE SHEETAUGUST 31, 2017

CurrentPeriod June 30, 2017

ASSETS AND DEFERRED OUTFLOWS (Unaudited)

CURRENT ASSETS

Cash and cash equivalents 10,235,883$ 3,992,275$ Accounts receivable: Patient accounts, less allowance for doubtful accounts 98,956,464 92,049,996 Other receivables 19,376,769 20,986,105

118,333,233 113,036,101

Medicare and Medi-Cal settlements 32,130,733 25,947,397 Inventories 7,870,219 8,168,590 Prepaid expenses 9,177,038 8,375,461 Current portion of assets whose use is limited 12,569,872 12,147,686

190,316,978 171,667,510

ASSETS WHOSE USE IS LIMITED, less current portion

Board designated cash and assets 257,675,771 269,913,339 Revenue bond assets held in trust 79,585,247 81,830,759 Assets in self-insurance trust fund 5,647,060 5,642,575

342,908,078 357,386,673

CAPITAL ASSETS

Land 15,758,181 15,758,181 Buildings and improvements 322,424,026 322,412,653 Equipment 193,657,699 193,438,466 Construction in progress 51,965,528 47,257,437

583,805,434 578,866,737

Less accumulated depreciation 290,038,296 286,440,763293,767,138 292,425,974

Property under capital leases, less accumulated amortization 7,142,984 7,485,184

300,910,122 299,911,158

OTHER ASSETS

Property not used in operations 3,413,370 3,420,518 Health-related investments 3,263,017 3,342,533 Other 6,909,836 7,002,445

13,586,223 13,765,496

DEFERRED OUTFLOWS 12,664,521 12,719,424

860,385,922$ 855,450,261$

KAWEAH DELTA HEALTH CARE DISTRICTBALANCE SHEETAUGUST 31, 2017


LIABILITIES AND NET ASSETS (Unaudited)

CURRENT LIABILITIES

Accounts payable and accrued expenses 26,304,514$ 31,349,099$ Accrued payroll and related liabilities 44,879,535 39,858,647 Long-term debt, current portion 8,291,021 8,180,021

79,475,070 79,387,767

LONG-TERM DEBT, less current portion Bonds payable 258,516,894 259,960,479 Capital leases 16,432,220 16,870,609

274,949,114 276,831,088

NET PENSION LIABILITY 51,852,454 51,749,371

OTHER LONG-TERM LIABILITIES 26,389,230 25,235,748

NET ASSETS

Unrestricted 295,873,502 291,811,158 Invested in capital assets, net of related debt 100,434,971 99,956,382 Restricted 31,411,581 30,478,747

427,720,054 422,246,287

860,385,922$ 855,450,261$

KAWEAH DELTA HEALTH CARE DISTRICTSUMMARY OF FUNDS

August 31, 2017

Maturity Investment G/LBoard designated funds Date Yield Type Account Amount Total

LAIF 1.08 Various 48,058,860 Cal Trust 1.45 Cal Trust 20,792,024 Wells Cap 0.02 Money market 98,003 PFM 0.02 Money market 1,154,024 PFM 15-Mar-20 1.57 ABS Ally Auto 320,000 PFM 15-Dec-21 1.75 ABS Ally Auto 360,000 PFM 5-May-21 2.25 MTN-C American Express 450,000 PFM 15-Dec-21 1.65 ABS American Express 330,000 PFM 15-Aug-19 2.25 MTN-C American Honda Mtn 1,305,000 PFM 20-Jul-20 2.00 MTN-C American Honda Mtn 420,000 PFM 7-Feb-19 1.88 CD Bank of CD 1,200,000 PFM 5-Apr-19 1.91 CD Bank of Nova 2,000,000 PFM 15-Apr-21 2.50 MTN-C Bank of NY 900,000 PFM 10-May-21 2.05 MTN-C BB T Corp 450,000 PFM 1-Oct-19 4.70 MTN-C Burlington North 425,000 PFM 30-Nov-18 1.76 CD Canadian C D 1,800,000 PFM 15-Nov-19 1.17 ABS Carmax Auto 384,264 PFM 20-Sep-21 1.85 MTN-C Cisco Systems Inc 800,000 PFM 25-Apr-22 2.75 MTN-C Citigroup 1,000,000 PFM 15-Jan-22 1.63 MTN-C Comcast Corp 450,000 PFM 15-Mar-19 1.97 Municipal Connecticut ST 500,000 PFM 5-Aug-19 0.88 U.S. Govt Agency FHLB 2,250,000 PFM 15-Nov-19 1.38 U.S. Govt Agency FHLB 1,440,000 PFM 14-Jul-21 1.13 U.S. Govt Agency FHLB 1,775,000 PFM 25-Jul-18 1.63 ABS FHLMC 163,638 PFM 15-Sep-21 6.72 ABS FHLMC 4,390 PFM 25-Feb-18 1.63 ABS FNMA 167,813 PFM 25-Apr-18 1.55 ABS FNMA 291,993 PFM 25-Jan-19 1.90 ABS FNMA 344,671 PFM 2-Aug-19 0.88 U.S. Govt Agency FNMA 1,000,000 PFM 28-Aug-19 1.00 U.S. Govt Agency FNMA 1,650,000 PFM 25-Sep-19 1.65 ABS FNMA 757,285 PFM 26-Nov-19 1.75 U.S. Govt Agency FNMA 750,000 PFM 6-May-21 1.25 U.S. Govt Agency FNMA 3,650,000 PFM 15-Nov-19 1.16 ABS Ford Credit Auto 238,631 PFM 15-Feb-20 1.41 ABS Ford Credit Auto 421,320 PFM 15-Jun-21 1.67 ABS Ford Credit Auto 355,000 PFM 8-Jan-20 5.50 MTN-C General Electric Cap 500,000 PFM 13-Dec-19 2.30 MTN-C Goldman Sachs 900,000 PFM 5-Jun-20 1.80 MTN-C Home Depot Inc 425,000 PFM 15-Aug-21 1.87 ABS Honda Auto 900,000 PFM 15-Sep-20 1.56 ABS Hyundai Auto 175,000 PFM 15-Apr-21 1.29 ABS Hyundai Auto 465,000 PFM 16-Aug-21 1.76 ABS Hyundai Auto 430,000 PFM 17-May-19 1.80 MTN-C IBM 875,000 PFM 15-Jun-20 1.25 ABS John Deere 195,000 PFM 22-Jun-20 1.95 MTN-C John Deere 200,000 PFM 15-Oct-21 1.82 ABS John Deere 340,000 PFM 23-Jun-20 1.41 MTN-C JP Morgan 1,000,000 PFM 12-Feb-22 2.38 MTN-C Microsoft Corp 450,000 PFM 21-Apr-21 2.50 MTN-C Morgan Stanley 450,000 PFM 15-Oct-19 1.15 ABS Nissan Auto 283,301 PFM 16-Mar-20 1.51 ABS Nissan Auto 509,881 PFM 30-Nov-18 1.76 CD Nordea Bank 1,800,000 PFM 15-Sep-21 1.90 MTN-C Oracle Corp 900,000 PFM 6-Oct-21 1.70 MTN-C Pepsico Inc 1,320,000 PFM 8-Mar-22 3.30 MTN-C PNC Funding Corp 494,000 PFM 9-Mar-18 1.70 CD Royal Bank CD 1,800,000 PFM 2-Aug-19 1.84 CD Skandin Ens CD 2,000,000 PFM 19-May-21 1.95 MTN-C State Street Corp 245,000 PFM 3-May-19 2.05 CD Sumito MTSU 1,625,000 PFM 10-Jan-19 1.89 CD Svenska NY CD 1,800,000 PFM 12-Mar-21 2.75 MTN-C Texas Instruments 180,000 PFM 15-May-19 1.27 ABS Toyota Auto Recvs 471,353 PFM 16-Feb-21 1.73 ABS Toyota Auto Recvs 225,000 PFM 15-Nov-21 2.00 ABS Toyota Auto Recvs 250,000 PFM 12-Mar-20 2.15 MTN-C Toyota Motor 550,000 PFM 16-May-22 2.35 MTN-C United Parcel 450,000 PFM 15-May-18 2.05 Municipal Univ of CA 1,180,000 PFM 24-May-21 4.13 MTN-C US Bancorp 900,000 PFM 3-Aug-20 2.05 CD Westpac Bking CD 1,570,000 PFM 4-Sep-20 1.63 MTN-C Intl BK 1,250,000 PFM 29-Feb-20 1.25 U.S. Govt Agency US Treasury Bill 2,325,000 PFM 31-Mar-20 1.38 U.S. Govt Agency US Treasury Bill 998,000 PFM 31-Jul-20 2.00 U.S. Govt Agency US Treasury Bill 1,375,000 PFM 31-Aug-20 2.13 U.S. Govt Agency US Treasury Bill 3,500,000 PFM 31-Oct-20 1.75 U.S. Govt Agency US Treasury Bill 2,875,000 PFM 15-Nov-20 2.63 U.S. Govt Agency US Treasury Bill 2,655,000 PFM 30-Nov-20 2.00 U.S. Govt Agency US Treasury Bill 1,950,000 PFM 31-Dec-20 2.38 U.S. Govt Agency US Treasury Bill 1,525,000 PFM 31-May-21 2.00 U.S. Govt Agency US Treasury Bill 1,750,000 PFM 31-Aug-21 2.00 U.S. Govt Agency US Treasury Bill 2,250,000 PFM 31-Aug-21 2.00 U.S. Govt Agency US Treasury Bill 5,750,000 PFM 31-Oct-21 1.25 U.S. Govt Agency US Treasury Bill 290,000 PFM 31-Dec-21 2.13 U.S. Govt Agency US Treasury Bill 3,600,000 PFM 28-Feb-22 1.75 U.S. Govt Agency US Treasury Bill 500,000 PFM 31-Oct-21 2.00 U.S. Govt Agency US Treasury Bill 2,000,000 PFM 4-Mar-22 2.45 MTN-C Walt Disney Co 375,000 PFM 30-Jan-20 2.15 MTN-C Wells Fargo Company 850,000 PFM 22-Jul-20 1.41 MTN-C Wells Fargo Company 1,150,000 Torrey Pines Bank 5-Mar-18 0.30 CD Torrey Pines Bank 3,002,269 Wells Cap 22-Feb-19 1.70 MTN-C American Honda Mtn 500,000 Wells Cap 23-Feb-21 2.25 MTN-C Apple, Inc 615,000 Wells Cap 15-Sep-20 2.25 MTN-C Automatic Data 800,000 Wells Cap 19-Apr-21 2.63 MTN-C Bank of America 435,000 Wells Cap 7-Feb-22 2.60 MTN-C Bank of NY 1,000,000 Wells Cap 29-Jun-20 2.63 MTN-C BB T Corp 1,280,000 Wells Cap 25-Nov-20 1.16 ABS BMW Vehicle Owner 980,000 Wells Cap 30-Oct-21 2.35 MTN-C Boeing Co 1,000,000 Wells Cap 1-Apr-21 2.63 Municipal California ST High 1,250,000 Wells Cap 25-Jul-18 2.20 MTN-C Charles Schwab 340,000 Wells Cap 15-Apr-20 1.35 ABS Chase Issuance 1,100,000 Wells Cap 1-Mar-19 2.13 MTN-C Cisco Systems Inc 435,000 Wells Cap 19-Nov-21 0.00 ABS Citibank Credit 1,100,000 Wells Cap 26-Sep-18 2.50 MTN-C Citigroup 250,000 Wells Cap 7-Dec-18 2.05 MTN-C Citigroup 500,000 Wells Cap 25-May-22 2.20 MTN-C Coca Cola Co 500,000 Wells Cap 18-May-22 2.30 MTN-C Costco Wholesale 1,000,000 Wells Cap 27-Apr-18 1.70 MTN-C Credit Suisse 500,000 Wells Cap 1-May-20 2.20 MTN-C E I DU PONT DE 500,000 Wells Cap 14-Dec-18 1.30 U.S. Govt Agency FFCB 700,000 Wells Cap 12-Jun-19 1.38 U.S. Govt Agency FFCB 750,000 Wells Cap 8-May-20 1.55 U.S. Govt Agency FFCB 1,050,000 Wells Cap 8-Mar-19 1.88 U.S. Govt Agency FHLB 495,000 Wells Cap 8-Mar-19 1.50 U.S. Govt Agency FHLB 800,000


August 31, 2017

Wells Cap 18-Feb-21 1.38 U.S. Govt Agency FHLB 980,000 Wells Cap 14-Jun-21 2.25 MTN-C Fifth Third Bank 800,000 Wells Cap 20-Jul-18 1.13 U.S. Govt Agency FNMA 300,000 Wells Cap 27-Nov-18 1.63 U.S. Govt Agency FNMA 500,000 Wells Cap 6-May-21 1.25 U.S. Govt Agency FNMA 700,000 Wells Cap 17-Aug-21 1.25 U.S. Govt Agency FNMA 1,400,000 Wells Cap 17-Aug-21 1.25 U.S. Govt Agency FNMA 1,500,000 Wells Cap 5-Apr-22 1.88 U.S. Govt Agency FNMA 920,000 Wells Cap 11-Dec-19 2.10 MTN-C General Electric Cap 1,200,000 Wells Cap 15-Sep-20 2.75 MTN-C Goldman Sachs 350,000 Wells Cap 15-Jan-21 1.34 ABS Harley Davidson 1,100,000 Wells Cap 18-Dec-20 1.47 ABS Honda Auto 720,000 Wells Cap 24-Sep-18 2.63 MTN-C HSBC USA Inc 500,000 Wells Cap 1-Sep-18 2.75 Municipal Inland Valley 750,000 Wells Cap 8-Jan-19 1.95 MTN-C John Deere 390,000 Wells Cap 3-Mar-22 2.25 MTN-C Johnson Johnson 500,000 Wells Cap 7-Jun-21 2.40 MTN-C JP Morgan 910,000 Wells Cap 1-Nov-18 2.34 Municipal Los Angeles, CA Muni 520,000 Wells Cap 25-Jul-19 2.25 MTN-C Manuf Traders Trust 650,000 Wells Cap 15-Apr-20 1.79 ABS Mercedes Benz Auto 1,200,000 Wells Cap 21-Apr-21 2.50 MTN-C Morgan Stanley 750,000 Wells Cap 25-Apr-22 2.40 MTN-C National Rural 950,000 Wells Cap 15-Apr-19 1.97 MTN-C NBC Universal 400,000 Wells Cap 15-Feb-19 1.09 Municipal New Jersey Economic 725,000 Wells Cap 18-Jun-19 2.15 MTN-C New York Life Mtn 500,000 Wells Cap 16-Aug-21 1.74 ABS Nissan Auto 1,050,000 Wells Cap 1-Sep-18 2.19 Municipal Oakland Ca 650,000 Wells Cap 15-Sep-19 2.20 MTN-C Paccar Fin Corp 600,000 Wells Cap 18-Oct-19 2.40 MTN-C PNC Bank 575,000 Wells Cap 29-Apr-21 2.15 MTN-C PNC Bank 400,000 Wells Cap 20-May-20 2.10 MTN-C Qualcomm Inc. 150,000 Wells Cap 29-Apr-19 2.50 MTN-C Reliance Stand Mtn 450,000 Wells Cap 1-Sep-17 2.19 Municipal Riverside County 900,000 Wells Cap 1-Sep-21 2.25 MTN-C Ryder System Inc 420,000 Wells Cap 1-Apr-21 3.54 Municipal Sacramento Ca Public 1,200,000 Wells Cap 1-Jul-18 2.54 Municipal San Diego Cnty 425,000 Wells Cap 1-Aug-18 2.12 Municipal San Francisco 900,000 Wells Cap 15-Mar-21 1.71 ABS Smart Trust 1,150,000 Wells Cap 18-Aug-20 2.55 MTN-C State Street Corp 830,000 Wells Cap 12-Mar-21 2.75 MTN-C Texas Instruments 630,000 Wells Cap 15-Oct-20 1.23 ABS Toyota Auto 650,000 Wells Cap 18-Jul-19 2.13 MTN-C Toyota Motor 500,000 Wells Cap 6-May-19 2.25 MTN-C Union Bank 500,000 Wells Cap 1-Jul-19 1.80 Municipal Univ California Ca 1,000,000 Wells Cap 28-Oct-19 2.13 MTN-C US Bank Na Mtn 575,000 Wells Cap 15-Nov-18 1.00 U.S. Govt Agency US Treasury Bill 240,000 Wells Cap 31-Jan-19 1.50 U.S. Govt Agency US Treasury Bill 190,000 Wells Cap 31-Jan-19 1.13 U.S. Govt Agency US Treasury Bill 1,100,000 Wells Cap 15-Apr-19 0.88 U.S. Govt Agency US Treasury Bill 1,535,000 Wells Cap 31-May-19 1.50 U.S. Govt Agency US Treasury Bill 625,000 Wells Cap 15-Jun-19 1.00 U.S. Govt Agency US Treasury Bill 2,000,000 Wells Cap 31-Jul-19 0.88 U.S. Govt Agency US Treasury Bill 300,000 Wells Cap 15-Sep-19 0.88 U.S. Govt Agency US Treasury Bill 825,000 Wells Cap 30-Sep-19 1.75 U.S. Govt Agency US Treasury Bill 1,950,000 Wells Cap 31-Dec-19 1.13 U.S. Govt Agency US Treasury Bill 1,000,000 Wells Cap 31-Jan-20 1.25 U.S. Govt Agency US Treasury Bill 900,000 Wells Cap 29-Feb-20 1.38 U.S. Govt Agency US Treasury Bill 945,000 Wells Cap 15-Mar-20 1.50 U.S. Govt Agency US Treasury Bill 4,000,000 Wells Cap 31-Mar-20 1.38 U.S. Govt Agency US Treasury Bill 700,000 Wells Cap 31-May-20 1.50 U.S. Govt Agency US Treasury Bill 1,650,000 Wells Cap 15-Jun-20 1.50 U.S. Govt Agency US Treasury Bill 1,000,000 Wells Cap 31-Aug-20 1.38 U.S. Govt Agency US Treasury Bill 1,055,000 Wells Cap 30-Sep-20 1.38 U.S. Govt Agency US Treasury Bill 400,000 Wells Cap 30-Sep-20 1.50 U.S. Govt Agency US Treasury Bill 1,500,000 Wells Cap 31-Oct-20 1.25 U.S. Govt Agency US Treasury Bill 400,000 Wells Cap 30-Nov-20 1.63 U.S. Govt Agency US Treasury Bill 150,000 Wells Cap 31-Dec-20 1.63 U.S. Govt Agency US Treasury Bill 600,000 Wells Cap 28-Feb-21 1.13 U.S. Govt Agency US Treasury Bill 700,000 Wells Cap 31-Mar-21 1.25 U.S. Govt Agency US Treasury Bill 935,000 Wells Cap 30-Apr-21 1.38 U.S. Govt Agency US Treasury Bill 875,000 Wells Cap 30-Jun-21 1.00 U.S. Govt Agency US Treasury Bill 400,000 Wells Cap 30-Nov-21 1.75 U.S. Govt Agency US Treasury Bill 1,160,000 Wells Cap 31-Dec-21 2.00 U.S. Govt Agency US Treasury Bill 1,225,000 Wells Cap 28-Feb-22 1.88 U.S. Govt Agency US Treasury Bill 390,000 Wells Cap 30-Apr-22 1.88 U.S. Govt Agency US Treasury Bill 800,000 Wells Cap 30-Jun-22 1.75 U.S. Govt Agency US Treasury Bill 660,000 Wells Cap 14-Dec-20 2.20 MTN-C Visa Inc 700,000 West America Bank 24-Feb-18 0.16 CD West America Bank 55,652

245,901,372$


August 31, 2017

Maturity Investment G/L Date Yield Type Account Amount Total

Self-insurance trust

Wells Cap Money market 110900 748,243Wells Cap Fixed income - L/T 152300 5,628,788

6,377,031

2012 revenue bondsUS Bank Project fund 152438 2,294,149 US Bank Principal/Interest payment fund 142112 1,510,949

3,805,098

2015A revenue bondsUS Bank Principal/Interest payment fund 142115 286,825

286,8252015B revenue bondsUS Bank Principal/Interest payment fund 142116 1,035,590 US Bank Project Fund 152442 77,077,995

78,113,5852017 revenue bondsUS Bank Principal/Interest payment fund 142117 291,939

291,9392014 general obligation bonds

LAIF Interest Payment fund 152440 1,598,941 1,598,941

Operations

Wells Fargo Bank 0.20 Checking 100000 (1,381,841)Wells Fargo Bank 0.20 Checking 100500 7,239,057

5,857,216Payroll

Wells Fargo Bank 0.20 Checking 100100 (13,218) Wells Fargo Bank 0.20 Checking Benesyst 100201 27,328 Wells Fargo Bank Checking Resident Fund 100205 850 Bancorp Checking 100202 42,197 Union Bank Checking Workers' Comp 100204 -

57,1575,914,373

Total investments 342,289,164$


Wells Fargo Bank Checking 100050 3,390,761$


Wells Fargo Bank Checking 100535 502,989$ Wells Fargo Bank Checking 100530 -

502,989$


VCB Checking Investments 100501 407,739$ Various S/T Investments 142200 4,001,951 Various L/T Investments 142300 12,364,024 Various Unrealized G/L 142400 1,501,830

18,275,544$

Summary of board designated funds:

Plant fund:

Uncommitted plant funds 188,047,559$ 142100Committed for capital 26,659,520 142100

214,707,079

GO Bond reserve - L/T 1,947,148 142100

401k Matching 4,780,370 142100

Cost report settlement - current 2,135,384 142104Cost report settlement - L/T 1,312,727 142100

3,448,111

Development fund/Memorial fund 115,664 112300

Workers compensation - current 4,962,000 112900Workers compensation - L/T 15,941,000 113900

20,903,000

245,901,372$


August 31, 2017

Total Trust Surplus Investments % Accounts Funds %

Investment summary by institution:

Bancorp 42,197$ 0.0% 42,197 0.0%Cal Trust 20,792,024 6.1% 20,792,024 8.3%Local Agency Investment Fund (LAIF) 48,058,860 14.0% 48,058,860 19.1%Local Agency Investment Fund (LAIF) - GOB Tax Rev 1,598,941 0.5% 1,598,941 - 0.0%Wells Cap 88,035,034 25.7% 6,377,031 81,658,003 32.4%PFM 92,334,564 27.0% 92,334,564 36.7%Torrey Pines Bank 3,002,269 0.9% 3,002,269 1.2%Wells Fargo Bank 5,872,176 1.7% 5,872,176 2.3%US Bank 82,497,447 24.1% 82,497,447 0.0%Union Bank - 0.0% - 0.0%WestAmerica Bank 55,652 0.0% 55,652 0.0%

Total investments 342,289,164$ 100.0% 90,473,419$ 251,815,745$ 100.0%

InvestmentInvestment summary of surplus funds by type: Limitations

Negotiable and other certificates of deposit 18,652,921$ 75,545,000$ (30%)Checking accounts 5,914,373 Local Agency Investment Fund (LAIF) 48,058,860 65,000,000Cal Trust 20,792,024 Medium-term notes (corporate) (MTN-C) 43,549,000 75,545,000 (30%)U.S. government agency 86,163,000 Municipal securities 10,000,000 Money market accounts 1,252,027 50,363,000 (20%)Asset Backed Securties 17,433,540 50,363,000 (20%)

251,815,745$

Return on investment:

Current month 1.30%

Year-to-date 1.37%

Prospective 1.58%

LAIF (year-to-date) 1.07%

Budget 1.45%

Material current-month nonroutine transactions:

Sell/Called/Matured:FNMA, $1,250,000, 0.875%US TREASURY NOTE, $800,000, 1.00%US TREASURY NOTE, $1,6100,000, 1.50%HSBC BANK, $2,000,000, 1.54%SKANDIN ENS CD, $2,000,000, 1.48%TOYOTA MOTOR, $900,000, 1.700%

Buy:US TREASURY NOTE, $500,000, 1.750%US TREASURY NOTE, $2,000,000 2.00%ALLY AUTO, $360,000, 1.75%SKADIN Ens CD, $2,000,000, 1.84%US BANCORP, $900,000, 4.125%WESTPAC BKING CD, $1570,000, 2.05%INTL Bk, $1,250,000, 1.625%

Fair market value disclosure for the quarter ended June 30, 2017 (District only): Quarter-to-date Year-to-date

Difference between fair value of investments and amortized cost (balance sheet effect) N/A (574,634)$

Change in unrealized gain (loss) on investments (income statement effect) 222,009$ (3,073,723)$


August 31, 2017

Investment summary of CDs:

Bank of CD 1,200,000$ Bank of Nova 2,000,000Canadian C D 1,800,000Nordea Bank 1,800,000 Royal Bank CD 1,800,000Skandin Ens CD 2,000,000Sumito Mtsu 1,625,000Svenska NY CD 1,800,000Torrey Pines Bank 3,002,269Westpac Bking CD 1,570,000West America Bank 55,652

18,652,921$

Investment summary of asset backed securities:

Ally Auto 680,000$ American Express 330,000BMW Vehicle Owner 980,000Carmax Auto 384,264Chase Issuance 1,100,000Citibank Credit 1,100,000FHLMC 168,028FNMA 1,561,762Ford Credit Auto 1,014,951Harley Davidson 1,100,000Honda Auto 1,620,000Hyundai Auto 1,070,000John Deere 535,000Mercedes Benz Auto 1,200,000Nissan Auto 1,843,182Smart Trust 1,150,000Toyota Auto 650,000Toyota Auto Recvs 946,353

17,433,540$

Investment summary of medium-term notes (corporate):

American Express 450,000$ American Honda Mtn 2,225,000Apple, Inc 615,000Automatic Data 800,000Bank of America 435,000Bank of NY 1,900,000BB T Corp 1,730,000Boeing Co 1,000,000Burlington North 425,000Charles Schwab 340,000Cisco Systems Inc 1,235,000Citigroup 1,750,000Coca Cola Co 500,000Comcast Corp 450,000Costco Wholesale 1,000,000Credit Suisse 500,000E I DU PONT DE 500,000Fifth Third Bank 800,000General Electric Cap 1,700,000Goldman Sachs 1,250,000Home Depot Inc 425,000HSBC USA Inc 500,000IBM 875,000Intl BK 1,250,000John Deere 590,000Johnson Johnson 500,000JP Morgan 1,910,000Manuf Traders Trust 650,000Microsoft Corp 450,000Morgan Stanley 1,200,000National Rural 950,000NBC Universal 400,000New York Life Mtn 500,000Oracle Corp 900,000Paccar Fin Corp 600,000Pepsico Inc 1,320,000PNC Bank 975,000PNC Funding Corp 494,000Qualcomm Inc. 150,000Reliance Stand Mtn 450,000Ryder System Inc 420,000State Street Corp 1,075,000Texas Instruments 810,000Toyota Motor 1,050,000Union Bank 500,000United Parcel 450,000US Bank Na Mtn 575,000US Bancorp 900,000Visa Inc 700,000Walt Disney Co 375,000Wells Fargo Company 2,000,000

43,549,000$

Investment summary of U.S. government agency:

Federal National Mortgage Association (FNMA) 12,370,000$ Federal Home Loan Bank (FHLB) 7,740,000Federal Farmers Credit Bank (FFCB) 2,500,000US Treasury Bill 63,553,000

86,163,000$

Investment summary of municipal securities:

California ST High 1,250,000$ Connecticut ST 500,000 Inland Valley 750,000Los Angeles, CA Muni 520,000New Jersey Economic 725,000Oakland Ca 650,000Riverside County 900,000Sacramento Ca Public 1,200,000San Diego Cnty 425,000San Francisco 900,000Univ California Ca 1,000,000Univ of CA 1,180,000

10,000,000$


Income Statement

Average Equiv Net Mgmt Other Mgmt Daily OP Patient Services Operating Contract Employee Depreciation Interest Services

Census Census Revenue Revenue Revenue Payroll Labor Benefits Expense Expense Expense

July 2017 419 12,156 48,230,073$ 2,211,182$ 4,670,590$ 22,049,818$ 575,620$ 4,914,452$ 1,997,288$ 405,981$ 2,142,677$

August 413 12,720 48,238,183$ 2,569,270$ 5,057,986$ 21,311,920$ 579,900$ 5,657,463$ 1,973,972$ 405,516$ 2,558,509$

September 412 12,504 46,009,412$ 2,254,768$ 5,335,119$ 20,964,051$ 648,394$ 6,337,098$ 1,974,564$ 410,858$ 2,171,516$

October

November

December

January

February

March

April

May

June 2018

Year-to-date 415 37,380 142,477,668 7,035,220 15,063,695 64,325,789 1,803,915 16,909,014 5,945,825 1,222,355 6,872,702

Budget 431 36,756 148,997,403 7,370,838 16,102,016 66,253,611 851,945 17,970,247 8,011,814 1,454,860 7,234,729

Variance (16) 624 (6,519,735)$ (335,618)$ (1,038,322)$ (1,927,822)$ 951,970$ (1,061,233)$ (2,065,989)$ (232,505)$ (362,027)$

Current month 412 12,504 46,009,412$ 2,254,768$ 5,335,119$ 20,964,051$ 648,394$ 6,337,098$ 1,974,564$ 410,858$ 2,171,516$

Budget 431 11,986 48,586,110 2,403,534 5,250,658 21,604,438 277,808 5,859,863 2,612,548 474,411 2,359,151

Variance (19) 518 (2,576,698)$ (148,766)$ 84,462$ (640,388)$ 370,586$ 477,235$ (637,984)$ (63,553)$ (187,635)$


July 2017

August

September

October

November

December

January

February

March

April

May

June 2018

Year-to-date

Budget

Variance

Current month

Budget

Variance

Income Statement

Chargeable Nonchargeable Other TotalPharmacy Supplies Supplies Operating Operating Operating Investment Net Income w/o Net GOBExpense Expense Expense Expense Expense Income Income** GOB, PF & IC Revenue Net Income

2,312,503$ 2,033,632$ 4,013,490$ 11,961,191$ 52,406,654$ 2,705,191$ 406,281$ 3,111,472$ 85,796$ 3,197,268$

2,250,857$ 2,483,328$ 4,170,744$ 12,804,515$ 54,196,725$ 1,668,713$ 372,435$ 2,041,148$ 89,831$ 2,130,979$

2,295,942$ 1,950,484$ 4,125,784$ 12,698,789$ 53,577,480$ 21,819$ 765,349$ 787,169$ 89,831$ 877,000$

6,859,302 6,467,444 12,310,017 37,464,496 160,180,859 4,395,723 1,544,065 5,939,789 265,459 6,205,247

7,716,658 6,097,458 11,055,627 41,269,940 167,916,888 4,553,370 1,104,756 5,658,126 268,483 5,926,609

(857,355)$ 369,987$ 1,254,390$ (3,805,444)$ (7,736,028)$ (157,646)$ 439,309$ 281,663$ (3,024)$ 278,638$

2,295,942$ 1,950,484$ 4,125,784$ 12,698,789$ 53,577,480$ 21,819$ 765,349$ 787,169$ 89,831$ 877,000$

2,516,301 1,988,301 3,605,096 13,457,589 54,755,507 1,484,795 360,247 1,845,041 89,494 1,934,535

(220,359)$ (37,817)$ 520,688$ (758,800)$ (1,178,027)$ (1,462,975)$ 405,103$ (1,057,873)$ 337$ (1,057,536)$


July 2017

August

September

October

November

December

January

February

March

April

May

June 2018

Year-to-date

Budget

Variance

Current month

Budget

Variance

Payroll Net Patient Net Patient & Contract

Net Revenue Revenue Labor as aOperating Income Gross Deductions Per Cost Per Per Cost Per % of Net pat I/P

Margin w/o GOB Patient from DFR & Adjusted Adjusted Adjusted Adjusted and Other Op I/P Revenue% % Revenue Revenue Bad Debt % Discharge Discharge Patient Day Patient Day Revenue Revenue %

4.9% 5.6% 167,760,145$ 119,530,072$ 71.3% 9,510$ 10,334$ 1,918$ 2,084$ 42.8% 86,669,968$ 51.7%

3.0% 3.6% 174,792,902$ 126,554,719$ 72.4% 8,934$ 10,037$ 1,891$ 2,125$ 41.1% 87,628,074$ 50.1%

0.0% 1.4% 159,848,080$ 113,838,668$ 71.2% 8,903$ 10,367$ 1,850$ 2,155$ 42.1% 79,461,126$ 49.7%

2.7% 3.6% 502,401,127 359,923,460 71.6% 9,110 10,242 1,887 2,121 42.0% 253,759,169$ 50.5%

2.6% 3.3% 504,897,512 355,900,110 70.5% 9,842 11,091 1,950 2,198 40.6% 261,956,767 51.9%

(2,496,385)$ 4,023,350$ 1.2% (731)$ (849)$ (64)$ (77)$ 1.3% (8,197,598)$ -1.4%

0.0% 1.4% 159,848,080$ 113,838,668$ 71.2% 8,903$ 10,367$ 1,850$ 2,155$ 42.1% 79,461,126$ 49.7%

2.6% 2.8% 164,640,493 116,054,384 70.5% 9,842 11,091 1,950 2,198 40.3% 85,420,685 51.9%

(4,792,413)$ (2,215,715)$ 0.7% (939)$ (724)$ (100)$ (43)$ 1.8% (5,959,558)$ -2.2%


July 2017

August

September

October

November

December

January

February

March

April

May

June 2018

Year-to-date

Budget

Variance

Current month

Budget

Variance

Average FTEs perO/P Daily Adjusted

O/P Revenue I/P Occupied Acute Days in Days in Days Cash Total Revenue % Revenue Bed ALOS A/R (Net) A/R (Gross) on Hand Surplus Cash

81,090,177$ 48.3% 6,671$ 4.74 4.82 59.59 57.35 164.41 267,353,335$

87,164,827$ 49.9% 6,852$ 4.75 4.53 63.62 59.79 155.09 256,733,495$

80,386,954$ 50.3% 6,429$ 4.62 4.63 64.31 61.17 143.68 240,867,284$

248,641,958$ 49.5% 6,653$ 4.70 4.66

242,940,745 48.1% 6,610

5,701,213$ 1.4% 43$

80,386,954$ 50.3%

79,219,808 48.1%

1,167,146$ 2.2%


July August September TotalIncreases to Net Revenue:

Intergovernmental TransfersMedi-Cal FFS 608,333$ 608,333$ 608,333$ 1,825,000$ Medi-Cal Managed Care 383,333 383,333 383,333 1,150,000

Medi-Cal Quality Assurance Funds 1,116,667 1,116,667 1,116,667 3,350,000

Medi-Cal DSH Funds 547,500 547,500 547,500 1,642,500

Medi-Cal Outpatient Supplemental Funds 108,990 62,282 101,137 272,409

Medi-Cal SNF Supplemental Funds - - - -

Incentive Payment for Medi-Cal Program - - - -

Total Increases 2,764,823 2,718,115 2,756,970 8,239,909

Decreases to Net Revenue:Value Based Purchasing Adjustment (9,564) (10,891) (10,562) (31,017)

Medicare Readmission Adjustment - - - -

Medicare DSH cuts effective 10/1/2013 42,364 23,972 15,916 82,251

Changes in RAC Allowance (76,359) 21,088 10,347 (44,924)

Total Decreases (43,560) 34,169 15,700 6,310


July August September TotalNet impact on net revenue 2,721,264$ 2,752,285$ 2,772,671$ 8,246,219$

RAC Receivable BalanceBeginning Receivable Balance 12,819,841$ 4,511,781$ 4,504,908$

Additional RAC Denials (8,308,060) (6,873) (16,524) 4,511,781 4,504,908 4,488,384

Beginning Allowance 4,126,937 4,050,578 4,071,666 Increases/Decreases to allowance (76,359) 21,088 (10,347)

4,050,578 4,071,666 4,061,319

Ending Receivable Balance (net of allowance) 461,203$ 433,242$ 427,065$

Acute Inpatient Payor MixMedicare 36.6% 39.8% 41.9% 39.4%Medicare Managed Care 8.8% 7.2% 7.5% 7.9%Medi-Cal FFS 8.8% 9.2% 8.1% 8.7%Medi-Cal Managed Care 29.9% 27.3% 26.5% 27.9%Charity 0.0% 0.3% 0.4% 0.2%Indemnity 1.4% 2.5% 2.2% 2.0%Managed 13.5% 13.3% 13.1% 13.3%Other 0.9% 0.3% 0.2% 0.5%

100% 100% 100% 100.0%

Surgical Cases Inpatient 296 335 282 913 Outpatient 409 544 424 1,377 Cardiac 39 39 24 102


July August September Total Robotic 25 14 20 59

769 932 750 2,451

Cardiac Cath Volumes Inpatient 539 589 354 1,483 Outpatient 463 735 392 1,589

1,002 1,324 746 3,072

ED Visits 7,531 7,536 7,450 22,517

Urgent Care and Sequoia Prompt Care Visits 6,797 7,528 7,476 21,801

Rural Health Clinic Visits 11,346 9,825 11,004 32,175

OB Deliveries 425 432 409 1,266

Percentage of Gross Revenue Inpatient 53.2% 51.7% 51.4% Outpatient 46.8% 48.3% 48.6%


STATEMENT OF REVENUE AND EXPENSESFISCAL YEAR 2018

September Year To DateFY18 FY17 $ Change % Change FY18 FY17 $ Change % Change

OPERATING REVENUE:Net patient service revenue 46,009,412$ 43,582,504$ 2,426,908$ 5.6% 142,477,668$ 133,722,397$ 8,755,271$ 6.5%Other operating revenue 7,589,887 7,301,433 288,455 4.0% 22,098,915 20,201,926 1,896,989 9.4%

Total operating revenue 53,599,299 50,883,937 2,715,362 5.3% 164,576,583 153,924,323 10,652,260 6.9%

OPERATING EXPENSES:Salaries and wages 20,964,051 19,859,187 1,104,863 5.6% 64,325,789 62,271,217 2,054,572 3.3%Employee benefits 6,337,098 5,764,919 572,179 9.9% 16,909,014 17,284,450 (375,436) -2.2%

Total employment expenses 27,301,149 25,624,107 1,677,042 6.5% 81,234,803 79,555,667 1,679,136 2.1%

Medical and other supplies 8,372,210 8,148,610 223,601 2.7% 25,636,764 24,106,881 1,529,883 6.3%Medical and other fees 6,685,470 6,246,075 439,395 7.0% 19,089,445 18,554,396 535,049 2.9%Purchased services 2,604,553 2,214,580 389,973 17.6% 8,403,763 7,160,775 1,242,988 17.4%Repairs and maintenance 1,896,436 1,792,826 103,610 5.8% 5,731,704 5,885,059 (153,355) -2.6%Utilities 531,480 556,210 (24,729) -4.4% 1,569,688 1,562,825 6,862 0.4%Rents and leases 476,749 444,596 32,153 7.2% 1,415,464 1,300,414 115,050 8.8%Depreciation and amortization 1,974,564 1,886,081 88,483 4.7% 5,945,825 5,663,530 282,295 5.0%Interest Expense 410,858 455,333 (44,475) -9.8% 1,222,355 1,363,671 (141,315) -10.4%Other Expenses 1,152,495 1,203,430 (50,936) -4.2% 3,058,347 3,478,801 (420,454) -12.1%Management Services Expenses 2,171,516 2,232,343 (60,827) -2.7% 6,872,702 6,357,411 515,291 8.1%

Total operating expenses 53,577,480 50,804,190 2,773,290 5.5% 160,180,859 154,989,429 5,191,430 3.3%

OPERATING MARGIN 21,819 79,746 (57,927) -72.6% 4,395,723 (1,065,106) 5,460,830 -512.7%

NONOPERATING REVENUE:Investment Income 765,349 (247,584) 1,012,934 -409.1% 1,544,065 480,025 1,064,040 221.7%Net GOB Revenue 89,831 84,747 5,084 6.0% 265,459 250,541 14,917 6.0%

Total nonoperating revenue 855,181 (162,837) 1,018,018 -625.2% 1,809,524 730,566 1,078,957 147.7%

EXCESS MARGIN 877,000$ (83,091)$ 960,090$ -1155.5% 6,205,247$ (334,540)$ 6,539,787$ -1954.9%

Kaweah Delta Health Care DistrictKaweah Delta Health Care District

(3.0%)(2.0%)(1.0%)

0.0%1.0%2.0%

3.0%4.0%5.0%6.0%7.0%8.0%

9.0% EXCESS MARGIN


(4.0%)(3.0%)(2.0%)(1.0%)

0.0%1.0%2.0%3.0%4.0%5.0%6.0%7.0%8.0%9.0%

10.0%OPERATING MARGIN


340

350

360

370

380

390

400

410

420

430

440

450

AVERAGE DAILY CENSUS



$1,700

$1,800

$1,900

$2,000

$2,100

$2,200

$2,300

$2,400

$2,500NET PATIENT REVENUE PER ADJ PATIENT DAY


$1,700

$1,800

$1,900

$2,000

$2,100

$2,200

$2,300

$2,400

$2,500

$2,600 COST PER ADJUSTED PATIENT DAY


4.3

4.4

4.5

4.6

4.7

4.8

4.9

5.0

5.1

5.2

5.3 FTEs PER ADJUSTED OCCUPIED BED




1.20

1.25

1.30

1.35

1.40

1.45

1.50

1.55

1.60CASE-MIX INDEX WITHOUT NORMAL NEWBORNS

FY 2018 FY 2017 FY 2018 YTD Avg

35.00

40.00

45.00

50.00

55.00

60.00

65.00

70.00

75.00 NET DAYS IN ACCOUNTS RECEIVABLE


130.00140.00150.00160.00170.00180.00190.00200.00210.00220.00230.00240.00 DAYS CASH ON HAND



0.0%5.0%

10.0%

15.0%20.0%

25.0%30.0%

35.0%40.0%

45.0%50.0%

55.0%

60.0%

Current 31 - 60 61 - 90 91 - 120 121 - 150 151 +

GROSS ACCOUNTS RECEIVABLE AGING

31-Dec 31-Mar 30-Jun 30-Sep

1,600,0001,650,0001,700,0001,750,0001,800,0001,850,0001,900,0001,950,0002,000,0002,050,0002,100,0002,150,0002,200,0002,250,0002,300,0002,350,0002,400,0002,450,0002,500,000

AVERAGE DAILY COLLECTIONS

FY 2018 FY 2017 FY 2018 YTD Avg

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

105.00%

110.00%

115.00%

120.00%

125.00%

CASH TO NET REVENUE REALIZATION

FY 2018 FY 2017 FY 2018 YTD Avg


13.00%

14.00%

15.00%

16.00%

17.00%

18.00%

19.00%

20.00%

21.00%

22.00%SUPPLIES COST AS A PERCENTAGE OF OPERATING REVENUE


35.00%

40.00%

45.00%

50.00%

55.00%

60.00%

65.00%

SALARIES & CONTRACT LABOR AS A % OF TOTAL OPERATING REVENUE


KAWEAH DELTA HEALTH CARE DISTRICTRATIO ANALYSIS REPORT

SEPTEMBER 30, 2017

June 30,Current Prior 2017 2016 Moody'sMonth Month Unaudited Median BenchmarkValue Value Value Aa A Baa

LIQUIDITY RATIOS

Current Ratio (x) 2.6 2.4 2.1 1.5 2.0 2.3

Accounts Receivable (days) 64.3 63.6 59.4 49.6 48.1 44.3

Cash On Hand (days) 143.7 155.1 158.8 264.6 215.5 157.6

Cushion Ratio (x) 16.1 17.1 17.4 32.4 22.2 13.4

Average Payment Period (days) 44.5 46.2 46.7 76.7 61.2 59.5

CAPITAL STRUCTURE RATIOS

Cash-to-Debt 100.6% 107.0% 109.6% 225.6% 160.6% 112.1%

Debt-To-Capitalization 35.3% 35.3% 35.6% 27.6% 33.9% 43.5%

Debt-to-Cash Flow (x) 4.6 4.1 5.3 2.3 2.7 3.6

Debt Service Coverage 3.2 3.7 2.8 7.1 5.5 3.3

Maximum Annual Debt Service Coverage (x) 3.2 3.6 2.8 6.4 5.0 3.5

Age Of Plant (years) 13.7 13.7 13.5 10.1 11.4 11.8

PROFITABILITY RATIOS

Operating Margin 2.7% 3.9% 2.3% 4.0% 3.2% 1.1%

Excess Margin 3.6% 4.6% 2.6% 7.5% 6.1% 3.4%

Operating Cash Flow Margin 7.0% 8.3% 6.7% 9.7% 10.0% 7.8%

Return on Assets 2.9% 3.6% 2.1% 5.4% 4.6% 2.8%

*For Moody's Reporting Purposes, bad debt is reflected as an operating expense

KAWEAH DELTA HEALTH CARE DISTRICTBALANCE SHEET

SEPTEMBER 30, 2017


ASSETS AND DEFERRED OUTFLOWS (Unaudited)

CURRENT ASSETS

Cash and cash equivalents 4,751,400$ 3,992,275$ Accounts receivable: Patient accounts, less allowance for doubtful accounts 99,599,209 92,049,996 Other receivables 26,546,737 20,986,105

126,145,946 113,036,101

Medicare and Medi-Cal settlements 35,733,167 26,326,424 Inventories 8,032,600 8,168,590 Prepaid expenses 8,895,705 8,375,461 Current portion of assets whose use is limited 13,608,497 12,147,686

197,167,315 172,046,537

ASSETS WHOSE USE IS LIMITED, less current portion

Board designated cash and assets 247,915,207 269,913,339 Revenue bond assets held in trust 79,219,375 81,830,759 Assets in self-insurance trust fund 5,656,543 5,642,575

332,791,125 357,386,673

CAPITAL ASSETS


586,747,791 578,866,737

Less accumulated depreciation 291,835,084 286,440,763294,912,707 292,425,974

Property under capital leases, less accumulated amortization 6,983,688 7,485,184

301,896,395 299,911,158

OTHER ASSETS

Property not used in operations 3,409,795 3,420,518 Health-related investments 3,281,242 3,342,533 Other 6,908,889 7,002,445

13,599,926 13,765,496

DEFERRED OUTFLOWS 12,637,066 12,719,424

858,091,827$ 855,829,288$

KAWEAH DELTA HEALTH CARE DISTRICTBALANCE SHEET

SEPTEMBER 30, 2017


LIABILITIES AND NET ASSETS (Unaudited)

CURRENT LIABILITIES

Accounts payable and accrued expenses 26,858,516$ 31,349,099$ Accrued payroll and related liabilities 41,914,321 40,928,648 Long-term debt, current portion 8,291,021 8,180,021

77,063,858 80,457,768

LONG-TERM DEBT, less current portion

Bonds payable 258,501,100 259,960,479 Capital leases 15,946,120 16,870,609

274,447,220 276,831,088



NET ASSETS

Unrestricted 293,376,792 291,120,184 Invested in capital assets, net of related debt 101,534,345 99,956,382 Restricted 33,089,305 30,478,747

428,000,442 421,555,313

858,091,827$ 855,829,288$


September 30, 2017

Maturity Investment G/LBoard designated funds Date Yield Type Account Amount Total

LAIF 1.11 Various 37,574,112 Cal Trust 1.47 Cal Trust 20,816,302 Wells Cap 0.02 Money market 17,188 PFM 0.02 Money market 191,253.00 West America Bank 24-Feb-18 0.16 CD West America Bank 55,652 PFM 25-Feb-18 1.63 ABS FNMA 131,119.00 Torrey Pines Bank 5-Mar-18 0.30 CD Torrey Pines Bank 3,004,539 PFM 9-Mar-18 1.70 CD Royal Bank CD 1,800,000.00 PFM 25-Apr-18 1.55 ABS FNMA 180,655.00 Wells Cap 27-Apr-18 1.70 MTN-C Credit Suisse 500,000 PFM 15-May-18 2.05 Municipal Univ of CA 1,180,000.00 Wells Cap 1-Jul-18 2.54 Municipal San Diego Cnty 425,000 PFM 25-Jul-18 1.63 ABS FHLMC 149,697.00 Wells Cap 1-Aug-18 2.12 Municipal San Francisco 900,000 Wells Cap 1-Sep-18 2.75 Municipal Inland Valley 750,000 Wells Cap 1-Sep-18 2.19 Municipal Oakland Ca 650,000 Wells Cap 24-Sep-18 2.63 MTN-C HSBC USA Inc 500,000 Wells Cap 26-Sep-18 2.50 MTN-C Citigroup 250,000 Wells Cap 1-Nov-18 2.34 Municipal Los Angeles, CA Muni 520,000 Wells Cap 27-Nov-18 1.63 U.S. Govt Agency FNMA 500,000 PFM 30-Nov-18 1.76 CD Canadian C D 1,800,000.00 PFM 30-Nov-18 1.76 CD Nordea Bank 1,800,000.00 Wells Cap 7-Dec-18 2.05 MTN-C Citigroup 500,000 Wells Cap 14-Dec-18 1.30 U.S. Govt Agency FFCB 700,000 Wells Cap 8-Jan-19 1.95 MTN-C John Deere 390,000 PFM 10-Jan-19 1.89 CD Svenska NY CD 1,800,000.00 PFM 25-Jan-19 1.90 ABS FNMA 280,174.00 Wells Cap 31-Jan-19 1.13 U.S. Govt Agency US Treasury Bill 500,000 PFM 7-Feb-19 1.88 CD Bank of CD 1,200,000.00 Wells Cap 15-Feb-19 1.09 Municipal New Jersey Economic 725,000 Wells Cap 22-Feb-19 1.70 MTN-C American Honda Mtn 500,000 Wells Cap 1-Mar-19 2.13 MTN-C Cisco Systems Inc 435,000 Wells Cap 8-Mar-19 1.88 U.S. Govt Agency FHLB 495,000 Wells Cap 8-Mar-19 1.50 U.S. Govt Agency FHLB 800,000 PFM 15-Mar-19 1.97 Municipal Connecticut ST 500,000.00 PFM 5-Apr-19 1.91 CD Bank of Nova 2,000,000.00 Wells Cap 15-Apr-19 1.97 MTN-C NBC Universal 400,000 Wells Cap 15-Apr-19 0.88 U.S. Govt Agency US Treasury Bill 1,535,000 Wells Cap 29-Apr-19 2.50 MTN-C Reliance Stand Mtn 450,000 PFM 3-May-19 2.05 CD Sumito MTSU 1,625,000.00 Wells Cap 6-May-19 2.25 MTN-C Union Bank 500,000 PFM 15-May-19 1.27 ABS Toyota Auto Recvs 414,730.00 PFM 17-May-19 1.80 MTN-C IBM 875,000.00 Wells Cap 31-May-19 1.50 U.S. Govt Agency US Treasury Bill 625,000 Wells Cap 12-Jun-19 1.38 U.S. Govt Agency FFCB 750,000 Wells Cap 15-Jun-19 1.00 U.S. Govt Agency US Treasury Bill 2,000,000 Wells Cap 18-Jun-19 2.15 MTN-C New York Life Mtn 500,000 Wells Cap 1-Jul-19 1.80 Municipal Univ California Ca 1,000,000 Wells Cap 18-Jul-19 2.13 MTN-C Toyota Motor 500,000 Wells Cap 25-Jul-19 2.25 MTN-C Manuf Traders Trust 650,000 Wells Cap 31-Jul-19 0.88 U.S. Govt Agency US Treasury Bill 300,000 PFM 2-Aug-19 1.84 CD Skandin Ens CD 2,000,000.00 PFM 5-Aug-19 0.88 U.S. Govt Agency FHLB 2,250,000.00 PFM 15-Aug-19 2.25 MTN-C American Honda Mtn 1,305,000.00 PFM 28-Aug-19 1.00 U.S. Govt Agency FNMA 1,650,000.00 Wells Cap 31-Aug-19 1.25 U.S. Govt Agency US Treasury Bill 1,000,000 Wells Cap 15-Sep-19 2.20 MTN-C Paccar Fin Corp 600,000 Wells Cap 15-Sep-19 0.88 U.S. Govt Agency US Treasury Bill 825,000 PFM 25-Sep-19 2.07 CD Bank of Tokyo CD 900,000.00 PFM 25-Sep-19 1.65 ABS FNMA 679,623.00 Wells Cap 30-Sep-19 1.75 U.S. Govt Agency US Treasury Bill 1,950,000 PFM 1-Oct-19 4.70 MTN-C Burlington North 425,000.00 PFM 7-Oct-19 1.88 MTN-C Intl Bk 1,750,000.00 PFM 15-Oct-19 1.15 ABS Nissan Auto 253,666.00 Wells Cap 18-Oct-19 2.40 MTN-C PNC Bank 575,000 Wells Cap 28-Oct-19 2.13 MTN-C US Bank Na Mtn 575,000 PFM 15-Nov-19 1.17 ABS Carmax Auto 333,060.00 PFM 15-Nov-19 1.38 U.S. Govt Agency FHLB 1,440,000.00 PFM 15-Nov-19 1.16 ABS Ford Credit Auto 213,550.00 PFM 26-Nov-19 1.75 U.S. Govt Agency FNMA 750,000.00 Wells Cap 11-Dec-19 2.10 MTN-C General Electric Cap 1,200,000 PFM 13-Dec-19 2.30 MTN-C Goldman Sachs 900,000.00 Wells Cap 31-Dec-19 1.13 U.S. Govt Agency US Treasury Bill 1,000,000 PFM 8-Jan-20 5.50 MTN-C General Electric Cap 500,000.00 PFM 30-Jan-20 2.15 MTN-C Wells Fargo Company 850,000.00 Wells Cap 31-Jan-20 1.25 U.S. Govt Agency US Treasury Bill 900,000 PFM 15-Feb-20 1.41 ABS Ford Credit Auto 385,649.00 PFM 29-Feb-20 1.25 U.S. Govt Agency US Treasury Bill 1,875,000.00 Wells Cap 29-Feb-20 1.38 U.S. Govt Agency US Treasury Bill 945,000 PFM 12-Mar-20 2.15 MTN-C Toyota Motor 550,000.00 PFM 15-Mar-20 1.57 ABS Ally Auto 320,000.00 Wells Cap 15-Mar-20 1.50 U.S. Govt Agency US Treasury Bill 4,000,000 PFM 16-Mar-20 1.51 ABS Nissan Auto 473,474.00 PFM 31-Mar-20 1.38 U.S. Govt Agency US Treasury Bill 998,000.00 Wells Cap 31-Mar-20 1.38 U.S. Govt Agency US Treasury Bill 700,000 Wells Cap 15-Apr-20 1.35 ABS Chase Issuance 1,100,000 Wells Cap 15-Apr-20 1.79 ABS Mercedes Benz Auto 1,200,000 Wells Cap 1-May-20 2.20 MTN-C E I DU PONT DE 500,000 Wells Cap 8-May-20 1.55 U.S. Govt Agency FFCB 1,050,000 Wells Cap 20-May-20 2.10 MTN-C Qualcomm Inc. 150,000 Wells Cap 31-May-20 1.50 U.S. Govt Agency US Treasury Bill 1,650,000 PFM 5-Jun-20 1.80 MTN-C Home Depot Inc 425,000.00 PFM 15-Jun-20 1.25 ABS John Deere 195,000.00 Wells Cap 15-Jun-20 1.50 U.S. Govt Agency US Treasury Bill 1,000,000 PFM 22-Jun-20 1.95 MTN-C John Deere 200,000.00 PFM 23-Jun-20 1.41 MTN-C JP Morgan 1,000,000.00 Wells Cap 29-Jun-20 2.63 MTN-C BB T Corp 1,280,000 PFM 20-Jul-20 2.00 MTN-C American Honda Mtn 420,000.00 PFM 22-Jul-20 1.41 MTN-C Wells Fargo Company 1,150,000.00 PFM 31-Jul-20 2.00 U.S. Govt Agency US Treasury Bill 735,000.00 PFM 3-Aug-20 2.05 CD Westpac Bking CD 1,570,000.00 Wells Cap 18-Aug-20 2.55 MTN-C State Street Corp 830,000 PFM 31-Aug-20 2.13 U.S. Govt Agency US Treasury Bill 1,080,000.00 Wells Cap 31-Aug-20 1.38 U.S. Govt Agency US Treasury Bill 1,055,000 PFM 4-Sep-20 1.85 MTN-C Caterpillar Finl Mtn 670,000.00 PFM 4-Sep-20 1.63 MTN-C Intl BK 1,250,000.00 PFM 12-Sep-20 1.56 MTN-C Intl Bk 1,750,000.00 PFM 15-Sep-20 1.56 ABS Hyundai Auto 175,000.00 Wells Cap 15-Sep-20 2.25 MTN-C Automatic Data 800,000 Wells Cap 15-Sep-20 2.75 MTN-C Goldman Sachs 350,000 Wells Cap 30-Sep-20 1.38 U.S. Govt Agency US Treasury Bill 400,000 Wells Cap 30-Sep-20 1.50 U.S. Govt Agency US Treasury Bill 1,500,000 Wells Cap 15-Oct-20 1.23 ABS Toyota Auto 650,000 PFM 31-Oct-20 1.75 U.S. Govt Agency US Treasury Bill 2,875,000.00 Wells Cap 31-Oct-20 1.25 U.S. Govt Agency US Treasury Bill 400,000


September 30, 2017

PFM 15-Nov-20 2.63 U.S. Govt Agency US Treasury Bill 2,655,000.00 Wells Cap 25-Nov-20 1.16 ABS BMW Vehicle Owner 980,000 PFM 30-Nov-20 2.00 U.S. Govt Agency US Treasury Bill 1,950,000.00 Wells Cap 30-Nov-20 1.63 U.S. Govt Agency US Treasury Bill 150,000 Wells Cap 14-Dec-20 2.20 MTN-C Visa Inc 700,000 Wells Cap 18-Dec-20 1.47 ABS Honda Auto 720,000 PFM 31-Dec-20 2.38 U.S. Govt Agency US Treasury Bill 1,525,000.00 Wells Cap 31-Dec-20 1.63 U.S. Govt Agency US Treasury Bill 600,000 Wells Cap 15-Jan-21 1.34 ABS Harley Davidson 1,100,000 PFM 20-Jan-21 1.80 MTN-C IBM 900,000.00 PFM 16-Feb-21 1.73 ABS Toyota Auto Recvs 225,000.00 Wells Cap 18-Feb-21 1.38 U.S. Govt Agency FHLB 980,000 Wells Cap 23-Feb-21 2.25 MTN-C Apple, Inc 615,000 Wells Cap 28-Feb-21 1.13 U.S. Govt Agency US Treasury Bill 700,000 PFM 12-Mar-21 2.75 MTN-C Texas Instruments 180,000.00 Wells Cap 12-Mar-21 2.75 MTN-C Texas Instruments 630,000 Wells Cap 15-Mar-21 1.71 ABS Smart Trust 1,150,000 Wells Cap 31-Mar-21 1.25 U.S. Govt Agency US Treasury Bill 935,000 Wells Cap 1-Apr-21 2.63 Municipal California ST High 1,250,000 Wells Cap 1-Apr-21 3.54 Municipal Sacramento Ca Public 1,200,000 PFM 15-Apr-21 2.50 MTN-C Bank of NY 900,000.00 PFM 15-Apr-21 1.29 ABS Hyundai Auto 465,000.00 Wells Cap 19-Apr-21 2.63 MTN-C Bank of America 435,000 PFM 21-Apr-21 2.50 MTN-C Morgan Stanley 450,000.00 Wells Cap 21-Apr-21 2.50 MTN-C Morgan Stanley 750,000 Wells Cap 29-Apr-21 2.15 MTN-C PNC Bank 400,000 Wells Cap 30-Apr-21 1.38 U.S. Govt Agency US Treasury Bill 875,000 PFM 5-May-21 2.25 MTN-C American Express 450,000.00 PFM 6-May-21 1.25 U.S. Govt Agency FNMA 3,650,000.00 Wells Cap 6-May-21 1.25 U.S. Govt Agency FNMA 700,000 PFM 10-May-21 2.05 MTN-C BB T Corp 450,000.00 Wells Cap 17-May-21 1.70 ABS USAA Auto Owner 370,000 PFM 19-May-21 1.95 MTN-C State Street Corp 245,000.00 PFM 24-May-21 4.13 MTN-C US Bancorp 900,000.00 PFM 31-May-21 2.00 U.S. Govt Agency US Treasury Bill 850,000.00 Wells Cap 7-Jun-21 2.40 MTN-C JP Morgan 910,000 Wells Cap 14-Jun-21 2.25 MTN-C Fifth Third Bank 800,000 PFM 15-Jun-21 1.67 ABS Ford Credit Auto 355,000.00 Wells Cap 30-Jun-21 1.00 U.S. Govt Agency US Treasury Bill 400,000 PFM 14-Jul-21 1.13 U.S. Govt Agency FHLB 1,775,000.00 PFM 15-Aug-21 1.87 ABS Honda Auto 900,000.00 PFM 16-Aug-21 1.76 ABS Hyundai Auto 430,000.00 Wells Cap 16-Aug-21 1.74 ABS Nissan Auto 1,050,000 Wells Cap 17-Aug-21 1.25 U.S. Govt Agency FNMA 1,400,000 Wells Cap 17-Aug-21 1.25 U.S. Govt Agency FNMA 1,500,000 PFM 31-Aug-21 2.00 U.S. Govt Agency US Treasury Bill 2,250,000.00 PFM 31-Aug-21 2.00 U.S. Govt Agency US Treasury Bill 5,750,000.00 Wells Cap 1-Sep-21 2.25 MTN-C Ryder System Inc 420,000 PFM 15-Sep-21 6.72 ABS FHLMC 4,231.00 PFM 15-Sep-21 1.90 MTN-C Oracle Corp 900,000.00 PFM 20-Sep-21 1.85 MTN-C Cisco Systems Inc 800,000.00 PFM 1-Oct-21 2.33 MTN-C Bank of America 640,000.00 PFM 6-Oct-21 1.70 MTN-C Pepsico Inc 1,320,000.00 PFM 15-Oct-21 1.82 ABS John Deere 340,000.00 Wells Cap 30-Oct-21 2.35 MTN-C Boeing Co 1,000,000 PFM 31-Oct-21 1.25 U.S. Govt Agency US Treasury Bill 290,000.00 PFM 31-Oct-21 2.00 U.S. Govt Agency US Treasury Bill 2,000,000.00 PFM 15-Nov-21 2.00 ABS Toyota Auto Recvs 250,000.00 Wells Cap 19-Nov-21 0.00 ABS Citibank Credit 1,100,000 Wells Cap 30-Nov-21 1.75 U.S. Govt Agency US Treasury Bill 1,160,000 PFM 15-Dec-21 1.75 ABS Ally Auto 360,000.00 PFM 15-Dec-21 1.65 ABS American Express 330,000.00 PFM 31-Dec-21 2.13 U.S. Govt Agency US Treasury Bill 3,600,000.00 Wells Cap 31-Dec-21 2.00 U.S. Govt Agency US Treasury Bill 1,225,000 PFM 15-Jan-22 1.63 MTN-C Comcast Corp 450,000.00 Wells Cap 7-Feb-22 2.60 MTN-C Bank of NY 1,000,000 PFM 12-Feb-22 2.38 MTN-C Microsoft Corp 450,000.00 Wells Cap 28-Feb-22 1.88 U.S. Govt Agency US Treasury Bill 390,000 Wells Cap 3-Mar-22 2.25 MTN-C Johnson Johnson 500,000 PFM 4-Mar-22 2.45 MTN-C Walt Disney Co 375,000.00 PFM 8-Mar-22 3.30 MTN-C PNC Funding Corp 494,000.00 PFM 1-Apr-22 2.75 MTN-C BB T Corp 450,000.00 Wells Cap 5-Apr-22 1.88 U.S. Govt Agency FNMA 920,000 PFM 25-Apr-22 2.75 MTN-C Citigroup 1,000,000.00 Wells Cap 25-Apr-22 2.40 MTN-C National Rural 950,000 Wells Cap 30-Apr-22 1.88 U.S. Govt Agency US Treasury Bill 800,000 PFM 16-May-22 2.35 MTN-C United Parcel 450,000.00 Wells Cap 18-May-22 2.30 MTN-C Costco Wholesale 1,000,000 Wells Cap 25-May-22 2.20 MTN-C Coca Cola Co 500,000 Wells Cap 30-Jun-22 1.75 U.S. Govt Agency US Treasury Bill 660,000 Wells Cap 31-Aug-22 1.75 U.S. Govt Agency US Treasury Bill 1,440,000 PFM 8-Sep-22 2.15 MTN-C Toyota Motor 450,000.00

235,700,674$


September 30, 2017

Maturity Investment G/L Date Yield Type Account Amount Total

Self-insurance trust

Wells Cap Money market 110900 748,243Wells Cap Fixed income - L/T 152300 5,638,919

6,387,162

2012 revenue bondsUS Bank Project fund 152438 2,552,554 US Bank Principal/Interest payment fund 142112 2,014,313

4,566,867

2015A revenue bondsUS Bank Principal/Interest payment fund 142115 382,115

382,1152015B revenue bondsUS Bank Principal/Interest payment fund 142116 1,381,049 US Bank Project Fund 152442 76,425,572

77,806,6212017 revenue bondsUS Bank Principal/Interest payment fund 142117 386,452

386,4522014 general obligation bonds

LAIF Interest Payment fund 152440 1,598,941 1,598,941

Operations

Wells Fargo Bank 0.20 Checking 100000 (1,334,725)Wells Fargo Bank 0.20 Checking 100500 2,480,303

1,145,578Payroll

Wells Fargo Bank 0.20 Checking 100100 (20,735) Wells Fargo Bank 0.20 Checking Benesyst 100201 29,549 Wells Fargo Bank Checking Resident Fund 100205 920 Bancorp Checking 100202 34,270 Union Bank Checking Workers' Comp 100204 -

44,0041,189,582

Total investments 328,018,414$


Wells Fargo Bank Checking 100050 3,000,921$


Wells Fargo Bank Checking 100535 37,935$ Wells Fargo Bank Checking 100530 -

37,935$


VCB Checking Investments 100501 633,496$ Various S/T Investments 142200 3,840,654 Various L/T Investments 142300 12,563,320 Various Unrealized G/L 142400 1,859,237

18,896,707$

Summary of board designated funds:

Plant fund:

Uncommitted plant funds 173,939,668$ 142100Committed for capital 30,018,302 142100

203,957,970

GO Bond reserve - L/T 1,947,148 142100

401k Matching 5,328,781 142100

Cost report settlement - current 2,135,384 142104Cost report settlement - L/T 1,312,727 142100

3,448,111

Development fund/Memorial fund 115,664 112300

Workers compensation - current 4,962,000 112900Workers compensation - L/T 15,941,000 113900

20,903,000

235,700,674$


September 30, 2017

Total Trust Surplus Investments % Accounts Funds %

Investment summary by institution:

Bancorp 34,270$ 0.0% 34,270 0.0%Cal Trust 20,816,302 6.3% 20,816,302 8.8%Local Agency Investment Fund (LAIF) 37,574,112 11.5% 37,574,112 15.9%Local Agency Investment Fund (LAIF) - GOB Tax Rev 1,598,941 0.5% 1,598,941 - 0.0%Wells Cap 88,204,350 26.9% 6,387,162 81,817,188 34.5%PFM 92,432,881 28.2% 92,432,881 39.0%Torrey Pines Bank 3,004,539 0.9% 3,004,539 1.3%Wells Fargo Bank 1,155,312 0.4% 1,155,312 0.5%US Bank 83,142,055 25.3% 83,142,055 0.0%Union Bank - 0.0% - 0.0%WestAmerica Bank 55,652 0.0% 55,652 0.0%

Total investments 328,018,414$ 100.0% 91,128,158$ 236,890,256$ 100.0%

InvestmentInvestment summary of surplus funds by type: Limitations

Negotiable and other certificates of deposit 19,555,191$ 71,067,000$ (30%)Checking accounts 1,189,582 Local Agency Investment Fund (LAIF) 37,574,112 65,000,000Cal Trust 20,816,302 Medium-term notes (corporate) (MTN-C) 49,819,000 71,067,000 (30%)U.S. government agency 81,363,000 Municipal securities 9,100,000 Money market accounts 208,441 47,378,000 (20%)Asset Backed Securties 17,264,628 47,378,000 (20%)

236,890,256$

Return on investment:

Current month 1.60%

Year-to-date 1.47%

Prospective 1.65%

LAIF (year-to-date) 1.08%

Budget 1.45%

Material current-month nonroutine transactions:

Sell/Called/Matured:FNMA, $1,000,000, 0.875%US Treasury, $450,000, 1.250%US Treasury, $500,000, 1.750%US Treasury, $900,000, 2.000%US Treasury, $640,000, 2.000%US Treasury, $670,000, 2.125%US Treasury, $1,750,000, 2.125%

FNMA, $250,000, 1.125%US Treasury, $600,000, 1.125%US Treasury, $240,000, 1.250%US Treasury, $190,000, 1.500%Charles Schwab, $340,000, 2.200%Riverside Cnty, $900,000, 2.190%

Buy:Bank of America, $640,000, 2.328%Bank of Tokyo CD, $900,000, 2.070%Bb T Corporation, $450,000, 2.750%Caterpillar Finl, $670,000, 1.850%IBM Credit Corp, $900,000, 1.80%Toyota Motor Credit, $450,000, 2.150%Intl Bk, $1,750,000, 1.876%Intl Bk, $1,750,000, 1.561%

US Treasury, $1,000,000, 1.250%US Treasury, $1,440,000, 1.750%USAA Auto Owner, $370,000, 1.700%

Fair market value disclosure for the quarter ended September 30, 2017 (District only): Quarter-to-date Year-to-date

Difference between fair value of investments and amortized cost (balance sheet effect) N/A (540,647)$

Change in unrealized gain (loss) on investments (income statement effect) 17,207$ 17,207$


September 30, 2017

Investment summary of CDs:

Bank of CD 1,200,000$ Bank of Nova 2,000,000Bank of Tokyo CD 900,000Canadian C D 1,800,000Nordea Bank 1,800,000 Royal Bank CD 1,800,000Skandin Ens CD 2,000,000Sumito Mtsu 1,625,000Svenska NY CD 1,800,000Torrey Pines Bank 3,004,539Westpac Bking CD 1,570,000West America Bank 55,652

19,555,191$

Investment summary of asset backed securities:

Ally Auto 680,000$ American Express 330,000BMW Vehicle Owner 980,000Carmax Auto 333,060Chase Issuance 1,100,000Citibank Credit 1,100,000FHLMC 153,928FNMA 1,271,571Ford Credit Auto 954,199Harley Davidson 1,100,000Honda Auto 1,620,000Hyundai Auto 1,070,000John Deere 535,000Mercedes Benz Auto 1,200,000Nissan Auto 1,777,140Smart Trust 1,150,000Toyota Auto 650,000Toyota Auto Recvs 889,730USAA Auto Owner 370,000

17,264,628$

Investment summary of medium-term notes (corporate):

American Express 450,000$ American Honda Mtn 2,225,000Apple, Inc 615,000Automatic Data 800,000Bank of America 1,075,000Bank of NY 1,900,000BB T Corp 2,180,000Boeing Co 1,000,000Burlington North 425,000Caterpillar Finl Mtn 670,000Cisco Systems Inc 1,235,000Citigroup 1,750,000Coca Cola Co 500,000Comcast Corp 450,000Costco Wholesale 1,000,000Credit Suisse 500,000E I DU PONT DE 500,000Fifth Third Bank 800,000General Electric Cap 1,700,000Goldman Sachs 1,250,000Home Depot Inc 425,000HSBC USA Inc 500,000IBM 1,775,000Intl BK 4,750,000John Deere 590,000Johnson Johnson 500,000JP Morgan 1,910,000Manuf Traders Trust 650,000Microsoft Corp 450,000Morgan Stanley 1,200,000National Rural 950,000NBC Universal 400,000New York Life Mtn 500,000Oracle Corp 900,000Paccar Fin Corp 600,000Pepsico Inc 1,320,000PNC Bank 975,000PNC Funding Corp 494,000Qualcomm Inc. 150,000Reliance Stand Mtn 450,000Ryder System Inc 420,000State Street Corp 1,075,000Texas Instruments 810,000Toyota Motor 1,500,000Union Bank 500,000United Parcel 450,000US Bank Na Mtn 575,000US Bancorp 900,000Visa Inc 700,000Walt Disney Co 375,000Wells Fargo Company 2,000,000

49,819,000$

Investment summary of U.S. government agency:

Federal National Mortgage Association (FNMA) 11,070,000$ Federal Home Loan Bank (FHLB) 7,740,000Federal Farmers Credit Bank (FFCB) 2,500,000US Treasury Bill 60,053,000

81,363,000$

Investment summary of municipal securities:

California ST High 1,250,000$ Connecticut ST 500,000 Inland Valley 750,000Los Angeles, CA Muni 520,000New Jersey Economic 725,000Oakland Ca 650,000Sacramento Ca Public 1,200,000San Diego Cnty 425,000San Francisco 900,000Univ California Ca 1,000,000Univ of CA 1,180,000

9,100,000$

Post-Surgical Care- 4S, 3N, Broderick Pavilion Kari Knudsen, RN, BSN, MPA, NE-BC Director of Post-Surgical Care 624-2196 October 23, 2017 Summary Issue/Service Considered • Nursing remains focused on charge nurse and staff development with specific attention to

Kaweah Care best practices to further improve the patient experience; each unit has focused goals and plans of action.

• Currently working on recruitment and retention to fill open positions and maintain qualified nursing staff.

• Active surveillance of quality measures and focused improvements in fall prevention, Hospital Acquired Pressure Injuries (HAPI) and Catheter Associated Urinary Tract Infections (CAUTI).

• Inpatient Medical Surgical and Critical Care KDHub projects completed; continued participation in RRT, Medication Process, Quality Initiatives, Bridge, end user training, and VTE applications.

• Promote and manage the failsafe program through the Medical-Surgical Nursing Certification Board (MSNCB) to increase national certification in the division.

Quality/Performance Improvement Data • Health Stream overall patient satisfaction FY 16/17 for the combined Post-Surgical

Division is the 77th percentile, a 4% gain since last year. BP maintains the 84th percentile, with 3N/4S exhibiting consistent gains.

The Post-Surgical units monitor the following nurse sensitive quality indicators:

CLINICAL QUALITY 3 NORTH 4 SOUTH BRODERICK PAVILION 3Q16 4Q16 1Q17 2Q17 3Q16 4Q16 1Q17 2Q17 3Q16 4Q16 1Q17 2Q17

Central line associated blood stream infection (CLABSI) 0.00 0.00 0.00 4.40 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

NHSN Mean 0.70 0.70 0.70 0.70 0.80 0.80 0.80 0.80 0.70 0.70 0.70 0.70 Catheter associated urinary tract infection (CAUTI) 0.00 1.70 0.00 1.60 0.00 0.00 5.20 0.00 0.00 0.00 0.00 0.00

NHSN Mean 1.30 1.30 1.30 1.30 1.30 1.30 1.30 1.30 1.30 1.30 1.30 1.30 Falls/1000 pt days 3.00 1.64 3.90 3.02 1.38 3.50 2.70 1.05 0.00 1.83 1.83 1.89

NDNQI Mean 2.31 2.40 2.46 2.42 2.99 3.04 3.17 3.03 2.31 2.40 2.46 2.42 Injury Falls/1000 pt days 0.67 0.66 0.97 0.00 0.00 0.35 0.00 0.00 0.00 0.00 1.83 0.00

NDNQI Mean 0.39 0.38 0.43 0.38 0.65 0.56 0.51 0.54 0.39 0.38 0.43 0.38 % pts. Stage 2+HAPI - 1 Day PREVALENCE 0.00 3.03 2.70 0.00 0.00 0.00 3.23 3.70 0.00 0.00 0.00 0.00

NDNQI Mean 1.17 1.01 1.06 0.99 1.14 0.82 1.19 1.00 1.17 1.01 1.06 0.99 *HAPI= Hospital Acquired Pressure Injury

Kaweah Delta Health Care District Annual Report to the Board of Directors

Policy, Strategic or Tactical Issues

• Active participation in multiple National Surgery and Quality Improvement Program (NSQIP) initiatives: Surgical Site Infection (SSI) reduction, Post-surgical Acute Kidney Injury (AKI) reduction, Improving Surgical Care and Recovery (ISCR).

• Plans of action in place for all clinical indicators higher than the mean. • Participation in the quest for Joint Commission National Stroke Certification. • Reduction in length of stay for orthopedic patients and overall medical surgical population. • Focused efforts on throughput and timely discharge through daily discharge rounds (3N,

4S) and participation in discharge management/throughput committees. • Renovated the suicide risk screening documentation, policy and education continues for

inpatient nursing.

Recommendations/Next Steps • Focused efforts on reduction in length of stay for colorectal and peripheral vascular

inpatient surgical patients. • Continued focused efforts on improving the patient experience and inspiring a culture o

excellence. • Continued Cerner development and implementation including renovation of all patient

care policies related to KDHub. • Maintain sustained improvements with HAPI and SSI reduction. • Continue focused partnership with the Clinical Education team and Advanced Practice

Nurse to shore up the on-boarding and orientation process for new staff on all units. • Promote active engagement of our physician partners.

Approvals/Conclusions

• Strive for overall quality outcomes and set goals to continue to improve. • Overall 2.1% increase in admissions: o 3N admissions increased by 2.2%. o 4S admissions increased by 0.24%. o Broderick Pavilion admissions increased by 10.5%.

• The Post-Surgical Care division has a positive gross income. We have experienced a decrease of 4.5% direct cost per unit of service and a slight increase in overall costs, increased patient volume results in increased gross revenue by 0.49%.



Broderick Pavilion, 3 North and 4 South

Kari Knudsen, Director (624-2196)

October 2017

Performance Report Data: Fiscal Year 2017

Patient Gross Gross Pat RevDirect CostService Volume Revenue Costs Per UOS Per UOS

3 North - Actual 12,747 $23,186,747 $7,367,261 $1,819 $5783 North - Fixed Budget 12,463 $23,721,000 $7,202,256 $1,903 $578Variance 284 ($534,253) $165,005 (84) $0

4 South - Actual 12,496 $21,314,590 $6,846,910 $1,706 $5484 South - Fixed Budget 12,466 $20,904,200 $6,544,209 $1,677 $525Variance 30 $410,390 $302,701 $29 $23

Broderick Pavilion - Actual 2,710 $4,635,457 $1,859,377 $1,711 $686Broderick Pavilion - Fixed Budg 2,453 $4,121,500 $2,082,032 $1,680 $849Variance 257 $513,957 ($222,655) $31 ($163)

Grand Total 27,953 $49,136,794 ########## $5,236 $1,812

Performance Report Data: Fiscal Year 2016

Patient Gross Gross Pat RevDirect CostService Volume Revenue Costs Per UOS Per UOS

3 North - Actual 12,503 $23,809,417 $7,345,699 $1,904 $5883 North - Fixed Budget 12,353 $23,677,200 $6,952,480 $1,917 $563Variance 150 $132,217 $393,219 (13) $25

4 South - Actual 12,441 $20,865,027 $6,627,668 $1,677 $5334 South - Fixed Budget 11,326 $18,978,900 $5,807,499 $1,676 $513Variance 1,115 $1,886,127 $820,169 $1 $20

Broderick Pavilion - Actual 2,525 $4,219,494 $1,965,509 $1,671 $778Broderick Pavilion - Fixed Budg 2,510 $4,209,300 $2,020,875 $1,677 $805Variance 15 $10,194 ($55,366) ($6) ($27)

Grand Total 27,469 $48,893,938 ########## $5,252 $1,899

Policy Submission Summary

Manual Name: Administrative Date: 10/12/17 Support Staff Name: Cindy Moccio

Policy/Procedure Title

#

Status – New, Revised, Reviewed,

or Deleted

* Name and phone extension of person who wrote or revised policy - * for New and Revised policies only

Access to legal counsel AP57 Revised C. Moccio x2330 Travel, Per Diem, and Other Employee Reimbursement AP19 Revised G. Herbst x2330 Use of District name and/or Stationery AP27 Reviewed C. Moccio x2330

Administrative, Administrative Manual

Policy Number: AP57 Date Created: No Date Set Document Owner: Cindy Moccio (Board Clerk/Exec Assist-CEO)

Date Approved: Not Approved Yet

Approvers: Board of Directors (Administration)

Access to Legal Counsel Printed copies are for reference only. Please refer to the electronic copy for the latest version. POLICY: In order to control the costs of legal fees, and to streamline the

dissemination of legal advice, direct access to legal counsel is limited to certain specific individuals.

Individuals authorized for direct and immediate access to District Administrative legal counsel are limited to: A. any member of the District Board of Directors; B. the Chief Executive Officer; C. the District Executive Assistant to Board/CEO & Board Clerk; D. any individual with the title of Kaweah Delta Health Care District

Senior Vice President, Vice President or Division Director; E. the Director of Risk Management; F. the District Compliance & Privacy Officer; G. the Director of Internal Audit; H. the Chief of Medical Staff; I. the Chair of the Medical Staff Credentials Committee; J. the Chair of the Medical Staff By-Laws Committee; K. the Director of Patient Accounting Services or Credit Manager.

Other staff members may be authorized for direct and immediate access to District legal counsel provided they are acting at the specific request or direction of an individual occupying any of the positions indicated above. Individuals authorized for direct and immediate access to Medial Staff legal counsel are limited to:

A. any member of the District Board of Directors; B. the Chief Executive Officer; C. any Medical Staff Officer; D. the Chair of the Medical Staff Credentials Committee; E. the Chief Medical Officer

Other staff members may be authorized for direct and immediate access to Medical Staff legal counsel provided they are acting at the specific request or direction of an individual occupying any of the positions indicated above. "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist.

Access to Legal Counsel 2 Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

Administrative, Administrative Manual

Policy Number: AP19 Date Created: No Date Set Document Owner: Cindy Moccio (Board Clerk/Exec Assist-CEO)


Approvers: Board of Directors (Administration)

Travel, Per Diem and Other Employee Reimbursement Printed copies are for reference only. Please refer to the electronic copy for the latest version. POLICY: Kaweah Delta Health Care District will reimburse employees for certain

travel and acceptable business expenses which are reasonably incurred in the course of District business. For travel costs relating to the cost of meals and incidentals while on travel to conduct District business, the employee will receive a per diem rate to cover such costs.

All expenses submitted for reimbursement will require original receipts when not covered by the per diem rate. All receipts must include a detail of all items purchased. A summary credit card receipt will not be sufficient for reimbursement. Unless otherwise approved by an Executive Team Member “ET", expenses submitted without original detailed receipts will not be reimbursed by the District.

REFERENCES: AP46 Commercial Card Expense Reporting Program (CCER) AP84 Mileage Reimbursements AP105 Professional and Service Club District Reimbursed Memberships AP156 Standard Procurement Practices AUTHORIZATION: Authorization for expenses will be obtained as follows:

• Pre-Approval: For conference travel, the employee must obtain written approval from their Director (Vice President for Directors)immediate supervisor prior to the travel taking place (email approval is acceptable). Travel expenses not receiving prior approval will not be reimbursed by the District unless later approved by an Executive Team ET member.

• After travel: Employee expenses must be approved by the employee’s authorized signer (generally a director or ET member). The approver must be an authorized signer with a completed Purchase Authorization Sheet on file with Materials Management (See District Policy AP156) having purchase limits and authority to approve travel expenses.

• Department Manager/Supervisor expenses must be approved by their Director, Vice President or Sr. Vice President.

Travel, Per Diem and Other Employee Reimbursement 2

• Vice Presidents may sign for expenses to the limit of the authority provided them through the budgeting process. Vice President / Sr. Vice President’s travel expenses must be approved by the Chief Executive Officer.

• Goods and services purchased for the benefit of employees and staff appreciation accounted for under any HR program (such as Job Well Done) must have VP and HR approval before the purchase is made to confirm that the department has sufficient budgeted funds available to secure the purchase.

METHODS OF PAYMENT: Method of payments of approved travel expense is as

follows:

• Payment by a District issued credit card – Approved business expenses paid for by using a District issued credit card must follow policies as set forth in AP46 (Commercial Card Expense Reporting (CCER))

• Prepayment by Accounts Payable – Travel expenses which are being paid for directly by the District to a third party vendor must be submitted on the attached Travel Reimbursement Form or nonstock before payment will be processed.

• Payment by the Employee (out of pocket expenses) – Approved business expenses may be paid by the employee and reimbursed based on employee reimbursement procedures as outlined herein.

PROCEDURE: Travel, and Per Diem, and other Employee Reimbursement not related to

travel: I. No matter what mode of travel is being used, travel costs paid for by the

District for travel subsequently cancelled must immediately be refunded to the District unless such cancellation is for the business benefit or convenience of the District and has been approved by a member of the ET. The approver authorizing the travel is responsible to ensure that the refund is received by the District timely and the appropriate cost center properly credited for the refund. Non-reimbursable travel and non-travel expenses include, but may not be limited to:

A. charge card fees B. meals in excess of the per diem rate, unless approved by the

Executive Team C. airline hospitality fees


D. frequent user program fees E. personal services and sundries F. personal gas or oil if a mileage allowance is received G. baby-sitting/child care fees H. traffic or parking violation citations I. laundry and valet services J. pet care K. replacement of lost luggage L. personal gifts M. alcoholic beverages except as permitted under section IV and

approved by a member of the ET or Board of Directors. II. Air Travel and Lodging

A. The lowest appropriate airfare will be obtained at all times unless alternative is specifically approved by the Department Director’Employee's supervisor as applicable. Employees will only be reimbursed for the cost of coach fares and standard luggage fees.

B. Hotels offering special or corporate rates will be used whenever possible. Lodging expenses shall not exceed $150.00 per day without the approval of the Department Directoremployee’s supervisor.

C. Employees may participate, to their own personal benefit, in frequent user bonus programs. KDHCD will not reimburse any employee for costs associated with participation in frequent user bonus programs.

III. Ground Transportation - Employees requiring ground transportation shall determine and utilize the most cost-effective means available. A. Personal Vehicle - When it is necessary for an employee to utilize their

personal vehicle to conduct District business, expenses will be reimbursed in accordance with AP84 (Mileage Reimbursement).

B. Taxi, Hotel or Airport Shuttle, Convenience Vans, etc. - Employees requiring transportation to or from a commercial carrier port such as an airport shall employ the most cost-effective alternative in arriving at their destination. Reimbursement will be made available to employees based upon actual costs incurred, supported by a detailed receipt. The use of alternate transportation shall only be used if more cost effective than the use of the employee’s personal vehicle. Any exceptions must be approved by the Department Directoremployee’s supervisor.

C. Rental Cars - When adequate transportation at lower cost is not available (i.e., personal car, hotel or airport shuttle, taxi, etc.), cars (up to mid-sized) may be rented from a local vendor. Employees will not be reimbursed for charges associated with the rental company fee for waiver for collision/loss damage or liability.


D. Private Limousine - Limousine costs will be reimbursed only when other reasonable transportation at a lower cost, (i.e., shuttle, rental car, taxi cab, etc.) is not available.

IV. Meals and incidentals – Other than specific identified exceptions, meals and incidentals will not be reimbursed based on the cost of the meal or item of purchase. Instead, employees shall receive a standard travel per diem rate to cover all meals and incidentals while traveling (See Per Diem Section below). Exception to the per diem rate for which meals can be reimbursed based on original receipt include:

A. Reimbursing an VP ET member, Director, or board Board member for

the cost of a group meal incurred while meeting with a business group consisting of employee(s), physician(s), vendor(s), employee or physician recruitment or any group meeting on District business.

B. Reimbursing an employee for the cost of a meal incurred while entertaining a visitor or other non-District employee on District business with the approval of the VP ET or board Board member.

C. Reimbursing an employee for the cost of a meal incurred while entertaining a prospective physician candidate with the approval of the Vice President of Human Resources or Medical Staff Office.

C.D. In the circumstances described above in items A, B, and C, alcoholic beverages may be consumer in connection with the mean and shall be considred a reimburseable business expense. Such purchases shall be reasonable and reflective of appropriate judgement/prudence.

V. Per Diem - Employees will receive a standard travel per diem rate to cover all

expenses incurred by the employee on behalf of the District during travel (aside from air fares, standard luggage fees, hotel registrations, mileage, transportation, and registration fees which are paid for by the District or directly reimbursed to the employee). A travel day includes the day immediately before and after the business event or if traveling on the same day as the business event, the travel day includes the official work day that is more than 12 hours but less than 24 hours as allowable by the U.S. General Service Administration located at www.gsa.gov/perdiem..

A. To receive a per diem payment prior to travel, the employee must

submit to Finance at least one week prior to travel an approved Travel Reimbursement Form (see attached form) requesting a per diem payment along with the required documentation described below in Section VII. If travel is canceled, and not approved by an ET member, the employee must immediately refund the District the per diem payment received for days not traveled.

B. To receive the per diem payment after travel has been completed the employee must submit to Finance within 60 days after travel has been completed an approved Travel Reimbursement Form (see attached form) requesting per diem pay along with the required documentation described below in Section VII.

Travel, Per Diem and Other Employee Reimbursement 5 VI. Entertainment – All requests for reimbursement of entertainment expenses

must be approved by an Executive Team member. VII. Required Documentation for all travel:

A. Instead of completing a nonstock form, the employee must complete the Travel Reimbursement Form (see attached form) and must include (i) appropriate approval for travel as discussed above under “Authorization”, (ii) the allowable per diem rate for location of travel as provided by the U.S. General Service Administration located at www.gsa.gov/perdiem and included on KD Central and (iii) evidence of the number of days traveling and location. The Travel Reimbursement Form is to be completed for each request for payment.

B. No receipts need to be submitted for expenses incurred that will be covered by the per diem rate. For expenses not covered by the per diem rate, original receipts MUST be submitted to the approver and attached to the Travel Reimbursement Form in order to be submitted to Finance for reimbursement. 1. For vendor purchases, a receipt including the vendor name,

transaction amount, date, and detail of the item(s) purchased. 2. For Internet purchases, a screen print or order confirmation

email 3. All receipts and/or invoices less than 8 ½ by 5 ½ inches must be

taped to a plain white sheet of paper. Multiple receipts may be included on the same sheet of paper, but they may not overlap.

C. In the rare and unique occurrence that a receipt cannot be located, an Executive Team member must sign the Travel Reimbursement Form approving the missing receipt. The executive team member can deny the reimbursement request.

D. If the business purpose of the transaction is not evident upon review of the receipt, further documentation of the business purpose is required.

Other Employee Reimbursements not relating to travel:

I. For other reimbursable employee business expenses which are reasonably incurred in the course of District business, the employee must submit to Finance within 60 days of the transaction an approved nonstock and attach the required documentation described below.

II. Non-reimbursable business expenses include, but may not be limited to:

A. charge card fees; B. Capital purchases C. meals in excess of the per diem rate, unless approved by the

Executive Team


D. personal services and sundries; E. baby-sitting/child care fees; F. traffic or parking violation citations; G. laundry and valet services; H. pet care; I. personal gifts J. alcoholic beverages

III. Required Documentation

A. Original receipts MUST be submitted to the approver. B. For vendor purchases, a receipt including the vendor name,

transaction amount, date, and detail of the item(s) purchased. C. For Internet purchases, a screen print or order confirmation email D. In the rare and unique occurrence that a receipt can not be located, an

Executive Team member must sign the nonstock approving the missing receipt. The executive team member can deny the reimbursement request.

E. If the business purpose of the transaction is not evident upon review of the receipt, further documentation of the business purpose is required.

F. All receipts and/or invoices less than 8 ½ by 5 ½ inches must be taped to a plain white sheet of paper. Multiple receipts may be included on the same sheet of paper, but they may not overlap

"These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."


Kaweah Delta Health Care District 400 W. Mineral King Visalia, CA 93291-6263 (559) 624-2000 Travel Approval and Reimbursement Form __________________________________________________________________________________________ *This form must be completed to submit request for conference and travel approval and for payment of per diem or reimbursement of travel expenses* Submit completed form with supporting documentation and/or receipts to your Department Manager / Supervisor or Vice President / Sr. Vice President / CEO as applicable. Name: __________________________________ Department # ___________ Date: ____________ Title of Seminar / Conference: ____________________________________________________________

Location (City, State) of Seminar / Conference: _______________________________________________ Dates of Conference From: ___________________ To: _____________________

TRIP DETAIL

Amount to be PaidEstimated

Expense

Actual Expense

Supporting Documentation for payment request Attached? If

“no” explain why. Registration Fees (608600) Mileage rate when using own car: Total miles _____ x $____ per mile

Rate is determined by IRS.gov rate

Public Transportation: Air, Bus, Train, Cab, etc.

Lodging(See AP19-“Air Travel and Lodging” Paragraph: Total days ____ x $___ per day*

Per Diem(See AP19 -“Per Diem” Section III)Working days ____ x $__ per day*Travel days ___ x $__ per day x 75%*

Meals(See AP19-“Meals” Section III)

Misc. Expenses (please specify) Parking / Car Rental, etc.

TRAVEL COSTS TO BE CHARGED

TO (608800)

* Amounts exceeding the per-day allowances must be approved by an Executive Team member prior to travel. Approval (Must include an Authorized Signor for the department being charged) Conference Approval Expense/Reimbursement Approval _________________________________________ ___________________________________________ Employee Signature Employee Signature _________________________________________ ___________________________________________ Department / Director SignatureAuthorizing Supervisor Authorizing Supervisor


Manual Name: Emergency Management Date: 10.9.17 Support Staff Name: Maribel Aguilar


#

Status – List policies in this order and identify if: New *,

Revised *, Reviewed, or Deleted

* Name and phone extension of person who wrote or revised policy - *

for New and Revised policies only

Media Plan DM 2107 Revised Maribel Aguilar 624-2381 Program Management – Emergency Management Committee

DM 2109 Revised Maribel Aguilar 624-2381

Dependent Care Plan DM 2111 Revised Maribel Aguilar 624-2381 Person In Charge DM 2115 Revised Maribel Aguilar 624-2381 Code Blue-Activation Plan DM 2202 Revised Maribel Aguilar 624-2381 Water Systems Failure Disruption DM 2216 Revised Maribel Aguilar 624-2381 Emergency Impact Assessment DM 2104 Reviewed Maribel Aguilar 624-2381

Elevator Use During Emergency Situations DM 2112 Reviewed Maribel Aguilar 624-2381 Reporting for Duty-Building Access DM 2116 Reviewed Maribel Aguilar 624-2381 Application for FEMA Financial Aid DM 2119 Reviewed Maribel Aguilar 624-2381 Post Disaster Recovery-Financial DM 2120 Reviewed Maribel Aguilar 624-2381 Critical Incident Stress management DM 2121 Reviewed Maribel Aguilar 624-2381 Code Triage-Activation Plan DM 2101 Reviewed Maribel Aguilar 624-2381 Code Gray-Activation Plan DM 2203 Reviewed Maribel Aguilar 624-2381 Code Red- Activation Plan DM 2207 Reviewed Maribel Aguilar 624-2381 Code Shelter in Place DM 2209 Reviewed Maribel Aguilar 624-2381 Code Orange-Hazardous Material Spill DM 2210 Reviewed Maribel Aguilar 624-2381 Earthquake Response DM 2212 Reviewed Maribel Aguilar 624-2381 Internal Flood-Activation Plan DM 2215 Reviewed Maribel Aguilar 624-2381 Anhydrous Ammonia Safety Procedures DM 2218 Reviewed Maribel Aguilar 624-2381 Surge Tent Use DM 2226 Reviewed Maribel Aguilar 624-2381 Total Evacuation Plan DM 2810 Reviewed Maribel Aguilar 624-2381

Emergency Preparedness

Policy Number: DM2107 Date Created: 07/01/2011 Document Owner: Maribel Aguilar (Safety Officer/Life Safety Cor)


Approvers: Board of Directors (Administration), Board of Directors (EOC/Emergency Preparedness)

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

During a major emergency or disaster, the District may need to communicate with employees and physicians who are not on campus at the time of an emergency regarding emergency staffing requirements or other staff instructions. The media may provide an efficient and effective means of communication between Kaweah Delta Health Care District (KDHCD) and off-campus employees.

In order to fulfill its obligation to inform the general public about the scope of the emergency, the media will seek casualty and other disaster-related information from the hospital. KDHCDKaweah Delta Health Care District will cooperate with this community mission to the best of its ability in a manner that will not interfere with patient care or hospital operations.

The Public Information Officer (PIO) is responsible for coordination and release of appropriate and relevant information to the media during an emergency incident or disaster.

II. Procedure A. Media Releases

The PIO, working as an integral component of the KDHCDKaweah Delta Health Care District Hospital Incident Command System (HICS) Team, will obtain approval from the Incident Commander for media releases during an emergency incident or disaster.

B. Media Relations

The PIO will serve as principal liaison with individual members of the media and will direct media representatives to the designated Media Area, which may be located in the Support Services Building. The PIO will confirm that media representatives have appropriate access to hospital facilities in a manner that will not interfere with patient care or hospital operations as follows:

1. News media persons will be taken to the designated Media Area during activation of the Emergency Management Plan.

2. Media personnel WILL NOT be allowed in Intensive Care, Emergency Department (ED), ER, Operating Room (OR), Morgue Area, Decontamination Areas, any Triage site or the Hospital Command Center (HCC) under any circumstances.

3. Security officers will be assigned to keep the media away from unauthorized areas, as needed.

Media Plan 2

C. Employee Communications

The PIO will coordinate and assist in preparation of written communication releases to on-duty staff with the Support Branch Director.

The PIO will work directly with news outlets to provide status information to physicians and employees on such issues as contingent staffing needs.

1. Staffing Requests to Off-Campus Employees – The PIO will coordinate with the Labor Pool and Credentialing Unit Leader the release of staffing requests for KDHCDKaweah Delta Health Care District employees off-campus by providing announcements to designated broadcasters for dissemination.

2. On-Campus Employees – The PIO will coordinate with the Situation Unit Leader for dissemination of incident-related information to KDHCDKaweah Delta Health Care District employees on campus.

D. Casualty Interviews

Interviews with casualties admitted to the hospital may be granted only by the Incident Commander following consultation with the attending physician. Any interview may be terminated at the discretion of the physician attending the patient.

E. Media Lists

Media lists, kept current by KDHCD’sKaweah Delta Health Care District’s Marketing Department, will be maintained as Attachments to the PIO Job Action Sheet.

F. Communications Group

The PIO will work with the following HICS positions to coordinate information collection and release: PIO, Situation Unit Leader, Patient Tracking Manager and Support Branch Director.



Policy Number: DM 2109 Date Created: 09/01/2008 Document Owner: Maribel Aguilar (Safety Officer/Life Safety Cor)



Program Management- Emergency Management Committee

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

The Emergency Management Committee is a subcommittee of the Kaweah Delta Health Care District (KDHCD) Environment of Care Committee. Under this oversight, it is charged with developing and maintaining the District’s Emergency Operations Plan. This shall be done through planning, implementation and evaluation of all elements of the program. The Emergency Management Committee ensures compliance with Federal, State, and other accreditation boards that control regulations regarding emergency management activities.

II. Procedure A. Responsibility

1. The Emergency Management Committee is responsible for development and maintenance of the Emergency Management Manual, planning and implementation of training exercises, review of all Hospital Incident Command System (HICS) activations, and communication of applicable Emergency Management information to the Environment of Care Committee.

2. Department Managers are responsible for ensuring that all employees within their department are familiar with the main components of the Emergency Operations Plan.

B. Membership of the Committee

1. The Emergency Management Committee is chaired by the District Safety Officer or designee.

2. The Emergency Management Committee is composed of representatives from:

• Emergency Department (MD and RN) • Risk Management

• Security • Maintenance

• Infection Control • Nutrition Services

• Communications • Human Resources

• Information Systems • Nursing

• Marketing • Environmental Services

• Imaging

Program Management- Emergency Management Committee 2

Additional KDHCD staff is invited to attend committee meetings as needed to share information and receive updates.

3. The District Safety Officer will be a member of the Environment of Care Committee and act as a liaison between the two committees.

C. Duties of the Emergency Management Committee.

1. Meeting Attendance Members attend regularly scheduled meetings.

2. Drill Requirements – The Joint Commission Ensures that the District conducts at least two drills per year. One includes an influx of volunteer or simulated patients. One includes a community wide drill relevant to the priority emergencies identified in the District’s Hazard Vulnerability Analysis (HVA) and that assesses communication, coordination, and the effectiveness of the hospital’s and the community’s command structure. The Emergency Management Committee also performs a post-exercise critique, and ensures written reports evaluate performance per JCAHO The Joint Commission requirements.

3. Drill Requirements – Title 22 Department of Public Health Services (DPHS) Assures that emergency management drills are performed in compliance with Title 22 requirements (at least once per shift per quarter). Contributes to written reports of all plan activations, including drills or actual events. The report outlines deficiencies, recommends plans of correction or improvement, identify person(s) or department(s) responsible for corrections.

4. Quality Improvement Approves and acts upon changes recommended as a result of post-exercise critiques. Monitors outcome at its regular meetings.

5. Annual Plan Review Reviews the Emergency Operations Plan annually, revises as needed, and submits a written report to the Environment of Care Committee.

6. Training Ensures that all personnel are instructed in the Emergency Operations plan to the degree necessary to assume their role in implementing the Plan.

7. Quarterly Reports Reports to the Environment of Care Committee, quarterly, all deficiencies and performance improvements.

D. Emergency Management Committee Chair

Liaisons with other community Emergency Operations Planning groups and reports back to the Emergency Management Committee.






Dependent Care Plan Printed copies are for reference only. Please refer to the electronic copy for the latest version. I. Policy

In the event of a long-lasting external emergency or civil disturbance where personnel will remain at the hospital for long periods, dependents, including children, elderly and disabled persons may be brought to the main campus, and housed in the designated dependent area. If no responsible person is available at home to provide care, these dependents will be housed in the dependent care area for the duration of the disturbance or until other arrangements are made.

II. Procedure This procedure outlines the process by which the Hospital Incident Command System (HICS) at Kaweah Delta Health Care District provides for sheltering and feeding of staff and volunteer dependents during an extended disaster or emergency event.

A. Mobilization – Upon request by the Operations Chief or the Incident Commander, the Family

Care Unit Leader shall mobilize sufficient staff and resources to activate a dependent care area removed from patient care areas. Primary location for children age 0 – 18 years is Kaweah Kids (KK Policy #127). Primary location for adult dependents will be Kaweah Delta Rehab Hospital located at 840 S. Akers St. Visalia Ca.

B. Safety Requirements – Prior to activation of the dependent care area, the Family Care Unit

Leader, with assistance of the Safety Officer or Designee, shall conduct a safety inspection of the area to remove any unsafe objects and to secure any equipment that could pose a safety hazard.

C. Staff

1. The Dependent Care Area shall be operated by at least two staff that will oversee

any other auxiliary volunteers requested from the Labor Pool, two clerical staff for registration. The staff will provide the appropriate ratio of staff to dependents as determined by acuity or age-related needs.

2. Staff and volunteers shall sign in and out when reporting to assist. 3. Staff shall monitor the area continuously for safety issues and respond to

dependents’ needs.

D. Supplies

The following supplies are needed to set up the Dependent Care Area. Requests for additional supplies should be directed to the Supply Unit Leader:

o Accordion alpha file (or file drawer for dependent records)

Dependent Care Plan 2

o Armbands o Backpacks o Camera o Printer for color photo prints o Cots o Dependent Care Binder o Dependent Care Registration forms o Diaper changing facilities and supplies o Diversions for children (VCR, videos, games, toys) o Emergency lighting o Flashlights o Non-sterile gloves, medium and small o Note pads for documentation o Red Hazardous Waste Disposal Bags o Sheets, blankets, pillows, towels and washcloths o Sticker tags o Water, bottled o Waterproof Pads (Chux)

E. Food – Meals and snacks for dependents shall be arranged by the Food Services Unit

Leader. F. Registration

1. Post signs indicating “Dependent Care Area – Responsible Adult Must Register

Dependent”. 2. Assign each family a Family Number. 3. All dependents shall be assigned a Dependent Number and shall register using the

Dependent Care Registration form. Establish the Dependent Number by adding a letter (A, B, C, D, etc.) to the Family Number for each dependent in a given family.

4. Apply an armband to each dependent upon arrival with name and dependent number

5. Take a photo of each dependent with Responsible Adult person responsible for the, and attach to Dependent Care Registration form.

6. The employee who registered them may sign out dependents or one of the individuals named as an emergency contact on the Dependent Care Registration form. The Employee ID badge or other legal form of photo identification must be used.

7. Tag medications, bottles, food and other belongings with dependent’s name and Dependent Number and store appropriately.

8. Assign each dependent to a dependent care provider and record on form.

G. Medications 1. Assure that dependents taking medications have a supply to last during the

estimated length of stay. 2. Arrange for a pediatric nurse or other licensed nurse to dispense medications as

appropriate.

H. Psychological Support – Arrange for the Employee Health & Well-Being Unit Leader to make routine contact with dependents in the shelter, as well as responding to specific incidents or individual needs.

I. Documentation

1. Document all care provided to individual dependents, such as medications, psychological services, toileting or dressing on the Dependent Care Record (on the reverse side of the Dependent Care Registration form).

2. Document all other actions and decisions and report routinely to the Support Branch Director.

J. Checking Out of Dependent Care Area

Dependent Care Plan 3

1. When dependent leaves area, compare picture with dependent and Responsible Adult.responsible person.

2. Check ID, verify name and obtain signature of Responsible Adult responsible person picking up dependent.

3. Retrieve and send all medications and personal items with dependent. 4. Collect armbands.






Person In Charge (Initial Response Coordinator) Printed copies are for reference only. Please refer to the electronic copy for the latest version. I. Policy

In the event of an internal disaster, the Department Manager or designee (in area in which the event occurs) will initiate and coordinate response efforts, until a person with higher authority or expertise takes over.

Background

The initial Person in Charge at the scene of a disaster must be knowledgeable and competent to take charge of the area, or have specific training to respond. An area Department Manager or other such personnel should be prepared to assume a leadership role to coordinate emergency response activities only until such time as the emergency response plan is activated and the Incident Commander or other officials (fire/police) take charge of the situation.

II. Procedure A. The Person in Charge will direct response activities as follows:

1. Notify PBX at Ext. 44. (Note: departments located outside of main campus dial 9-911 medical or life safety emergencies .to report any emergency, followed by a call to Ext. 44.)

a. Announce the Emergency Code overhead, if appropriate. b. Alert Administration, via Nursing Supervisor.

2. Assess situation.

a. Define the event. b. Assess risks/hazards. c. Determine what is needed to secure the situation. d. Check to see if area has appropriate and adequate resources.

3. Provide direction to staff at the scene.

4. Notify appropriate personnel.

5. Alert and coordinate with Administration if the response needs to be escalated or expanded (i.e., “Code Triage”).

6. Document the incident on the Emergency Occurrence/Drill Critique and submit to the Safety Office as soon as possible.

Person In Charge (Initial Response Coordinator) 2

B. When the incident is over, the Incident Commander will authorize PBX to announce the appropriate “All Clear” announcement.






Code Blue/Code White Activation

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

This policy is designed to provide a coordinated and effective response by a trained team of professionals to cardiopulmonary arrest.

Definitions: Code Blue: Adult CPR Medical Emergency Code White: Pediatric Medical Emergency Procedure A. Background

In the event of a cardiopulmonary arrest the assigned Code Blue Team members will respond to the location of the arrest. All other personnel are to stay out of the area unless assigned by the team leader. Please refer to PC.189 policy and procedure in the Patient Care Manual.

B. Response

See attached checklist and flowchart.

Code Blue/Code White Activation 2

CODE BLUE/WHITE – Medical Emergency Purpose: To provide assistance if you witness or become aware of a medical emergency

involving a fellow employee, patient or visitor at the hospital.

STAFF RESPONSE CHECKLIST When you are the first person to find a patient, visitor or employee who appears to be a victim of a medical emergency or to be in life threatening distress, immediately initiate the following: If the victim is in an area of the hospital where a physician or nurse is nearby: Yell for help. The physician or nurse will assess the situation. If there is a cardiac/respiratory arrest or medical emergency the Physician or Nurse will direct

staff to dial Ext. 44 to report a Code Blue/Code White with the location. Off site facilities will call 9-911.

If trained in CPR, initiate. Await the arrival of the Code Blue Team. If the victim is in an area of the hospital where no physician or nurse is present but other people are present: Yell for help – Direct responder to dial Ext. 44 to report situation and location. Remain with victim until the Code Blue Team arrives. Off site facilities will call 9-911. If trained in CPR, initiate. If not trained in CPR, attempt to arouse victim. If the victim is in an area of the hospital where no one else is present but you: Go to the nearest phone and dial Ext. 44 to report situation and location. Return to the victim and initiate CPR, if trained, and await Code Blue Team arrival. If the victim is in an area on campus but not in the main hospital buildings: Go to the nearest phone and dial 911. Return to the victim and initiate CPR, if trained, and await paramedics. If the victim is in an outside facility - not in the main hospital buildings: Yell for help □ Go to the nearest phone and dial 9-911. Return to the victim and initiate CPR, if trained, and await paramedics.

PBX Checklist Announce “Code Blue” or “Code White” (3x) and state the location over PA system. Immediately send out a page via paging system.

All Clear After “Code Blue, All Clear” is announced (3x), return to your normal work duties, unless otherwise directed.

Code Blue/Code White Activation 3

Yell “Code Blue” or “Code White”for help.

Dial Ext. 44 and state, “Code Blue” or “Code Whtie” andlocation. If at offsite location, call 911.

Begin CPR if trained. Continue CPR untilCode Blue Team arrives.

Complete requireddocumentation.

If a physician or nurse is nearby, allow toassess the situation.

Code Blue/White(Medical Emergency)

Return to normal duties after“All Clear” is announced.

Emergency Management ManualCode Blue /White - Medical Emergency






Water Systems Failure/Disruption

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

I. Policy

In the event of a water systems failure, Kaweah Delta Health Care District (KDHCD) will activate its Water Systems Failure/Disruption procedure. There is built-in redundancy.

II. Procedure

A. The following equipment may be disrupted due to a water systems failure in the affected building:

Equipment Disrupted

Air Conditioning and Heating Dialysis Diesel Generators — Dietary Dishwasher Fire Sprinklers Hand Washing (sinks) Linear Accelerator/CT/MRI Medical Air — Medical Vacuum — Other High-Tech Heat-Generating Equipment

Radiology Film Developer — Sanitary Waste Disposal Some Refrigerators/Freezers Steam Sterilizers Toilets

= probable equipment disruption — = not applicable

Water Systems Failure/Disruption 2

B. In the event that the water service is interrupted for reasons other than a shut down for repairs, the following steps will be taken.

The Maintenance Department will immediately be notified. Each department will be notified to limit the use of water. CALL: CALIFORNIA WATER SERVICE 559-624-1600 Ask for an estimate of the time that service will be interrupted.

C. IF WATER IS CUT OFF TO THE HOSPITAL:

1. Pressure will drop until water is exhausted.

2. Boilers will be turned off. There will be no heat or sterilization.n

3. Food Services will utilize single service dishes and utensils instead of china. Meal preparation will be adjusted to utilize cold food preparation techniques.

D. During a water outage everyone should take precautions to conserve as much

as possible. Patient baths, toilet flushing, and washing procedures should be kept to a minimum.

Maintenance is responsible for the distribution of emergency water supplies.

III. Emergency Water Supplies: Main Campus: In the event of an emergency, water supplies would be needed for approximately 1,000 people for 96 hours. One gallon per person per day totals 4,000 gallons. Potable water contained in hot water tanks: 3,000 gallon tank located in Mineral King Wing building 4,000 gallons tank located in two 2,000 gallon tanks in Acequia Wing building Total: 7,000 gallons potable water available at main campus. In addition, there are 5 pallets of bottled water located at the downtown campus. There is a total of 1,673 gallons of bottled water available for all campuses. South Campus: In the event of an emergency, water supplies would be needed for approximately 200 people for 96 hours. One gallon per person per day would total 800 gallons. 55 gallons of water in Kkitchen ice machines 65 gallons of water in hot water tank outside kitchen 1,000 gallons of water in Hhot water Ttank 112 gallons of water from bottled water Total: 1,232 gallons of potable water available at South Campus West Campus


In the event of an emergency, water supplies would be needed for approximately 300 people for 96 hours. One gallon per person per day would total 1,200 gallons of water. 650 gallons of water in the Rehab hot water tank 600 gallons of water in the Lifestyles hot water tank 440 gallons of water in the Mental Health hot water tank 150 gallons of water in the SRCC hot water tank 600 gallons of water in the Dialysis hot water tank 44 gallons of water in Kkitchen Iice machines 80 gallons of water in bottles available & kept in storage Total: 2,564 gallons of potable water available at West Campus In case of a county disaster that disrupts the KDHCD water system, the Tulare County Office of Emergency Planning will be handling certain aspects of supplying services and can be called upon for service. (559-686-3461) OTHER SOURCES OF WATER AND TRANSPORTATION OF WATER IN CASES OF EMERGENCY ARE:

Kraft Foods-Tulare (Knudsen Dairy) 559-685-0790

California National Guard 559-733-3062

Major-Sysco 1-800-877-4194 Pepsi-Cola 1-800-932-0966

559-485-5050 Alhambra -Sierra Springs 1-800-453-0293 Culligan / Lindsay-office 559-562-6361 Culligan Personnel to contact: Cary Miller 559-359-8650 Alex Blackwell 559-361-3686 Sepp Becker 559-359-5320

Nancy Becker 559-359-3287

Formatted: Centered, Tab stops: Not at 0.5"+ 3" + 6"


Emergency Management Manual

WATER SYSTEMS FAILURE/DISRUPTION Purpose: In the event of a partial or total disruption of the water supply, the hospital will

provide specific procedures for staff to follow. Note: A large-scale incident may develop into a Code Triage.

STAFF RESPONSE CHECKLIST Notify EngineeringMaintenance by calling PBX at Ext. 44. Immediately cease use of water and check with Department Manager or designee

for department procedures. To wash hands, use hand gel sanitizer. Soap and water should be used as sparingly

as needed if hands are visibly soiled. . To use “dry toilets” tape a red plastic bag over the 2 red bags already taped to the

toilet. Remove the single bag after use, tie the bag, and dispose in a covered large, double-lined, leak-proof container.

Steam/Steris and water required sterilization devices Sterilization will be lostnot function. Use alternate cold sterilizing methods.

If given advance notice, take the following steps: Fill all available sinks, basins, etc., with water. Have patients bathed prior to shut down. Obtain waterless hand washing product from storeroom for hand washing. (Should

be on all units.) In surgery and Emergency Department (ED), obtain bottled water for surgical scrubs. Line toilets with red bags. Maintenance to obtain water tanker for on site. Ensure public toilets are closed.

DEPARTMENT CHECKLIST Implement Water Systems Failure/Disruption procedures in the department. Establish adequate inventory of hand gel sanitizer in department. Direct that the use

of bathing facilities be immediately discontinued. Obtain water supply for hand hygiene when sanitizer is not appropriate. If loss of services is for an extended period of time, as determined by the Incident

Commander, consider dismissal of non-patient-related employees. Have employees report to Labor Pool for assistance in patient care areas if needed. Do not dispose of any waste in drains during utility failure until service has been

restored. Identify procedures which require water that can be delayed or canceled. Assess and report department status to the Incident Commander on the

Emergency/Disaster Status Report regarding the following items: Calculate the amount of water needed by determining the number of patients and

staff on duty in the department. (A minimum of 1 gallon of water per person per 24-hour period is needed.)

Determine other patient fluid requirements or special department needs for the next 24 hours.

Inventory available potable water and non-potable water in the department (i.e., potable drinking water, canned drinks, IV fluids, distilled water, non-potable water in tubs, mop buckets, etc.).

Identify critical areas of impact within the department. (Refer to the grid on page 1 of this policy.)


ENVIRONMENTAL SERVICES CHECKLIST Ensure that water for cleaning is restricted to whatever non-potable water is

available. Determine the number and location of “dry toilets” and which toilets may be locked (in

consultation with Maintenance). Check germicidal wipe availability in patient care areas. Restrict use of toilets and sinks and post “Do Not Use” signs. Provide red plastic bags and large double-lined leak-proof containers to designated

bathrooms that remain in use. Assist in waste collection. Make necessary cleaning adjustments to conserve water use. Schedule additional rounds for picking up waste from nursing units. Obtain extra containers for waste and deliver to floors. Do not dispose of any waste in drains during utility failure until service has been

restored. MAINTENANCE CHECKLIST

Maintenance will assess the water disruption and inform Administration and affected departments of the expected duration.

Based on assessment, Engineering will activate the “Water Systems Failure/Disruption” procedure.

Implement Engineering Department water disruption/failure plan. Institute Fire Watch as necessary. Order portable toilets with hand washing facility for each hospital entrance. Complete Utility Failure Report detailing the circumstances surrounding the utility

loss and corrective action taken. FOOD SERVICES CHECKLIST

Go to disposable service and implement other water-saving measures. Use foods that do not require use of water for preparation. Use non-steam-operated

equipment. Close cafeteria and have food catered, if necessary. Do not dispose of any waste in drains during utility failure until service has been

restored. SURGERY CHECKLIST

Cancel all elective procedures, if necessary. Use bottled water already in the department (sterile and distilled). Use instruments sterilized prior to water outage. Borrow instruments from another

facility, if necessary. Use waterless hand washing product for hand washing supplied on each unit and

from the storeroom. Line hoppers with red bags. Do not dispose of any waste in drains during utility failure until services has been

restored. SterisSteam and water required sterilization equipment will not function.

NURSING AREAS CHECKLIST Do not use disposable wipes for cleaning patients, only use product designed for skin

cleaning. Use hand sanitizer for hand washing supplied on each unit and from the storeroom. Line toilets with red bags. Discharge as many patients as possible (if needed). Use bedside commodes/bedpans and dispose of waste in red “hazardous waste”

bags. Do not dispose of any waste in drains during utility failure until service has been

restored.


RADIOLOGY CHECKLIST Shut off processor until actually ready for processing. Process only emergency films. Obtain extra containers for waste and deliver to floors. Do not dispose of any waste in drains during utility failure until service has been

restored. LABORATORY CHECKLIST

Drain liquid instrument waste into spill-proof, leak-proof, hazardous waste containers supplied by Environmental Services.

Do not dispose of any waste in drains during utility failure until service has been restored.

SECURITY CHECKLIST Conduct fire watch throughout the hospital, if directed. Assist in ensuring public toilets are not used by putting up signs and tape on doors. Do not dispose of any waste in drains during utility failure until service has been

restored. ALL CLEAR

When “Water Systems Disruption, All Clear” is announced, return to your normal work duties unless otherwise directed.


Water Systems Failure/Disruption 8 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."


Manual Name: Environment of Care Date: 10.9.17 Support Staff Name: Maribel Aguilar


#

Status – List policies in this order and identify if: New *,

Revised *, Reviewed, or Deleted

* Name and phone extension of person who wrote or revised policy - *

for New and Revised policies only

Failure of Air Conditioning EOC 1039 Revised Maribel Aguilar 624-2381 Fire Watch EOC 5003 Revised Maribel Aguilar 624-2381 Clinical Engineering management Plan EOC 6001 Revised Maribel Aguilar 624-2381 Environment of Care Communication Flow Chart

EOC 1002 Revised Maribel Aguilar 624-2381

Indoor Air Quality EOC 1020 Revised Maribel Aguilar 624-2381 Disruption of Service, Sewage EOC 1037 Reviewed Maribel Aguilar 624-2381

Emergency Generator Testing and Fuel Levels

EOC 7403 Reviewed Maribel Aguilar 624-2381

Infection Control Risk Assessment EOC 5021 Reviewed Maribel Aguilar 624-2381 Utilities Management Inventory EOC 7305 Reviewed Maribel Aguilar 624-2381 Compressed Gas and Oxygen Use EOC 4007 Reviewed Maribel Aguilar 624-2381 Department Decorations EOC 5041 Reviewed Maribel Aguilar 624-2381 Disruption of Service, Elevator EOC 1041 Reviewed Maribel Aguilar 624-2381 Ergonomics EOC 1071 Reviewed Maribel Aguilar 624-2381 Failure or Absence of Nurse Call System while Caring for Patient


Formaldehyde Spill EOC 4404 Reviewed Maribel Aguilar 624-2381 Key Control Policy EOC 3010 Reviewed Maribel Aguilar 624-2381 Medical Equipment Hazardous Device and Recall Notification Policy


Storage and Warming of Blankets in Warming Cabinet


Environment of Care

Policy Number: EOC 1039 Date Created: 04/01/2010 Document Owner: Maribel Aguilar (Safety Officer/Life Safety Cor)



Failure of Air Conditioner Printed copies are for reference only. Please refer to the electronic copy for the latest version. POLICY:

The Engineering Department, will take the necessary steps to correct any failures of essential equipment or major utilities. by following the procedures outlined in the Engineering Procedure Manual. PROCEDURE: Notify a qualified vendor the proper service or persons when repair of the air conditioning system is beyond the scope of engineering staff. Consider utilizing fans or portable HVAC units to assist in cooling until repairs can be completed.

Notify the house supervisor and all departments that are affected. Tell them approximately how long repairs will take. Follow unit specific procedures. The Nursing Supervisor shall decide if Code Triage or Code Triage Alert needs to be called, if patients and/or building occupants need to be relocated. Notify affected departments upon restoration of service.

Formatted: Indent: First line: 0", Tab stops:Not at 1"

Formatted: Font: 12 pt, Font color: Black

Failure of Air Conditioner 2 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

Z

Environment of Care



Approvers: Board of Directors (Administration); Board of Directors (EOC/Emergency Preparedness); Aguilar, Maribel; Moccio, Cindy

Fire Watch

Printed copies are for reference only. Please refer to the electronic copy for the latest version. PURPOSE: To provide emergency measures for monitoring any fire alarm and/or fire sprinkled building in the Kaweah Delta Health Care District (District) in the event of an impaired fire alarm or fire sprinkler system. DEFINITIONS: Fire Watch: A temporary measure that provides surveillance rounding to the area(s) of the building where the fire alarm and/or fire sprinkler are not currently in full functioning capacity. Fire Watch allows buildings to be temporarily occupied when the fire suppression systems or the fire alarms are out of service. Fire Watcher: A dedicated, trained person(s), whose sole responsibility is to, either, look for fires within an appointed area or watch the fire alarm panel for the duration of the unsafe condition. The fire watcher is required to patrol the affected area(s), initiate Code Red, prevent a fire from occurring and extinguish small fires, if safe to do so. System Bypass: When the fire alarm and/or fire sprinkler reporting system has been bypassed so that it will not remotely report a fire or trouble alarm to the off-site monitoring company. These systems will still alarm to the fire alarm panel itself. System Down: When the fire alarm has been completely taken off line and will not ring at the panel, if needed, or report out to the off-site monitoring company. Fire Watch rounds are to be implemented immediately when this occurs. System down also applies when the fire sprinklers have to be drained for repair work to be completed. Fire Watch rounds will also be implemented immediately when this occurs. POLICY: Fire Watch is required to be implemented when any of the following takes place:

1. The fire alarm and/or sprinkler system is temporarily shut down or taken off-line

for more than four (4) hours in a twenty-four (24) hour period (does not need to be consecutive). Fire Watch will begin, immediately, at the end of the four (4) hour window.

2. A system failure of the fire alarm control panel or monitoring capabilities occurs.

In this instance, Fire Watch will start immediately.

2.3. The fire watch log (Attachment A) must be completed by facilities lead/manage/on-call or construction manager/designee.

Conducting Fire Watch Rounds:

1. Only Fire Watch trained personnel, who are familiar with the building(s) and evacuation plan(s), shall conduct Fire Watch rounds.

2. Fire Watchers shall have knowledge of: preventing, identifying and controlling fire

hazards.

3. In the event that Security or Maintenance is not available for Fire Watch, staff will be trained by condensed orientation and literature review.

Documentation of completed training, See “Attachment B,” shall be kept by the Safety Department or designee; a copy will also be kept in the employee file.

4. Fire Watchers will be familiar with fire extinguisher locations.

5. When on Fire Watch, Fire Watcher will be solely dedicated to this task. They will

not be pulled off for other duties (without being replaced) or asked to do any other tasks while on Fire Watch rounds.

Discontinuing Fire Watch Rounds:

1. Fire Watch shall not be discontinued without approval from the Maintenance Department.

PROCEDURE:

1. Routine maintenance, testing and inspection:

A. When routine maintenance is performed and the fire alarm and/or fire sprinkler system is put into bypass, a timer shall be started or resumed from original timing (if previous Fire Watch was started during the previous twenty-four (24) hours). Attachment “A” shall be filled out during business hours with 24 hour notice.

Formatted: Left, Indent: Left: 0.5", Nobullets or numbering

B. When the timer reaches a combined total of four (4) hours, the Fire Watcher will immediately notify Maintenance and PBX that a Fire Watch is now being implemented.

C. Rounds will commence immediately and be conducted within every 60

minutes.

D. Rounds will be tracked on the Fire Watch Log “Attachment A,” see attached.

E. During the 60 minute rounds of the Fire Watcher, rooms that will be

checked include: storage areas, hazardous areas, restrooms, break rooms, offices, exit corridors, and exit stairwells.

F. After the system(s) have been repaired and tested, Maintenance will

notify Security and PBX that Fire Watch is no longer necessary.

G. Security will then send the Fire Watch Log(s) to Maintenance via EFAX and give the originals to the Security Department Manager.

2. Emergency Deactivation of System(s):

A. When an emergency occurs and the fire alarm and/or fire sprinkler system is inoperable, the facility shall immediately be put into Fire Watch and rounds will be conducted accordingly.

B. Rounds will be tracked on the Fire Watch Log “Attachment A,” see

attached.

C. During the 60 minute rounds of the Fire Watcher, rooms that will be checked include: storage areas, hazardous areas, restrooms, break rooms, offices, exit corridors, and exit stairwells.

D. After the system(s) have been repaired and tested, Maintenance will

notify Security and PBX that Fire Watch is no longer necessary.

E. Security will then send the Fire Watch Log(s) to Maintenance via EFAX and give the originals to the Security Department Manager.

RESPONSIBILITIES:

1. Maintenance/Construction::

A. When putting the system in bypass (non-emergency):

I. Notify: Maintenance Lead, Maintenance Manager, or the On-Call Maintenance individual (Swing/Night Shift) of the need for Fire Watch. Document the need and time for Fire Watch in the pass

down log, fire watch log (attachment A) and the fire watch control log (attachment C).

II. Call the Fire Alarm monitoring company and let them know how long the

system will be in bypass. III. Call the Visalia Fire Department Dispatch Center at: 559-734-8117 and

let them know how long we will be in bypass and at which building/campus.

IV. Call the Security Department Lead on duty and notify them of the

condition of the system. If you cannot reach the Lead directly, call PBX and have them contact the Lead to call you back. It is very important to speak with Security directly.

V. When repairs, tests, inspections or emergencies have been completed

and the system is back in normal condition, call each of the above places to notify them that we are no longer on Fire Watch. Document the need and time for Fire Watch in the pass down log.

B. When putting the system in bypass (emergency):

I. Notify: Maintenance Lead, Maintenance Manager,, Facilities Director,

House Supervisor and the On-Call Maintenance individual (Swing/Night Shift) of the need for Fire Watch. Document the need and time for Fire Watch in the pass down log., on the fire watch log and the fire watch control log.

II. Call the Fire Alarm monitoring company and let them know how long the

system will be in bypass.

III. Call the Visalia Fire Department Dispatch Center at: 559-734-8117 and let them know how long we will be in bypass and at which building/campus.

IV. Call the Security Department Lead on duty and notify them of the

condition of the system. If you cannot reach the Lead directly, call PBX and have them contact the Lead to call you back. It is very important to speak with Security directly.

V. When repairs, tests, inspections or emergencies have been completed

and the system is back in normal condition, call each of the above places to notify them that we are no longer on Fire Watch. Document the need and time for Fire Watch in the pass down log.

2. Security:

A. System(s) in bypass:

I. Upon receiving notification from Maintenance that the fire alarm and/or fire sprinkler systems are in bypass for testing, inspection or repair, Security will check the Fire Watch clipboard, located in PBX, to notate the Fire Watch Control Log (Attachment “C”) and check the last time that a bypass was requested.

II. Check the guidelines below and start the timer:

a. If the system was last in bypass during the last 24 hours,

the timer will CONTINUE from the last point it stopped. b. If the system was last in bypass more than 24 hours ago,

the timer will RESTART for the 4 hour countdown.

III. If/when the timer runs out and the system has been on bypass for 4 hours (total) in a 24 hour period, Fire Watch will begin immediately. Contact Maintenance to inform them that Fire Watch rounds have begun.

B. System(s) down:

I. Upon receiving notification from Maintenance that the fire alarm

and/or fire sprinkler system(s) are completely down, due to repair or an emergency, Security will begin Fire Watch rounds immediately.

3. Safety, Facilities Director and/or Designee:

Upon notification that the facility is in Fire Watch, the designated person will complete the following:

A. Contact the District’s Director of Risk Management or Designee to inform them that a building (specify) is on Fire Watch.

B. Contact the Fire Marshal (Authority Having Jurisdiction) to notify which

building (give the address and location) is in Fire Watch. Be as specific as possible with dates and times.

C. When fire watch rounds are complete and the system is back on line:

I. Call Risk Management to notify that rounds are complete and that

the system is back on line.

II. Call the Fire Marshal to notify that rounds are complete and that the system is back on line.

4. Risk Management:

A. After the initial 4 hour grace period, notify the California Department of Public Health (CDPH) by fax at: 661.336.0529 to notify them that we are

on fire watch and the estimated time when we will be back to normal function.

B. When fire watch rounds are complete and the system is back on line, fax the completed fire watch rounding sheets to CDPH along with a memo stating that the rounds have been completed. If there was a repair to be made, note that the repair was made and attach the service record from the vendor.

5. Unable to perform Fire Watch:

A. If Security is unable to perform Fire Watch duties, the task will be performed by the Maintenance and/or Construction Department.

B. If Maintenance is unable to perform Fire Watch duties, they will call their

immediate Supervisor. and then the House Supervisor.

TRAINING: Upon new hire, training shall be held for Security and Maintenance personnel to teach best practices in order to conduct Fire Watch. REGULATIONS AND STANDARDS: 2010 California Fire Code, Title 24, Part 9, Chapter 9, Section 901.7 NFPA 101:2012 Life Safety Code, §9.6.1.8 The Joint Commission, Life Safety Code, LS.01.02.01, EP 1


Attachment “A”

FIRE WATCH LOG

1. ** To be filled out by facilities manager/lead/designee or construction manager/designee. Copy to be kept in PBX during fire watch.

2. A. Who is completing form: ______________________ B. Who is performing work:_______________________ C. Contact name: ______________________________ D. Contact phone number: _______________________

FIRE WATCH LOG ASSIGNED BUILDING/AREA: DATE: TIME NOTIFIED: _ TIME FIRE WATCH TO START:

WHY IS THE FIRE WATCH IN EFFECT?

FIRE-WATCHER: INITIALS:

FIRE-WATCHER: INITIALS:

FIRE-WATCHER: INITIALS: (May add additional names and initials on the back of this form)

Fire watch personnel must perform continuous, un-interrupted tours such that rooms in their assigned area are checked at no less than 60 minute intervals. Times must be recorded using the 24-hour clock and initialed. Any problems found during the fire watch must be documented (along with the time found and initialed) and reported immediately, at the time of discovery, to the maintenance lead, manager and/or designee for immediate correction.

I certify (by my initials below) that I completed a tour of my entire assigned area at the following times:

A. System Working 1

A. System bypassed for scheduled repairs or maintenance and testing while being monitored by vendor at annunciator and can verbally communicate alarms to PBX operator. 1

A. System bypassed for scheduled repairs or maintenance and testing while NOT being monitored by vendor at annunciator and B. Has the system been disabled for 4 or more hours in the last 24 hours?

3

A. System bypassed for scheduled repairs or maintenance and testing while NOT being monitored by vendor at annunciator and B. Has the system been disabled between 0 to 4 hours in the last 24 hrs?

2

A. Has the system broke down or malfunctioned 3 1=No fire watch, 2*=Start fire watch after a total of 4 hours in the last 24 hours, 3*=Start fire watch NOW

* Only the area(s) effected by the Malfunctioned/Repair/Testing need to be under Fire Watch

A. System Working 1

A. System bypassed for scheduled repairs or maintenance and testing while being monitored by vendor at annunciator and can verbally communicate alarms to PBX operator. 1

A. System bypassed for scheduled repairs or maintenance and testing while NOT being monitored by vendor at annunciator and B. Has the system been disabled for 4 or more hours in the last 24 hours?

3

A. System bypassed for scheduled repairs or maintenance and testing while NOT being monitored by vendor at annunciator and B. Has the system been disabled between 0 to 4 hours in the last 24 hrs?

2

A. Has the system broke down or malfunctioned 3 1=No fire watch, 2*=Start fire watch after a total of 4 hours in the last 24 hours, 3*=Start fire watch NOW

* Only the area(s) effected by the Malfunctioned/Repair/Testing need to be under Fire Watch

Circle One

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Fire Watch 8

Time Tour Completed Initials

Time Tour Completed Initials

Time Tour Completed Initials Time Tour

Completed Initials

00__ 06__ 12__ 18__

01__

07__

13__

19__

02__ 08__ 14__ 20__

03__ 09__ 15__ 21__

04__ 10__ 16__ 22__

05__ 11__ 17__ 23__

Problems noted during fire watch (also note who you reported the problems to):

By signing this form you agree that you have verified the accuracy of this Fire Watch Log:Security Lead Signature: ______________________________________ Date: ______________

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Fire Watch 9

Attachment “A” continued


FIRE WATCH IMPLEMENTATION CHECKLIST

Your primary role, as the Fire Watcher, is to serve as a “human smoke/heat/fire detector” and to notify the Switchboard at x44 at the first sign of smoke, excessive heat or fire.

Conduct a continuous patrol of the entire area(s), including but not limited to: storage areas, hazardous areas, restrooms, break rooms, offices, exit corridors, and exit stairwells. Remain alert to signs of smoke, excessive heat and fire.

To be a human smoke/heat/fire detector: Remain attentive. Patrol your designated area, at least, every 60 minutes Listen for in-room smoke detectors sounding Look for observable signs of smoke and/or fire Enter all stairwells – open doors and look into each stairwell

At the first sign of smoke and/or fire: Call PBX at x44 and initiate a Code Red (off-site facilities also dial 9-911) If possible and safe, use a nearby fire extinguisher to extinguish the flames (P.A.S.S.) If the fire is too big to extinguish or too dangerous, initiate R.A.C.E.

Fire Watch 10

Attachment “B”


FIRE WATCH ACKNOWLEDGEMENT OF TRAINING I understand that, during Fire Watch, I will be responsible for all of the items listed below: 1. Rounds must be conducted, at a minimum, of every 60 minutes for the area where I am assigned. 2. Be aware of your surroundings. Use your nose, eyes and ears to detect fire and/or smoke. In

addition, listen to your intuition, if something does not seem right find out why. 3. During the 60 minute rounds rooms that will be checked include: storage areas, hazardous areas,

restrooms, break rooms, patient rooms, offices, exit corridors, and exit stairwells. 4. Corridors and Exits must be kept free and clear of all obstructions. 5. Check to ensure that exit and fire doors are not blocked by anything that could keep them from

closing. By signing below, I agree that I have been made aware of the expectations placed upon me during a Fire Watch at Kaweah Delta Health Care District. I agree to conduct Fire Watch Rounds within 60 minutes for my designated area. I agree that I have been informed that Fire Watch Rounds are to be completed by me and that I am not to conduct any other business during this time period. I will be solely dedicated to the task of Fire Watch Rounds. If, at any time, I feel that I cannot conduct these Fire Watch Rounds (for various reasons), I agree to contact my Supervisor immediately. Print Name: __________________________________Date: __________________ Signature: ___________________________________

Fire Watch 11

Attachment “C”


FIRE WATCH CONTROL LOG (To be kept updated in PBX)

Building Date

Time notified by

Maintenance to Start

Time notified by Maintenance

to Stop

Time Fire Watch

Rounds will Start (within 24

hours)

Total Time that the

System was off

(within 24 hours)

Environment of Care




Clinical Engineering Management PlanMedical Equipment Management Policy


I. OBJECTIVES EC 02.04.01 – The hospital manages medical equipment risks. I. The objectives of the Medical Equipment Management Policy which governs Kaweah Delta Health Care District (KDHCD) are to provide an environment that works to ensure medical equipment is safe, manage and reliable, properly maintained and efficiently used operations of medical equipment used in the delivery of patient care. To ensure operational reliability of medical equipment, the development of a medical equipment inventory contained and managed in a Computerized Maintenance Management System (CMMS), where an inspection and maintenance program designed to minimize risks to our patients has been established and is continually managed. Specific goals of the Medical Equipment Management Policy include the following: o Inventory MMaintenance anagement Program o Preventive Maintenance Program o Corrective Maintenance Program o User and Maintainer Training o Performance Indicators o Annual Evaluation of the Medical Equipment Management Plan o Equipment Selection and Review Process o Contract Review and Financial Oversight

o This Policy including the following policies and others are part of the District’s Medical Equipment Management Plan (MEMP):

EOC 6002 Medical Equipment Defective Repairs Policy EOC 6004 Medical Equipment / Hazardous Device Notification and Recall Policy EOC 6009 District Safe Medical Device / Device Tracking and Reporting Policy EOC 6018 Retirement and Deletion of Medical Equipment AP.60 Technology Assessment Process (Administrative Policy Manual)

II. SCOPE

The scope of this management plan applies to Kaweah Delta Health Care DistrictKDHCD, and any off- site areas as listed on the KDHCD License, and for all medical equipment that is used on our patients, whether it be owned, rented, leased or non-hospital owned.

The following is a list of all areas

o Kaweah Delta Medical Center, 400 West Mineral King, Visalia, CA. o Kaweah Delta Visalia Dialysis, 5040 West Tulare Ave., Visalia, CA.


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Clinical Engineering Management Plan 2

o Kaweah Delta Exeter Health Clinic, 1014 San Juan Avenue, Exeter, CA. o Kaweah Delta Hospice, 900 West Oak, Visalia, CA. o Kaweah Delta Home Health, 403 West Main, Visalia, CA. o Kaweah Delta Infusion Pharmacy, 602 Willow, Visalia, CA. o Kaweah Delta Mental Health, 1100 South Akers, Visalia, CA. o Kaweah Delta Porterville Dialysis, 385 North Pearson, Porterville, CA. o Kaweah Delta Rehab Hospital, 840 South Akers, Visalia, CA. o Kaweah Delta Skilled Nursing, 1633 South Court Street, Visalia, CA. o Kaweah Delta Urgent Care, 1633 South Court Street, Visalia, CA. o Sequoia Regional Radiation Oncology Center, 4945 West Cypress Ave., Visalia, CA. o Sequoia Regional Radiation Oncology – Hanford, 1443 West 7th Street, Hanford, CA. o Kaweah Delta Imaging 4949 W Cypress Ave, Visalia Ca o Kaweah Delta Lindsay Health Clinic, 839 North Sequoia Ave,. Lindsay, CA. o Sequoia Prompt Care Center, 1110 S. Ben Maddox Way, Visalia, CA and Sequoia Medical Plaza,

820 S Akers Rd, Visalia, Ca. o Central California Physical Therapy Services, 3362 S. Fairway, Visalia, CA. o Outpatient Therapy Services – Lovers Lane, 1337 So. Lovers Lane, Visalia, CA. o Kaweah Delta Woodlake health Clinic, 180 East Antelope Ave., Woodlake, CA. o Kaweah Delta Wound Center, 840 South Akers Rd., Visalia, CA. o Lifestyle Center (Outpatient Therapies), 5105 W. Cypress Ave., Visalia, CA. Kaweah Delta Sleep Center, 126 S. Floral, Visalia, CA. Therapy Specialists, Sequoia Medical Plaza, 820 S Akers Rd, Suite 200 o Therapy Specialists, Exeter, 1131 W Visalia Rd

.

Off site areas are monitored for compliance with this plan during routine surveillance by Environment of Care committee members. It is the responsibility of the Safety Officer to assess and document compliance with the Medical Equipment program for the offsite areas through the structure of the Environment of Care (EOC) Committee.

III. AUTHORITY The authority for the Management Plan for Medical Equipment is EC. 02.04.01. The authority for overseeing and monitoring the Medical Equipment Management Policy medical equipment plan and programMEMP lies in the (EOC)Environment of Care Committee, whose members will ensure activities relating to medical equipment management are identified, monitored and evaluated, and for ensuring that regulatory activities are monitored and enforced as necessary. IV. ORGANIZATION The following represents the organization of the Management Plan for Medical Equipment at the medical center:

Organization Medical Equipment Management Plan

Medical Care Review

Committee

Board of Directors

Quality Council

Environment of Care Committee

Clinical Engineering Director and Management



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V. RESPONSIBILITIES Leadership within the medical center have varying levels of responsibility and work together in the

management of medical equipment as identified below:

Governing Board: The Board of Directors supports the Medical Equipment Management Policy by: • Review and feedback if applicable of the quarterly and annual (EOC)Environment of Care report • Endorsing budget support as applicable to fund and empower implementation of the Medical

Equipment Management Plan (MEMP). Medical Care Review Committee: Reviews annual (EOC)Environment of Care reports from the (EOC)Environment of Care Committee, providing feedback if applicable. Quality Council: Reviews annual (EOC)Environment of Care report from the (EOC)Environment of Care Committee, and provides broad direction in the establishment of performance monitoring standards relating to medical equipment risks. Administrative Staff: Administrative staff provide active representation at the (EOC)Environment of Care Committee meetings and set an expectation of accountability for compliance with the Medical Equipment Program MEMP. (EOC)Environment of Care Committee: (EOC)Environment of Care Committee members review and approve the quarterly Environment of CareEOC reports, which contain a medical equipment component, and oversee any issues relating to the overall Medical Equipment ProgramMEMP. Directors and Department Managers: These individuals support the Medical Equipment Management Policy by: • Reviewing and correcting deficiencies identified through the hazard surveillance process that

relate to medical equipment risks. • Communicating recommendations from the (EOC)Environment of Care Committee to aaffected staff in a timely manner. • Developing education programs within applicable departments that insure compliance with the

policies of the Management Plan for Medical EquipmentMEMP.Medical Equipment Management Program.

• Supporting all required medical equipment education and training to include a disciplinary policy for employees who fail to meet the expectations.

• Serving as a resource for staff on matters of medical equipment usage.

Clinical Engineering ManagerDirector: The Manager Director or designated Manager of the Clinical Engineering Department is responsible for the coordination, liaison, development and establishment of the overall organization and management of the Medical Equipment Management Planlan (MEMP).

• Submits completed reports at least every three months to the EOC Committee on findings, recommendations, actions, and monitoring conducted.

• Provides an annual evaluation of the effectiveness of the Management Plan for Medical EquipmentMEMP Medical Equipment Management Program, which is to be submitted to the EOC Committee.

• Coordinates and/or participates in the development of departmental as well as facility-wide mMedical eEquipment management policies and procedures.

• Ensures that departmental clinical equipment management policies and procedures are consistent with and integrated into the facility-wide safety management plan; reviews these procedures as frequently as needed, but at least every three years.

• Ensures that mMedical eEquipment incidents are reported to the appropriate aauthorities/committees/departments/individuals. (AP.010)HH-L-4-012 Occurrence Reporting)












• Monitors the Hemodialysis facilities to ensure completion of Infection Prevention activities (e.g., water treatment analysis) for dialysis units.

Employees. Employees of the medical center are required to participate in the Management Plan for Medical EquipmentMEMPMedical Equipment Management program by:

• Completing applicable medical equipment training..

• Completing applicable medical equipment training. • Not using medical equipment with patients without ensuring a non-expired Clinical Engineering

issued inspection sticker exists on the device to reduce risk. • Reporting medical equipment failures to their supervisor and Clinical Engineering. • Reporting any observed or suspected unsafe conditions to department manager as soon as

possible after upon identifying a medical equipment risk. • Reporting any medical equipment with expired PM Inspection stickers to management and

Clinical Engineering..

Medical Staff: Medical Staff will support the Management Plan for Medical EquipmentMEMP Medical Equipment Management Program by abiding by the hospital’s policies and procedures relating to the use, care and reporting of failures and incidents as related to of medical equipment.

The hospital solicits input from individuals who operate and service equipment when it selects and acquires medical equipment. EC. 02.04.01- EP 011 Selecting / Acquiring of New Clinical Equipment: The selecting and acquiring of Clinical Medical Equipment is a combined effort of Clinical Engineering, the Value Analysis and EMTAC Committeees, Materials Management, the using Departments/Services, Medical Staff, and Administration and vendors as required.

New and upgraded cClinical equipment is evaluated and selected through the combined efforts of the Clinical Engineering Department, various management committees, and using departments and/or physicians. These devices:

* Must meet NFPA standards * Must meet guidelines specified in UL / FDA / IEC Standard 60601-1 * Must meet or exceed KDHCD electrical safety standards * Will be evaluated through the Value Analysis, and / or EMTAC Committees for

purchase and through requests submitted through these this entityies by District Management.

* Clinical Engineering department staff will provide technical evaluations for new device selections or technology requests as necessary.

* Must be approved through the procedures contained in Administrative Policy AP.60

* Equipment shall meet or exceed the standards set for in the ANSI/AAMI, NFPA-02, UL544 UL60601-1 and IEC 602. .

The hospital maintains either a written inventory of all medical equipment. or a written inventory of selected equipment categorized by physical risk associated with use (including all life support equipment) and equipment incident history. The hospital evaluates new types of equipment before initial use to determine whether they should be included in the inventory. EC.02.04.01- EP 022 Equipment Inventory: The establishing of criteria for identifying, evaluating and taking inventory of Medical Equipment to be included in the program before the equipment is used is based on equipment function, physical risks associated with use, maintenance requirements and equipment incident history. All owned, leased, rented and borrowed/loaned cClinical eEquipment is evaluated for inclusion in the program, including equipment at all off site locations.

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The assessing and minimizing of clinical and physical risks of equipment use through inspection, testing and maintenance is a combined effort of the Clinical Engineering Department, designated users, and contract services managed by the Clinical Engineering Department.

The monitoring and acting on equipment hazard notices and recalls is coordinated through Risk Management, the EOC Committee, Materials Management and Clinical Engineering.

Monitoring and reporting of incidents in which a medical device is connected to the death, serious injury, or serious illness of any individual (as required by the Safe Medical Device Act) is to be reported immediately but not to exceed 24 hours and coordinated through Risk Management.

The reporting and investigation of equipment management problems, failures and user errors are accomplished on a quarterly basis with reports to the EOC Committee. Items that may be included into the Clinical Medical Equipment Management Program’s Medical Equipment Database Database Inventory, shall include, but not be limited to; Any and All Electrical, Electronic, Mechanical, and Electro-Mechanical Healthcare Devices. Devices shall be evaluated in one of two areas:

• High Risk (Including Life Support Equipment) • Non-High Risk

• Life Support Devices

• High RiskNon-Life Support Devices

Each area item shall be further categorized as listed below.

All Devices items to be included into this Inventory Database will be added to the Medical Equipment Database (MEDB) and shall be evaluated for excessive, inherent risks to patients and categorized accordingly. Each device shall be inspected prior to its initial use, after major repairs or upgrades and at intervals to be identified utilizing a Risk Based evaluation system listed below. Each device shall be evaluated according to the following criteria:

1. Device Function: Is the device function critical to life support, ,

diagnosis, or monitoring.? 2. Risk associated with Device Use: Does the use of the device itself create a risk to the patient or operator.?

3. Device Maintenance Requirements: How frequently is the device to be used? What are the manufacturer's recommended requirements for maintaining the device? Will the device be cost effective.?

4. Likelihood of Failure: Is there a history of incidents related to the device failure

during patient use, and how often can this device might be expected to fail based on similar device history.?

5. Environmental Use: What Identify what will be the most common area in which

this device shall be expected to be used.?

The above five categories are given specific values which are then added together to provide each individual device with a specific Equipment Maintenance nNumber. This EM number shall be the determining factor with which device inclusion into the Clinical Equipment Management ProgramMEDB shall use.

To further define, this is equipment which could be described by one or more of the following statements:

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• Evaluated or projected for high potential for patient injury • Evaluated or projected high user errors • High preventive maintenance requirements

Evaluated or projected high failure rate Devices with an EM number assigned with a value of five (5) or greater, shall be included in the Clinical Equipment Management Program Inventory Database, and its schedule shall be assigned according to specific needs.

DEVICE FUNCTION shall be assigned values in the range of 2 - 10 as below:

10 - Life Support Device 9 - Surgical and Intensive Care Device 8 - Physical Therapy and Treatment Device 7 - Surgical and Intensive Care Monitoring Device 6 - Additional Physiological Monitoring and Diagnostics 5 - Analytical Laboratory 4 - Laboratory Accessories 3 - Computer and Related Devices 2 - Patient Related and Other

DEVICE RISK shall be assigned values in the range of 1 - 5 as below: 5 - Patient Death 4 - Patient or Operator Injury 3 - Inappropriate Therapy or Misdiagnosis 2 - Minimal Impact or Risk 1 - No Significant Risk

DEVICE MAINTENANCE REQUIREMENTS shall be assigned values in the range of 1 - 5 as below:

5 - Extensive 4 - Above Average 3 - Average 2 - Below Average

1 - Minimal

LIKELIHOOD OF FAILURE REQUIREMENTS shall be assigned values in the range of 1 - 5 as listed below:

5 - Less than three months

4 - Approximately six months 3 - Approximately one year 2 - Approximately three years

1 - Greater than five years

ENVIRONMENTAL USE REQUIREMENTS shall be assigned values in the range of 1 – 5 as listed below:

5 - Anesthetizing Locations 4 - Critical Care Locations 3 - Wet Locations 2 - General Care Locations 1 - Non-Patient Care Areas The hospital identifies the activities and associated frequencies, in writing, for maintaining, inspecting and testing for all medical equipment on the inventory. These activities and associated frequencies are in

Clinical Engineering Management Plan 7 accordance with manufacturers’ recommendations or with strategies of an alternative equipment maintenance (AEM) program. EC.02.04.01-3EP04 Equipment Maintenance: The Clinical Engineering Department at Kaweah Delta Healthcare DistrictKDHCD shall be responsible, unless otherwise specified, for all Scheduled Preventive Maintenance, Demand Repairs, Calibrations, and Adjustments required for the maintainence of all Electrical/ Electronic / Electromechanical, and certain Non-Electrical Health Care Devices contained in the Clinical Equipment Management Program used to treat patients of Kaweah Delta Health Care DistrictKDHCD. The Manager of Clinical Engineering shall have the ultimate responsibility for ensuring that all Scheduled Preventive Maintenance, Initial Receipt, Safety, Operational, Functional, and Calibration Inspections, as well as Unscheduled Demand Repairs, are completed in a timely, efficient, and effective manner. Emphasis to cost effectiveness, and ensuring that device down time is kept to an absolute minimum will be an objective of this program continuously. Preventive Maintenance Inspection Intervals shall reference the suggested manufacturer service guidelines for each device contained in the Clinical Equipment Database Inventory. These inspection intervals can and shall be modified as the service history, and equipment needs dictate, but not less than the recommended inspection / calibration intervals required by the manufacturer of the device. Required Title 22 and OSHA regulations; (All devices included in the Clinical Equipment Management Program Inventory database, shall be inspected on a No Less Than annual basis). A criteria will be used should an Alternate Maintenance Equipment strategy be used, and the equipment shall so be identified in the inventory, and evaluated annually to determine the effectiveness of the alternate maintenance strategy. Each device that has been inspected shall have a dated inspection sticker affixed to it, which will indicate it's current Preventive Maintenance Inspection status. Note: Devices contained within the Clinical Equipment Management Inventory Database that cannot be located for a minimum of two (2) consecutive PMI cycles, shall be considered "lost" and shall be removed from the Active Inventory and PM Inspection cycle unless other device status is supplied by the responsible owning department for the device.

Service records for all devices contained in the CMMS shall be maintained for a period of not less than three (3) years. Method of storage shall be on computer server, with backup copies on long term storage server. Records, PM Inspection and Repair, older than three (3) years may be purged from the system in order to keep program within a reasonable working database size. Devices that are brought into the District through Rental companies shall be tracked and logged separately, but shall meet the above policy with specific regards to Preventive Maintenance and Electrical Safety inspections of each device. The vendor responsible for supplying these devices shall provide documentation supporting the current Preventive Maintenance Inspection status of each device. Further, upon delivery to the District, each device shall be accompanied by a current Electrical Safety inspection sheet, which shall be retained by the Requesting Department for the duration of the rental period. The Rental Supply Company shall notify the District of any devices that are due for Preventive Maintenance Inspection(s), and shall make all necessary arrangements for the removal and replacement of these devices. Replacement devices shall meet all necessary documentation requirements listed above. All requests for such items will be in accordance with the procedures and directives contained in AP.132. The hospital monitors and reports all incidents in which medical equipment is suspected in or attributed to the death, serious injury, or serious illness of any individual, as required by the Safety Medical Devices Act of 1990. EC.02.04.01-5

Equipment Safety: The Clinical Engineering Department will be the cornerstone in maintaining the medical device-reporting program, investigating incidents, and evaluating the safety of the medical devices. The Clinical Engineering Department works very closely with the Risk Management Department in the investigation of any event to determine whether a device caused or contributed to the event. The Clinical Engineering Department, in their investigation of an event, does the following:


• Assists the Risk Management Department in the collection of data, which includes device service and history information as well as other relevant information made known by those involved. • Submits appropriate reports to the Food and Drug Administration (FDA), and/or the medical device manufacturer in accordance with the law, regulations and procedures contained in EOC 6009. • Ensures that the applicable data, along with the Risk Management Department and Safety Officer are incorporated into the occurrence reporting system.

The District will ensure compliance with the Safe Medical Device Act of 1990, and Device Tracking Regulations set forth by the Food and Drug Administration. Also, to specify actions which are necessary to minimize patient risk resulting from Medical Device related incidents.

In the event of receipt of a Hazardous Device Notification, Medical Device Recall, or Notification of Event, (Occurrence Report), the procedures contained in the District Safe Medical Device Act / Hazardous Device Tracking and Reporting Policy, EOC 6009, will be strictly adhered to without exception.

The hospital has written procedures to follow when medical equipment fails, including using emergency clinical interventions and backup equipment. EC.02.04.01-6 1. What to do in the event of equipment disruption or failure 2. When and how to perform emergency clinical interventions when medical equipment fails 3. Availability of backup equipment 4. How to obtain repair services

Emergency Plans: Emergency plans that specifically address emergency response, which include,

appropriate clinical interventions, alternative life supporting procedures (e.g., manual ventilation), access to back-up equipment, and listings of alternate sources of back up equipment and repair services are in place in the Patient Care Manual, Policy MS.04, and subsequent policies.

Before initial use of medical equipment on the medical equipment inventory, the hospital performs safety, operational and functional checks. EC.02.04.03-1 Incoming Inspection: Before initial use of medical equipment identified in the medical equipment inventory, Clinical Engineering staff perform safety, operational and functional safety checks. This is referred to as the Incoming Inspection process.

The Hospital inspects tests and maintains all life supporthigh risk equipment. These activities are

documented. EC. 02.04.03-2 and 3

Life SupportHigh Risk Equipment: Maintenance records of equipment used for High Risk life support is maintained in the Clinical Engineering Department. The hospital uses a risk-based criteria for identifying and evaluating High Risk life support versus non-life support medical equipment. The criteria addresses equipment function (High Risk life support versus diagnosis, care, treatment and monitoring), and the physical risks associated with use. The initial inspection of the medical equipment includes an evaluation of the complexity of the equipment for its role in life support. Does the medical equipment support life while in use, or is it used to diagnose conditions and diseases, or treat a condition, or provide monitor function? Also included in the evaluation of the medical equipment when determining if it is a High Risk life support piece of medical equipment, is the physical risk of usage of the equipment. For example, the physical risk of a ventilator or anesthesia machine includes the possibility of death or serious injury if failure occurs





Clinical Engineering Management Plan 9 The hospital conducts performance testing of and maintains all sterilizers. These activities are documented. EC.02.04.03-4

Sterilizer Support Equipment: Maintenance records of equipment that is used for Sterilizer support is maintained in the Clinical Engineering Department.

The hospital performs equipment maintenance and chemical and biological testing of water used in hemodialysis. These activities are documented. EC.02.04.03-5

Renal Dialysis Equipment: Chemical and biological testing of water used in renal dialysis, and other applicable tests based upon regulations, manufacturer’s recommendations and hospital experience are performed by Hemodiaysis Lead personnel.

For hospitals that use Joint Commission accreditation for deemed status purposes: Qualified hospital staff inspect, test and calibrate nuclear medicine equipment annually. The dates of these activities are documented. EC.02.04.03-14

Nuclear Medicine Equipment: Clinical Engineering Department maintains a copy of the maintenance records provided by the Radiology Department Maintenance records of equipment that is used for nuclear medicine support is maintained in the Clinical Engineering Department.

For hospitals in California that provide computed tomography (CT) services: A qualified medical physicist measures the actual radiation dose* produced by each diagnostic CT imaging system at least annually and verified that the radiation dose displayed on the system for standard adult brain, adult abdomen, and pediatric brain protocols is within 20 percent of the actual amount of radiation dose delivered. The dates of these verifications is documented. *for the definition of radiation dose refer to section 115111(f) of the California Health and Safety Code. EC.02.04.03-17

Computed Tomography Equipment: Clinical Engineering Department records the date a computed tomography (CT) physicist measures the accuracy of the CT system. A copy of the preliminary and final report are to be maintained by the Radiology Department and a copy provided to the Clinical Engineering Department will be maintained. EC.02.04.03-19 A QUALIFIED MEDICAL PHYSICIST, AT LEAST ANNUALLY, CONDUCTS A PERFORMANCE EVALUATION OF ALL CT IMAGING EQUIPMENT. THE RESULTS, ALONG WITH ANY CORRECTIVE ACTIONS, ARE DOCUMENTED. THE EVALUATION INCLUDES THE USE OF PHANTOMS TO ASSESS THE FOLLOWING IMAGING METRICS:

• Image uniformity ● Slice thickness accuracy ● Slice position accuracy (when prescribed from a scout image) ● Alignment light accuracy ● Table travel accuracy ● Radiation beam width ● High-contrast resolution ● Low-contrast resolution ● Geometric or distance accuracy ● CT number accuracy and uniformity ● Artifact evaluation Biomedical staff members work in collaboration with Imaging leadership to ensure an annual performance evaluation of all CT Imaging equipment is completed, with the use of Phantoms to measure the specified imaging metrics identified above. EC.02.04.03-20 A QUALIFIED MEDICAL PHYSICIST, AT LEAST ANNUALLY, CONDUCTS A PERFORMANCE EVALUATION OF ALL

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Clinical Engineering Management Plan 10 MRI IMAGING EQUIPMENT. THE RESULTS, ALONG WITH ANY CORRECTIVE ACTIONS, ARE DOCUMENTED. THE EVALUATION INCLUDES THE USE OF PHANTOMS TO ASSESS THE FOLLOWING IMAGING METRICS:

• Image uniformity for all radiofrequency (RF) coils used clinically • Signal-to-noise ratio (SNR) for all coils used clinically • Slice position accuracy • Alignment light accuracy • High-contrast resolution • Low-contrast resolution (or contrast-to-noise ratio) • Geometric or distance accuracy • Magnetic field homogeneity • Artifact evaluation

Biomedical staff members work in collaboration with Imaging leadership to ensure an annual performance evaluation of all MRI Imaging equipment is completed, with the use of Phantoms to measure the specified imaging metrics identified above. EC.02.04.03-21

A QUALIFIED MEDICAL PHYSICIST, AT LEAST ANNUALLY, CONDUCTS A PERFORMANCE EVALUATION OF ALL NUCLEAR MEDICINE IMAGING EQUIPMENT. THE RESULTS, ALONG WITH ANY CORRECTIVE ACTIONS, ARE DOCUMENTED. THE EVALUATIONS ARE CONDUCTED FOR ALL OF THE IMAGE TYPES PRODUCED CLINICALLY BE EACH NM SCANNER (FOR EXAMPLE, PLANAR AND /OR TOMOGRAPHIC) AND INCLUDE THE USE OF PHANTOMS TO ASSESS THE FOLLOWING IMAGING METRICS: • Image uniformity/system uniformity ● High-contrast resolution/system spatial resolution ● Low-contrast resolution or detectability (not applicable for planar acquisitions) ● Sensitivity ● Energy resolution ● Count-rate performance ● Artifact evaluation

Biomedical staff members work in collaboration with Imaging leadership to ensure an annual performance evaluation of all Nuclear Medicine Imaging equipment is completed, with the use of Phantoms to measure the specified imaging metrics identified above.

EC.02.04.03-22 A QUALIFIED MEDICAL PHYSICIST, AT LEAST ANNUALLY, CONDUCTS A PERFORMANCE EVALUATION OF ALL

PET IMAGING EQUIPMENT. THE RESULTS, ALONG WITH ANY CORRECTIVE ACTIONS, ARE DOCUMENTED. THEVALUATIONS ARE CONDUCTED FOR ALL OF THE IMAGE TYPES PRODUCED CLINICALLY BE EACH PET SCANNER (FOR EXAMPLE, PLANAR AND OR TOMOGRAPHIC) AND INCLUDE THE USE OF PHANTOMS TO ASSESS THE FOLLOWING IMAGING METRICS: ● Image uniformity/system uniformity ● High-contrast resolution/system spatial resolution ● Low-contrast resolution or detectability (not applicable for planar acquisitions) ● Artifact evaluation (A-D)

Note: The following tests are recommended, but not required, for PET scanner testing: sensitivity, energy resolution, and count-rate performance. Biomedical staff members work in collaboration with Imaging leadership to ensure an annual performance evaluation of all PET Imaging equipment is completed, with the use of Phantoms to measure the specified imaging metrics identified above.

EC.02.04.03-24 – ALTERNATE MAINTENANCE STRATEGIES The hospital inspects, tests, and maintains the following in accordance with manufacturers’ recommendations:

• Medical lasers • Imaging and radiologic equipment (whether used for









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diagnostic or therapeutic purposes) • New medical equipment with insufficient maintenance history to support the use of alternative

maintenance strategies Biomedical Management will develop maintenance strategies for medical lasers, imaging and radiological equipment or diagnostic and therapeutic purposes, and new medical equipment with insufficient maintenance history, based upon manufacturers’ recommendations. Preferred Vendor Policy. In the event a piece of medical equipment is needed in an emergency situation, biomedical management will allow certain preferred vendors to deliver the medical equipment to the affected department for usage on a patient in critical need of the equipment. The affected manager must notify biomedical management when they arrive, and biomedical management will conduct an inspection no later than a 24-hour interval from the time the medical equipment was initiated for use on the critical patient. The preferred vendor is one in which their preventive maintenance standards equal those at the medical center. At least annually the biomedical manager visits preferred vendors and audits their preventive maintenance records for specific types of equipment that are used by the medical center. The visit and assessment process is documented and maintained with biomedical management. A Preferred Vendor policy is in place with biomedical management. Ongoing Education for Users and Maintainers HR.01.05.03-1

Each individual who is tasked with the use, operation, or application of a Medical Device shall be fully trained in those areas of responsibility. On newly purchased devices and current inventory, a factory

trained representative, or an appropriate clinician or staff member may be designated to provide training. Documentation shall be maintained.

INFORMATION COLLECTION SYSTEM TO MONITOR CONDITIONS IN THE ENVIRONMENT EC.04.01.01-EP’S 1-11

The hospital establishes process(es) for continually monitoring, internally reporting, and improving the following:

• Medical or laboratory equipment management problems, failures and user errors • Medical or laboratory equipment management problems, failures and user errors are investigated

by biomedical staff, and reported to the Environment of Care Committee. A user error is an equipment related problem that is reported by using staff as an equipment failure. However, upon investigation by biomedical staff, the equipment failure cannot be duplicated through established testing procedures, and biomedical staff confirms the using staff has likely used the equipment incorrectly.

ANNUAL EVALUATION OF THE MEDICAL EQUIPMENT MANAGEMENT PLAN EC.04.01.01-EP-15

To ensure effectiveness, and compliance with all areas of concern in the Clinical Equipment Management Plan, and to promote confidence in the operation of this process in the Environment of Care, an annual evaluation of this Program Effectiveness shall be conducted, and a report shall be submitted to the District Environment of Care Committee for review. Included in the annual evaluation will be an evaluation of the objectives, scope, performance and overall effectiveness of the Medical Equipment Management Plan. The annual evaluation of the Medical Equipment Management plan shall be done every 12 months with a 30 day grace period. This plan along with the following Policies and others are part of the District’s MEMP : EOC 1083 Disposing of Recalled Product EOC 6002 Medical Equipment Defective Repairs Policy EOC 6004 Medical Equipment / Hazardous Device Notification and Recall Policy EOC 6009 District Safe Medical Device / Device Tracking and Reporting Policy MS.04 Staff Response to High Risk Equipment Failures (Patient Care Manual) MS.01 Equipment Acquiring Information and Proper use of (Patient Care Manual)



Clinical Engineering Management Plan 12 AP.60 Technology Assessment Process (Administrative Policy Manual)

THE HOSPITAL ANALYZES IDENTIFIED ENVIRONMENT OF CARE ISSUES EC.04.01.03-EP-1-2

Environment of careEOC issues relating to medical equipment are identified and analyzed through the Environment of CareEOC Committee with recommendations made for resolution. It is the responsibility of the Environment of CareEOC Committee chairperson to establish an agenda, set the meetings, coordinate the meeting and ensure follow-up occurs where indicated.

PRIORITY IMPROVEMENT PROJECT EC.04.01.03-EP-3

Annually, one or more priority Improvement activities are selected by the Environment of CareEOC

Committee members. If risk has been determined with respect to medical equipment processes, the result may be a performance improvement project for this Environment of CareEOC component.

THE HOSPITAL IMPROVES ITS ENVIRONMENT OF CARE EC.04.01.05-EP1-3 Performance standards are identified monitored and evaluated that measure effective outcomes in the area of medical equipment management. Performance standards are also identified for Safety, Security, Hazardous Materials, Emergency Management, Fire Prevention and Utilities management. Whenever possible, the environment of care is changed in a positive direction by the ongoing monitoring, and changes in actions that promote an improved performance.

PATIENT SAFETY Periodically there may be an environment of care issue that has impact on the safety of our patients relating to medical equipment. This may be determined from Sentinel Event surveillance, environmental surveillance, user adverse event reporting, patient safety standards or consequential actions identified through the risk management process. When a patient-safety issue relating to medical equipment emerges, it is the responsibility of the Clinical Engineering Director or Safety Officer to bring forth the issue to the Patient Safety Committee.












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Environment of Care




Environment of Care Communication Flow Chart Printed copies are for reference only. Please refer to the electronic copy for the latest version. Note: This flow chart is intended to illustrate the usual flow of safety-related information. Generally, data is obtained from incident reports, security incidents, hazard surveillance reports and other sources of information.

KDHCD Board of Directors

Utilities Program

Life Safety

Program

Professional Staff Quality Committee or "PROSTAFF"

Performance Improvement

Environment Of Care

Committee

Hazardous Waste and Materials

Program

Security Program


Committee Clinical

Engineering Program

Safety Program

Environment of Care Communication Flow Chart 2 Notice this data is forwarded to appropriate committee is communicated to the Environment of Care Committee and can ultimately be provided to the KDHCD Board of Directors.

Environment of Care Communication Flow Chart 3 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

Environment of Care




Indoor Air Quality Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: Ensure a safe environment for patients, staff and visitors when toxic

moldIndoor Air Quality is suspected or identified. Policy: KDHCD will immediately assess all suspected cases of toxic bad

unsafe moldIndoor Air Quality in District facilities and provide timely intervention.

Procedure:

1) MoldIndoor Air Quality concerns may be identified by any individual stating a concern. This includes visual identification, odors, and/or a complaint filed with EHS of non-seasonal respiratory symptoms occurring only in the work environment.

2) The Director of Facilities (DOF) is responsible for completing all moldIndoor

Air Quality investigations and remediation. An oversight group called the Indoor Air Quality (IAQ) Team shall be notified by the DOF of all suspected or confirmed complaints of moldIndoor Air Quality. The IAQ Team shall consist of representatives from the District Infection Prevention Team, Safety Officer, and Risk Management. Employee Health Services may be included as needed.

3) The Director of the affected department shall be notified by the DOF that a

moldIndoor Air Quality concern has been reported in their department. An internal assessment shall be initiated immediatelyas soon as possible.

i) An IAQ Occurrence Report shall be initiated by the DOF as the required processes/notifications are completed. (Attachment A)

4) If the moldIndoor Air Quality concern of the affected area is validated, the

area will be sealed with plastic barrier and remain sealed until consultation and testing with the outside contractor is complete. Interim Life Safety Measures (ILSM) will be initiated.

5) The contractor shall , at a minimum, conduct the following investigations:

i) Air spore sample

Indoor Air Quality 2

ii) Visual inspection iii) Moisture meter survey

6) Remediation for any positive results shall be conducted timely by the outside

contractor upon approval of the DOF.

7) The IAQ Team and Department Director shall be kept informed of the current status and of all test results.

8) The IAQ Team evaluates each case to determine if additional communication

or follow up is indicated. The IAQ Team does not need to approve each project before work begins.

9) Prior to occupancy, the outside consultant shall conduct air quality samples to

ensure a safe environment.

10) Completed IAQ Occurrence Reports shall be reported to the Environment of Care and Infection Prevention Committees at least quarterly and as needed.


KDHCD Indoor Air Quality Occurrence Report EOC 1020 Indoor Air Quality (MoldIndoor Air Quality Remediation) Policy – Attachment A

Instructions: Must be completed by the District Safety Officer (or designee) for EACH suspected or confirmed occurrence of moldIndoor Air Quality within any District facility.

Date of Report: _____/_____/_____ Time: _________ Location: ____________________

Date/Time Initial ACTION Complaint received by Facilities office IAQ Team notified Infection Prevention, IAQ Chair (State name) Safety officer (State name) N/A Risk Management (State name) N/A Employee Health Service (State name)

Department Director of moldIndoor Air Quality location notified Initial internal assessment by Facilities completed Barrier applied to affected area YES NO ILSM initiated Outside contractor notified

Name: ______________________________________ Phone: __________________

Contractor testing start Contractor testing end Written recommendation for room closure YES NO Written test results & report received by Safety, IP and Facilities Remediation Priority Assigned Circle one: 1 2 3 4 IAQ Team meeting with Remediation Contractor & Department Director ICRA & permit issued for remediation Remediation start Remediation end Contractor final clearance test report received Clearance report to IAQ Team, Department Director Construction ICRA & permit issued for construction

Committee report: Environment of Care Infection Prevention Other (describe as needed)

INITIAL NAME (Print) SIGNATURE

ORIGINAL REPORT WILL BE FILED WITH THE KDHCD SAFETY OFFICER



APPENDIX D

POLICY SUBMISSION SUMMARY

Manual Name: Hematology Date 09/05/2017 Support Staff Name: Patsy Turner Policy/Procedure Title: Policy/Procedure

# Status

(New, Revised, Reviewed, Deleted)

Name & Phone # of Person who wrote new

policy or revised one Quality Control Protocol HE-00097 Revised Patsy Turner x5059 Alternate Methodology HE-00055 Revised Patsy Turner x5059 Protocol for Platelet Poor Plasma Validation

HE-00072 Revised Patsy Turner x5059

Clinical Laboratory, Hematology

Policy Number: HE-00097 Date Created: Not Set Document Owner: Patricia Turner (Laboratory Section Chief)

Date Approved: Not Set

Approvers: Board of Directors (Administration), David Hewitt (Pathology)

Quality Control Protocol Printed copies are for reference only. Please refer to the electronic copy for the latest version. All control values must be verified for acceptability before reporting patient results

INSTRUMENT

OR TEST

CONTROL

MATERIAL

FREQUENCY LEVEL DOCUMENT

1 Sysmex XN-3000

PM

XN-check

Levels 1,2,3

Daily

Day, week, as needed

Low/Normal/High

S1-2,3

S2-1,2

S3-1,3

In QC file, on instrument

Monthly review QM

PM Log

2 TEG

Channels 1-8

PLT Mapping Kit

PM

TEG commercial

Normal patient

Clean and e check

Daily

S1-channels 1-8

S2-channels 1-4*

S3-channels 5-8*

*if additional channels used on shift, QC must be performed.

Lot change

Daily

Level 1 & 2

Shift 1

NOVIUS QC

Monthly review QM

QC/PM Log

PM Log

3 TOP 1

PM

IL-Commercial Plasma Control

Normal 1

Abnormal 3

QFA Low

D-Dimer Low & High

UF Heparin (Anti-Xa) Low & High

Day of use/reagent change

S-1, S-2, S-3

Day, week, month

Normal 1, Abnormal 3, QFA Low, DD Low, DD High, UFH Low, UFH High

NOVIUS QC

Monthly review QM

Top 1 PM Log

Formatted Table

Quality Control Protocol 2

4 TOP 2

PM

IL-Commercial Plasma Control

Normal 1

Abnormal 3

QFA Low

D-Dimer Low & High

UF Heparin (Anti-Xa) Low & High

Day of use/reagent change

S-1, S-2, S-3

Day, week, month

Normal 1, Abnormal 3, QFA Low, DD Low, DD High, UFH Low, UFH High

NOVIUS QC

Monthly review QM

Top 2 PM Log

5 Iris IChem Velocity

PM

IriSpec CA, CB & CC

IQ Control & Focus Set

Day of use

S-1, S-2

Day, week, month

IRIS IChem Velocity Log

Monthly review QM

Iris PM Log

5 Occult Blood Hemoccult Card for stool

Internal control

Positive/Negative

Gastrocult for gastric

Each Reaction Card

Positive/Negative Occult Blood Worksheet

Daily review QM

6 Micro Hematocrit Patient sample from instrument

Day of use Auto vs manual comparison

MicroHematocrit control log

7 Clinitest Commercial Urine Cont

Normal (I)

Abnormal (II)

Daily-Shift 1 Normal (I)

Abnormal (II)

Urinalysis Control Log

Monthly review

8

Refractometer

PM

Commercial Urine

Control

Daily-Shift 1

Day of use

Level 1 & 2

DiH2O zero check

Annual cal check w/ 5% NaCl 1.025


Monthly review QM

10 Reticuloycyte Test performed on Sysmex XN 3000

XN-Check

Daily See Sysmex XN3000

NOVIUS QC

Monthly review QM

11 ALCOR iSED

PM

SEDiTROL

Daily-Shift 1

Empty waste daily

Level 1 & 2

NOVIUS QC

ESR QC Log

Quality Control Protocol 3

Monthly review QM

12

PH

PM

Certified Buffer

Day of use

Day of use

Level 4.00 & 7.40 PH QC log

Monthly review QM

13 Apt Patient Day of testing Adult and Cord

Blood

Body fluid work sheet

Daily worksheet review

14

Clinitek Status +

PM

Commercial Urine Cont

Normal (I)

Abnormal (II)

Day of use only

S-1, S-2

I, II


Monthly review QM

15 PFA-100 Normal Patient whole blood in Na Citrate

Each new lot #

Epi & ADP

PFA-100 Log

16 IQ 200 Body Fluid Iris Body Fluid Control

Level 1 & 2

Background check

Day of testing

S-1

Weekly

1 & 2 IQ Body Fluid Log

Monthly review QM



Policy Number: HE-00055 Date Created: No Date Set Document Owner: Patricia Turner (Laboratory Section Chief)



Alternate Methodology or Instrument, Reference Laboratory Printed copies are for reference only. Please refer to the electronic copy for the latest version. OBJECTIVE: To be able to perform, generate laboratory test result(s) without jeopardizing turnaround time, integrity of specimens when primary instrument is down.

I. DEPARTMENT

a. Hematology -– CBC, Reticulocyte Primary Instrument: Sysmex XN 3000 right instrument Secondary Instrument: Sysmen XN 3000 left instrument Third Alternate: Tulaure District Hospital Laboratory or ARUP

b. Coagulation – PT, APTT, Fibrinogen, DDimer, anti Xa

Primary Instrument: ACL TOP 1 Secondary Instrument: ACL TOP 2 Third Alternate: Tulaure District Hospital Laboratory or ARUP

c. Urinalysis Primary Instrument: Iris IQ 200 Secondary Instrument: Bayer Clinitek Status + Third Alternate: Tulaure District Hospital Laboratory or ARUP

d. PFA 100

Secondary: Hanford District Hospital:

e. TEG Primary Instrument: TEG 1, 2, 3, or 4 Secondary Instrument: TEG 5,6,7 or 8

f. ESR Stat Plus

Primary: Alcor iSED instrument 1 Secondary: Alcor iSED instrument 2

II. REFRIGERATION

Primary refrigerator: Fisher Double Wide Secondary refrigerator: Jewitt Double Wide Third Alternate: Walk-in refrigerator

Alternate Methodology or Instrument, Reference Laboratory 2 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."


Policy Number: HE-00072 Date Created: No Date Set Document Owner: Patricia Turner (Laboratory Section Chief)



Protocol for Platelet Poor Plasma Validation Printed copies are for reference only. Please refer to the electronic copy for the latest version. Principle: The Stat Spin Express can produce plasma of a quality essentially equivalent to

tubes spun for 7-10 minutes or more in conventional clinical-type centrifuges. Stat Spin speeds > 8000 rpm produces force > 4400 g is sufficient to produce platelet poor plasma (< 10x10 3/uL). Validation of the plasma platelet count with the Sysmex XN 3000 and spin time of 120 seconds is recommended annually and when the centrifuge is refurbished. Alternatively, the Silencer 2100 is used to obtain platelet poor plasma, using a speed of 6000 (rcf 4838) for 3 minutes. Validation of Silencer 2100 should also be performed annually.

Equipment & Materials:

1. Stat Spin Express or Silencer 2100 2. Vacuette Sodium Citrate Tubes 3.2%

Procedure:

1. Check centrifuge spin time is 120 second with a stopwatch. 3 minute spin time for Silencer 2100.

2. Spin blood samples in normal mode for 120 seconds, for Stat Spin, 3 minutes for Silencer 2100..

3. Check background count on the Sysmex XE 2100XN 3000 as baseline. 4. Analyze the plasma by inserting the aspiration probe into the upper one third

of the plasma. Cycle the system to obtain platelet count. 5. Test a minimum of 5 separate blood coagulation samples every six months. 6. Record the results.

Results: Platelet poor plasma should have counts less than 10.0 x K/uL. This validates the

spin time is adequate to produce proper samples for routine coagulation testing. Unit # ______________ Spin Time ______________ sec

1 2 3 4 5

1. Review the results for counts < 10.0 x K/uL. If all the counts are less than stated reference value, then the centrifuge speed time and force are valid to produce coagulation platelet poor plasma.

2. If the results exceed the reference range. Check the centrifuge is operating correctly. Retest with five new samples.

Protocol for Platelet Poor Plasma Validation 2

3. If the centrifuge fails second testing. Remove from service and send to Stat Spin for service.

Reference: Stat Spin an Iris Company; Norwood, MA


1

Manual Name: Hospice Date: 10/2/17 Support Staff Name: N/A Routed To: Board of Directors

Approved By: District Board

Policy/Procedure Title #

Status (New,

Revised, Reviewed, Deleted)

Name and Phone # of person who wrote the new policy or revised an existing policy

Initial and Comprehensive Assessments

HO2-029

Revised Susan Buscaglia, MSN, RN Director of Hospice Services

733-0642 Emergency Management Plan

HO6-011

Revised Susan Buscaglia, MSN, RN Director of Hospice Services

733-0642

Hospice Pediatric Concurrent Care

Policy Number: HO2-029 Date Created: No Date Set Document Owner: Susan Buscaglia (Director of Hospice Services)


Approvers: Board of Directors (Administration), Susan Buscaglia (Director of Hospice Services)

Initial Interdisciplinary Team Comprehensive Assessment Initial and Comprehensive Assessments


PURPOSE To provide guidelines for the initial interdisciplinary team comprehensive assessment. POLICY An initial hospice patient assessment will be performed by the Registered Nurse, the Case Manager if possible, within 48 hours after the election of hospice care. The hospice interdisciplinary group (IDG), in collaboration with the patient’s attending physician, in consultation with the individual’s attending physician, if any, will complete the a comprehensive assessment that identifies the patient’s need for hospice care and services, as well as their need for physical, emotional, and spiritual care. no later than 5 calendar days after the election of hospice care. The assessment will include all areas of hospice care related to the palliation and management of the terminal illness and related conditions. The IDG, in collaboration with the patient’s physician, will establish an individualized, written plan of care for each patients based on patient and family needs identified in the initial and ongoing comprehensive assessments. The comprehensive assessment will identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process. The hospice interdisciplinary group in consultation with the patient’s physician will prepare a written plan of care for each patient based on the patient and family-specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions. PROCEDURE

I. Initial assessment

A. The hospice registered nurse (RN) must complete an initial assessment within 48 hours after the election of hospice care

B. The initial assessment will include all baseline data and other relevant information including the following:

Initial and Comprehensive Assessments 2

i. Probable prognosis of six (6) months or less, if disease runs its normal course

ii. Physical, psychosocial, emotional and spiritual needs

iii. Patient and family/caregiver needs iv. Patient and family/caregiver goals of care v. Services needed to meet patient and family/caregiver goals and needs vi. Anticipated discharge needs vii. Funeral planning and bereavement needs viii. An evaluation of the home environment and assessment of emergency

preparedness of the patient.

II. Comprehensive assessment

A. The hospice IDG, in consultation with the patient’s attending physician, must complete the comprehensive assessment no later than 5 calendar days after the election of hospice care.

B. The comprehensive assessment must identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient’s well-being, comfort, and dignity throughout the dying process.

III. Update of the comprehensive assessment

A. The IDG, in collaboration with the patient’s attending physician, must assess any changes that have taken place since the initial assessment

B. Documentation must include information on the patient’s progress toward desired outcomes, as well as a reassessment of the patient’s response to care

C. The assessment update must be done as frequently as the condition of the

patient requires, but no less frequently than every 15 days

IV. Documenting assessments

A. All disciplines are responsible for documenting assessments in the electronic medical record (EMR) within 2 hours after the end of their shift

V. An individualized plan of care will be established by the IDG and documented in the EMR

I. During the initial patient assessment, all baseline data and other relevant information will

be documented in the patient's clinical record, including at least the following information, as relevant. The interdisciplinary team assessment should determine:

A. Probable prognosis of six (6) months or less, if disease runs its normal course

B. Patient and family/caregiver problems and needs related to the terminal illness

C. Patient and family/caregiver goals related to the terminal illness

D. Type of services, frequency, and duration needed to meet patient and

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family/caregiver care needs

E. Anticipated discharge needs, including bereavement and funeral preparation

F. The need for an alternative level of care

G. Need for referral to and further evaluation by appropriate health professionals.

II. II The Registered Nurse will assess the following:

A. An assessment of pain, including the origin, location, duration, severity, and relief measures (see “Pain Assessment, Reassessment and Management, “ Policy No. 2-031)

B. An assessment of severity of secondary symptoms, such as nausea, vomiting,

constipation, respiratory distress

C. Alleviating and exacerbating factors for physical symptoms

D. Diet and nutritional status

E. An assessment of the patient's response to palliative treatment

F. A physical assessment, including blood pressure, temperature, pulse, respiration and other relevant data related to pertinent physical findings and the patient's terminal illness.

G. Braden Score for assessing Pressure Ulcer Risk and an assessment of overall

skin integrity.

H. Assessment of fall risk.

I. Patient's functional status including, but not limited to, the degree of self-care and the amount and level of assistance needed

J. Patient's past and present medical and surgical care including dates of

onset/exacerbation including pertinent co-morbidities

K. Pertinent labs, if available and any pertinent diagnoses

L. Name and address of the patient's attending physician

M. Name of the hospital and other agencies or persons involved in the past and present care of the patient, if available

N. An evaluation of the safety of the home environment including fire/oxygen safety

as appropriate.

O. Assessment of emergency preparedness of the patient

P. Presence of any Advance Directives for care and/or discussions with patient and family/caregiver regarding the withholding of resuscitative services or the


withdrawal of life-sustaining treatment and POLST form.

Q. Medical equipment presently in home and potentially needed by patient

R. Patient’s medication profile, including prescription medications, over-the-counter medications, oxygen, vitamins, herbals, homeopathic remedies and medicated wound care products including food and drug allergies, drug sensitivities, medication compliance and past adverse drug reactions, alcohol and other drug history, TB screening as appropriate. The nurse will also assess for medication effectiveness, side effects, interactions, duplication, need for lab monitoring and identify ineffective medication therapies.

S. Immunization history for pediatric patients

T. The patient’s and family/caregiver’s educational needs, abilities, motivation, and

readiness to learn.

U. Standardized Palliative Care assessments such as:

i. Palliative Performance Score (PPS) for all patients ii. Functional Assessment Staging Test (FAST) for patients with Alzheimer’s

disease and related dementia iii. Eastern Cooperative Oncology Group (ECOG) performance status for

patients with Cancer. iv. New York Heart Association Heart Failure Classification for patients with

Heart Failure V. An assessment of the need for volunteer services to offer support or respite to the

patient and family/caregiver

III. The Social Worker will assess the following:

A. Patient and family/caregiver support systems and the care the family/caregiver is available, capable, and willing to provide, including applicable strengths of patient, physical, psychosocial, and/or spiritual resources available

B. Involvement of family/caregiver, neighbors, and/or other individuals/organizations,

including involvement in any support groups. Specific, individualized patient needs/problems pertinent to the hospice care being provided.

C. An assessment of bereavement needs and survivor risk factors, such as:

1. The nature of the relationship to the patient

2. Circumstances surrounding the illness/prognosis

3. Behaviors prior to and after the illness/prognosis

4. Survivor needs

5. Potential for pathological grief reactions


D. The patient’s and family/caregiver’s psychosocial status, including emotional barriers to treatment, cultural practices, cognitive limitations, memory and orientation confusion, restlessness, anxiety, sleep disorders and family relationships, social history, source and adequacy of financial, environmental and other resources, coping mechanisms and the patient’s and family/caregiver’s reaction to illness.

IV. The Chaplain will assess the following:

A. Cultural and religious practices that may affect care and impact the patient’s and family’s ability to cope with the patient’s death.

B. Patient's family/caregiver's spiritual orientation, including, as appropriate, any involvement in a religious group such as a church or synagogue and spiritual concerns or needs such as despair, suffering, guilt, etc.

V. Documentation

A. All disciplines will be responsible for documentation of their assessments in the clinical record within 24 hours of the assessment visit.

B. Based on the initial assessment by each discipline, the plan of care will be

established within 48 hours of each discipline’s initial assessment. .

C. The initial hospice assessments will be filed in the patient's clinical record.

D. The Nurse Manager will be responsible for assuring that the documentation of

clinical findings supports the terminal diagnosis. Related Documents None References Hospice Medicare Conditions Of Participation (2008), L-Tag 418.45- Initial and

comprehensive assessment of patientConditions of Participation for Hospice Care (October 29, 2015)

Comprehensive Accreditation Manual for Home Care (2012), Standard 01.02.01, Assessment of patient National Hospice and Palliative Care Organization Standards of Practice for Hospice Programs (2010), Standard CES 1

Initial and Comprehensive Assessments 6 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

Hospice

Policy Number: HO6-011 Date Created: No Date Set Document Owner: Susan Buscaglia (Director of Hospice Services)


Approvers: Board of Directors (Administration), Susan Buscaglia (Director of Hospice Services)

Emergency Management Plan Printed copies are for reference only. Please refer to the electronic copy for the latest version. PURPOSE To establish a plan which will allow for continuation of services in the event of an emergency or a disaster affecting Kaweah Delta Hospice. Definitions 1. Emergency/Disaster: An event that can affect the facility internally as well as the overall

target population or the community at large or community or a geographic area.

2. Emergency: A hazard impact causing adverse physical, social, psychological, economic or political effects that challenges the ability to respond rapidly and effectively. It requires a stepped-up capacity and capability to meet the expected outcome, and commonly requires change from routine management methods to an incident command process to achieve the expexted outsome. It can inxlude a natural or man-made event that significantly disrupts the environment of care, such as damage to the hospice organization’s buildings or grounds due to a severe storm or earthquake; that significantly disrupts care and services, such as loss of utilities due to floods, civil disturbances, accidents or emergencies within the organization or community; or that results in sudden, significantly changed or increased demands for the organization’s services, such as bioterrorist attack, building collapse, or a plane crash in the organization’s community.

1.3. Disaster: A hazard impact causing adverse physical, social, psychological,

economic or political effects that challenges the ability to respond rapidly and effectively. Despite a stepped-up capacity and capability and change frount routine management methods to an incident command/management process, the outcome is lower than expected compared with a smaller scale or lower magnitude impact.

2.4. Hazard Vulnerability AnalysisRisk Assessment: The process used to assess and document potential hazards that are likely to impact the geographical region, community, facility, and patient population. It includes identification of potential emergencies and the direct and indirect effects these emergencies may have on the home health hospice organization’s operations and the demand for its services.

3.5. Mitigation Activities: Those activities an organization undertakes in trying to lessen the severity and impact of a potential emergency.

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Emergency Management Plan 2 4.6. Preparedness Activities: Those activities an organization undertakes to build

capacity and identify resources that may be utilized during an emergency. POLICY Planning Process Organization leadership will conduct a an all-hazards vulnerability analysis to identify potential emergencies that could affect the need for services or the ability to provide services. Staff will work with Kaweah Delta Health Care District Emergency Preparedness Committee and county emergency management planning agencies, where available, in: 1. Establishing priorities among the potential emergencies identified in the hazard

vulnerability analysisrisk assessment

2. Defining organization’s role in relation to the community-wide emergency management program

2.

3. Developing an “all-hazards” command structure within the organization that links with the community command structure

Specific procedures that describe mitigation, preparedness, response and recovery strategies, actions, and responsibilities will be developed for each priority emergency. The plan will provide processes for initiating the response and recovery phases of the plan, including a description of how, when, and by who the phases are to be activated for each priority emergency event. Based on the hazard vulnerability analysis and community planning activities, the organization’s general emergency plan may be enhanced or revised according to identified potential emergencies and planning activities. See Hospice Hazard Vulnerability Analysis HVA in Hospice Safety Manual See plans for Management of top 3 priority HVA events: Policy 6-012-Zero Visibility Fog Alert, Management of; Policy 6-013-Nation Wide Fuel Shortage, Management of; and Policy 6-014-Influx of Communicable Disease Patients, Management of. Refer to KDHCD Environment of Care Manual Policy 2000-“Emergency Operations Plan” for more information on the organizational emergency management plan. PROCEDUREe General Plan I. The decision to implement the emergency management plan will be made by the Director of Hospice, or designee, upon becoming aware of any emergency situation. II. . An alternate site will be designated in the event the office must be evacuated or is not accessible due to the emergency. Any clinical and financial records or blank documentation forms necessary for care during the emergency will be maintained in the off-site space in the event the office must be evacuated.


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Emergency Management Plan 3 III. The Clinical SupervisorsDirector and management staff, or designee(s), will be responsible for triaging all patient care, according to the following categories: 1. Category I Same Day: Patients who cannot safely forego care and require Hospice intervention regardless of other conditions. Patients in this category may include: highly unstable patients with a high probability of inpatient admission if home care is not provided; IV therapy patients with infusion pumps; highly skilled wound care patients that require a high skill level of wound care with no family/caregiver or other outside support; patients in need of critical supplies or medications; patients imminently dying.

2. Category II “Within 24 hours: Patients with recent exacerbation of disease process; patients requiring moderate level of skilled care that should be provided that day; patients with essential untrained family/caregivers not prepared to provide needed care.

Category III Within 48 hours: Patients who can safely forego care or a scheduled visit without a high probability of harm or deleterious effects; this category may include homemaker patients, routine supervisory visits, evaluation visits for routine care, patients with frequencies of one (1) or two (2) times a week, if health status permits, or if a competent family member/caregiver is present. 1. PROCEDURE

I. IV. Once the decision has been made to implement the emergency management plan, the Director or designee will initiate the Hospice Services Disaster Recall List in Hospice Safety ManualEmergency Phone Tree to notify personnel and community authorities, as appropriate. Personnel must listen to the organization-identified Emergency Broadcasting System for organization instructions and updates, if the telephone system is not functioning. Additionally, as able, personnel are to report to the office or alternate site if the office building is not accessible and normal communication systems are not working.

The alternate site will be the designated Incident Command Center for the hospital, or the labor pool site as designted by the Incident Commanger

II. V. The Director and management personnel will be responsible for identifying and assigning staff to cover all essential functions.

III. VI. Following the initiation of the Hospice Services Emergency Phone Tree, all

available and qualified personnel will be mobilized to perform identified services. VII. The Nurse Manager or designee(s) will assign category classifications for all current patients. IV. VIII. If feasible, the Nurse Manager, or designee(s), will assign all available, qualified

personnel to care for Category 1 patients first and Category 2 patients second. Category 3 patients and any other patients who do not receive scheduled care will be contacted by telephone as soon as possible. If transportation is needed to safely get personnel to patient homes, it will be arranged via county support services, such as the police, fire, or sheriff’s office.

V. IX.. If care cannot be provided to Category I patients, the Director, or designee, will

contact the hospital command center to request additional resources. If sufficient resources are not available, emergency transport to alternate care delivery sites will

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Emergency Management Plan 4

be arranged with community support agencies as as designated in EM.02.01.01-7 of the District Emergency Operations Plan .

VI. X. New patients will not be accepted for care until the emergency situation is

controlled or staffing levels permit. Patients accepted, but not yet admitted, will be triaged as noted above.

VII. X. In the event of a prolonged emergency situation, the Director, or designee, will:

A. Determine staffing availability and limitations, including assistance available from external staffing agencies

B. Identify those patients who could be discharged from Hospice services

C. Determine the course of action based on the above information D. Identify patients with continuing care needs

E. Contact other area Hospice organizations to determine the degree to which they

may be able to accept new patients, if the decision is made to transfer

F. Notify attending physicians and/or the Hospice Medical Director regarding their ability to continue caring for patients

G. Make transfer or discharge arrangements as necessary, notifying patients and

family/caregivers by telephone as appropriate

H. In prolonged emergency situations, the organization will retain only those patients for whom it can safely and adequately provide care

I. For patients in need of evacuation, refer to EM.02.02.11 Evacuation of Patients in

the District Emergency Operations Plan. VIII. XII. Safety of patients and organization personnelstaff will take priority in all

emergency situations.

A.. Weather and road conditions will be monitored via local weather reports and state patrol reports. reports.

B. Natural or community disasters will be monitored via the Emergency Broadcasting

System, reports from local authorities, or reports from other local health care facilities in the event there is no telephone communication.

C. In the event the office building is determined to be unsafe, the Director, or

designee, will communicate the location to which all personnel are to report for work.

Communication Plan XIII. In coordination with the District, in all emergency situations, the Director will maintain communications with the District’s communications department Incident Command Center and, when directed, will act as the spokesperson among other facilities, media, and






Emergency Management Plan 5 community and safety authorities. In addition, the procedures outlined in EM.02.02.01-1 through 17 of the District Emergency Operations Plan will be followed. Training and Testing

I. XIV. Kaweah Delta Hospice will test the emergency management plan at least twice annually, either in response to an actual emergency or planned drills. All actual responses and drills will be critiqued to identify deficiencies and opportunities for improvement. These critiques will be documented.

II. XV. Organization leadership will provide for orientation and education of all

personnel regarding participation in the emergency management plan. Education will be provided during orientation and annually thereafter..

Related Documents: NoneEOC 2000 Emergency Operations Plan HO6-012 Zero Visibility Fog Alert Management Plan HO6-013 Nation Wide Fuel Shortage Management Plan HO6-014 Influx of Communicable Disease Patients Management Plan References: None Medicare Conditions of Participation for Hospice Care, October 29, 2015 The Joint Commission Comprehensive Accreditation Manual for Home Care





Page 1 of 1

Manual Name: Imaging & SRCC Radiation Oncology Services

October 10, 2017

Support Staff Name: Carla Hernandez Board of Directors

Policy/Procedure Title #

Status (New, Revised, Reviewed, Deleted)

Name and Phone # of person who wrote the new policy or revised an

existing policy

Substantial Radiation Dose Management for Fluoroscopically-Guided Procedures

IS 5.7 New Teri Braun-Hernandez, ext. 4930

Communication of Mammography Results to Patients

IS 7.02 Revised Rebecca Wright, ext. 3219

Mammography Image Release


Mammography Infection Control


Mammographic Localization IS 17.15 Revised Rebecca Wright, ext. 3219 Mammography Stereotactic Biopsy IS 17.17 Revised Rebecca Wright, ext. 3219

Communication of Critical Findings

IS 7.4

Reviewed

Radiology T-Tube Cholangiogram-Physician Preference

IS 17.22 Reviewed

Mammography Ductogram – Physician Preference

IS 17.23 Reviewed

Radiology Venogram – Physician Preference IS 17.24 Reviewed

Radiology Enteroclysis – Physician Preference

IS 17.26 Reviewed

Radiology Sialogram – Physician Preference IS 17.27 Reviewed Radiology Voiding Cystogram (VCUG) IS 17.30 Reviewed

Radiology Porta-cath Check – Physician Preference

IS 17.33 Reviewed

Contrast/Medication – CT Oral Contrast Administration

IS 18.7 Reviewed

Pediatric Radiation Safety IS 19.2 Reviewed Routine Pediatric Radiography IS 19.4 Reviewed

CT - KDIC & KDMC: Imaging Services:

Radiology: Policy Number: IS 5.7 Date Created: 12/29/2016 Document Owner: Carla Hernandez (Administrative Assistant)


Approvers: Board of Directors (Administration), Carla Hernandez (Administrative Assistant), Cindy Moccio (Board Clerk/Exec Assist-CEO), Daniel Hightower (Radiology), Deana Hale (Imaging Services Manager), Glade Roper (Radiology), Gordon Ah Tye (Dir Imaging & Radiation Svcs), Jose Thekkumthala (Clinical Radiation Physicist), Renee Lauck (Dir OP Rad Onc & Imaging Svcs)

Substantial Radiation Dose Management for Fluoroscopically-Guided Procedures

Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: To provide guidance for fluoroscopic-guided interventional (FGI) procedures that are classified as potentially-high radiation dose procedures. Policy: A. The National Council on Radiation Protection and Measures (NCRP) defines a

potentially high radiation dose procedure if more than 5% of the cases of that procedure result in a cumulative air kerma exceeding 3Gray or cumulative DAP exceeding 300 Gray cm2.

1. Other medical applications of fluoroscopy examinations are outside the scope of this policy; examination of the GI tract and open surgical procedures. Although we do request that the fluoroscopy log books contain as much of the radiation dose metrics as possible.

2. The procedures that fall into the preview of this policy are the Fluoro Guided Imaging (FGI) procedures performed in interventional radiology, interventional cardiology, and interventional neurology.

B. Some beneficial, clinically justified FGI procedures, even when optimized for radiation protection, deliver substantial doses of radiation to patient. This puts the patient at risk for radiogenic stochastic effects and occasionally induces radiogenic deterministic effects. Many uncontrollable factors increase the radiation exposure to the patient and staff for the FGI procedure including the patient’s anatomy, pathology, and size. Reaching the significant radiation dose limit (SRDL) alone is not an indication of inexperience or poor radiation safety technique.

C. Radiation risks should be part of the risk benefit analysis of the FGI procedure and included in the informed consent process with the patient.

D. Splitting procedures into multiple episodes does not separate the cumulative radiation dose for the procedure. The summative dose should be used in evaluating the SRDL trigger levels.

E. Potential radiation induced injuries for patients that reach SRDL will be tracked. 1. Patient fluoroscopic procedure logs will include the patient identifying

information, the procedure performed, proceduralist, Fluoro-time, Cumulative Air Kerma mGy, and Cumulative DAP mGy/CM2 for all patients with studies involving fluoroscopy.

Substantial Radiation Dose Management for Fluoroscopically-Guided Procedures 2

a. Kaweah Delta Health Care District (KDHCD) has adopted the FDA recommended NCRP Report No. 168 suggested values for first and subsequent notification and the SRDL.

b. If the equipment does not produce all 3 radiation measurements the radiologic technologist will log what is available.

2. The fluoroscopy logs will be presented at the quarterly radiation safety meetings.

Procedure: A. An informed consent is obtained prior to the procedure. B. Identification of fluoroscopy administered Substantial Radiation Doses.

1. Fluoroscopy time is the least accurate trigger level and is used only when the Cumulative Air Kerma or other exposure data are not available.

2. Radiation dose should be closely monitored throughout the procedure. a. If the equipment has the capability of reporting the dose, the

interventionalist should be notified when the dose to the patient has reached 2 Gy (the point at which cutaneous radiation injury may become evident) and notification should be repeated every 0.5 Gy after that (See table below for alternate metrics).

b. If equipment can only monitor fluoroscopy time, notification of the interventionalist should occur at 30 minutes of beam on-time and every 15 minutes thereafter.

c. The Interventionalist should be notified at 1 minute increments of cine.

3. Doses that reach the SRDL must be reported to the radiation safety officer. When the SRDL is reached or exceeded, an incident report should be filed by the radiologic technologist.

a. The study should be marked on the modality in a manner that it will not be erased from the modality until after a qualified physicist has reviewed the data.

b. Determining actual patient dose estimates should only be attempted by a qualified physicist.

Dose Metric First Notification

Subsequent Notifications (increments)

Substantial Radiation Dose Limit

SRDL Dskin, max 2Gy 0.5Gy 3 Gy Cumulative Air Kerma

3Gy 1Gy 5 Gy

Cumulative DAP 300Gy-cm2b 100Gy-cm2B 500Gy-cm2b Fluoro time 30 minutes 15 minutes 60 minutes

C. Patient Follow up

1. If a SRDL is exceeded for a FGI procedure, the patient and any caregivers should be informed, prior to discharge, about possible deterministic effects and recommended follow up.

a. The patient should understand the potential radiation effects that might result when a particular skin area has received a dose that might cause deterministic effects. This will help the patient understand any skin changes that may develop and to seek


appropriate medical care. Patients, caregivers, and responsible healthcare professionals should be made aware of the possible radiologic etiology of relevant signs and symptoms.

b. Clinical follow-up intended to diagnose radiogenic, visually disabling cataracts may not be practicable at lower radiation levels because of a dose-depended latent period (i.e., the higher the dose, the more rapidly cataracts develop), ranging from years to decades between irradiation and lens opacification.

2. Follow up for possible deterministic effects shall remain the responsibility of the interventionalist for at least 1 year after an FGI procedure. Follow up may be performed by another healthcare provider who remains in contact with the interventionalist.

a. All relevant signs and symptoms should be regarded as radiogenic unless an alternative diagnosis is established.

D. The Joint Commission has recommended that cumulative doses of > 15 Gy (1500 Rads) to a single field (6 month to one year time frame is considered reasonable) be investigated as Sentinel Events.

1. Any case where 15Gy (1500 Rads) has been exceeded will be referred to Risk Management for a Root Cause Analysis (RCA). Failure to pursue an adequate RCA within 45 days of recognition of an event can result in the loss of Joint Commission accreditation.

2. The Joint Commission recommends that doses from previous studies to the same body area be summed together over a 6-12 month period.

E. Note, it only takes 1 to 2 minutes of cine to reach 2Gy (200 Rads) and may take as little as 7 minutes to reach 15 Gy (1500 Rads).

Documentation: A. Fluoro Log: The radiologic technologists must record the cumulative radiation

exposure values in the fluoroscopy patient logs for every fluoroscopic procedure: 1. Patient identifying information 2. The procedure performed 3. Interventionalist 4. Fluoro-time 5. Cumulative Air Kerma mGy 6. Cumulative DAP mGy/CM2

B. SRDL Documentation 1. Technologists Responsibilities

a. When the SRDL is reached or exceeded, an Incident Reporting Intranet System (IRIS) should be completed by the radiologic technologist with the following information:

i. Patient identifying information ii. The procedure performed iii. interventionalist iv. Cumulative Air Kerma mGy v. Cumulative DAP mGy/CM2 vi. Fluoro-time vii. Any helpful information about the procedure factors that

contributed to reaching the SRDL. 2. Interventionalist Responsibilities


a. Ensures that all available radiation metrics (Dskin, max, a, r, PKA, fluoroscopy time and number of frames) are recorded in the electronic health record (EHR).

b. Writes an appropriate note in the EHR if any of the values in the last column of the table is exceeded, signifying that an SRDL has been exceeded and indicating the reason.

i. Notation in the EHR may also be appropriate even if these values are not exceeded, such as for patients on whom other procedures involving radiation exposure are planned or have already been performed within six months.

Related Documents: Definitions included at bottom of document. References: BALTER, S. and MOSES, J. (2007). “Managing patient does in interventional cardiology,” Catheter Cardiovasc. Interv. 70(2), 244-249. HIRSHFELD, J.W., JR., BALTER, S., BRINKER, J.A., KERN, M.J., KLEIN, L.W., LINDSAY, B.D., TOMMASO, C.L., TRACY, C.M. WAGNER, L.K., CREAGER, M.A., ELNICKI, M., LORELL, B.H., RODGERS, G.P., TRACY, C.M. and WEITZ, H.H. (2004). “ACCF/AHA/HRS/SCAI clinical competence statement on physician knowledge to optimize patient safety and image quality in fluoroscopically guided invasive cardiovascular procedures: A report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training,” J. Am. Coll. Cardio. 44(11), 2259-2282. NCRP, (2011), NCRP Report 168: Radiation Dose Management for Fluoroscopically-Guided Interventional Medical Procedures, NCRP, Bethesda, MD. STECHER, M.S., BALTER, S., TOWBIN, R.B., MILLER, D.L., VANO, E., BARTAL, G., ANGLE, J.F., CHAO, C.P., COHEN, A.M. DIXON, R.G., GROSS, K., HARTNELL, G.G., SHUELER, B., STATLER, J.D., DE BAIRE, T. and CARDELLA, J.F. (2009). “Guidelines for patient radiation dose management,” J. Vasc. Interv. Radiol. 20(7 Suppl.), S263-S273. TJC (2006). The Joint Commission. Radiation Overdose as a Reviewable Sentinel Event (The Joint Commission, Oakbrook Terrace, Illinois). TJC (2007). The Joint Commission. Sentinel Event Policy and Procedures, (The Joint Commission, Oakbrook Terrace, Illinois). WORGUL, B.V., KUNDIEV, Y., LIKHTAREV, I., SERGIENKO, N., WEGENER, A. and MEDVEDOVSKY, C.P. (1996). “Use of subjective and non-subjective methodologies to evaluate lens radiation damage in exposed populations – an overview”, Radiat. Environ. Biophys. 35(3), 137-144. Definitions: Absorbed dose: The energy imparted to matter by ionizing radiation per unit mass of irradiated material at the point of interest. In the Systeme Internationale (SI), the unit is J kg -1 with the special name gray (Gy).

Substantial Radiation Dose Management for Fluoroscopically-Guided Procedures 5 Air Kerma/Air Kerma-air product (PKA): The energy released per unit mass of small volume of air when it is irradiated by an x-ray beam. For diagnostic x-rays, air kerma is the same as the absorbed dose delivered to the volume of air in the absence of scatter. Air kerma is measured in Gray. As Low As Reasonably Achievable (ALARA): A principle of radiation protection philosophy that requires that exposures to ionizing radiation be kept as low as reasonably schievable, economic and societal factors being taken into account. The ALARA principle is satisfied when the expenditure of further resources would be unwarranted by the reduction in exposure that would be achieved. Cine: A particular mode used in fluoroscopic examinations that enables the user to image in real time. This is a useful tool in contrast enhanced angiographic studies. Cine sequences result in considerably higher radiation doses than conventional fluoroscopy. Cumulative dose (CD): The air kerma accumulated at a specific point in space relative to the fluoroscopic gantry (the interventional reference point) during a procedure. CD does not include tissue backscatter and is measured in Gy. CD is sometimes referred to as cumulative air kerma. Cutaneuous Radiation Injury: Injury to the skin and underlying tissues from acute exposure to a large external dose of radiation. Deterministic effects: Effects that occur in all individuals who receive greater than a threshold dose; the severity of the effect varies with the dose above the threshold. Examples are radiation induced cataracts (lens of the eye) and radiation-induced erythema (skin). Dose: A general term used to denote mean absorbed dose or effective dose. In this document the term “dose” will refer to the absorbed dose received during a fluoroscopic examination. Dose-area-product (DAP): The integral of air kerma (absorbed dose to air) across the entire x-ray beam emitted from the x-ray tube. DAP is a surrogate measurement for the entire amount of energy delivered to the patient by the beam. DAP is measured in Gy·cm2. Exposure: Being exposed to ionizing radiation or to radioactive material. Fluoroscope (medical): An instrument used in medical procedures for observing the internal structure of the body by means of the image of the anatomy examined formed on an image receptor when the patient is placed between the image receptor and an x-ray beam. Fluoroscopically-guided interventional (FGI) procedure: An interventional diagnostic or therapeutic procedure performed via percutaneous or other access routes, usually with local anesthesia or intravenous sedation, which uses external

Substantial Radiation Dose Management for Fluoroscopically-Guided Procedures 6 ionizing radiation in the form of fluoroscopy to: localize or characterize a lesion, diagnostic site, or treatment site; monitor the procedure; and control and document therapy. Fluoroscopy: A medical x-ray procedure used for observation of the internal features of the body by means of the fluorescence produced on a screen by a continuous field of x-rays transmitted through the body. Fluoroscopy is intended to observe moving objects for relatively long periods of time (seconds to minutes) without the intent of preserving the images. Fluorography: Radiographic imaging by means of an image intensifier or digital panel and an x-ray generating tube. The intent of fluorography is to record images of moving objects for a few seconds at a time (e.g., cinefluorography of the heart). Exposure rates are 10 to 100 times greater than fluoroscopic images of the same patient and anatomical view. Gray (Gy): A unit of measurement that refers to the dose of radiation a patient received during an examination/treatment. (1 Gy = 100 rads). The special name for the SI unit J kg -1 (i.e., energy imparted per unit mass of a material). 1 Gy=1 Jkg. -1. Interventionalist: In this policy, an individual who has been grated clinical privileges to perform or supervise FGI procedures in a facility, and who is personally responsible for the use of radiation during a specific FGI procedure in that facility. There physicians have varying academic backgrounds and radiation safety training and normally include Interventional Radiologists, Interventional Cardiologists, and Interventional Neurologists. Kerma (Kinetic Energy Released in Matter): The amount of energy transferred from the x-ray beam to charged particles per nit mass in the medium of interest. For diagnostic x-rays, this is equivalent to absorbed dose in the specified medium (eg, air, soft tissue, bone). Kerma is measured in Gy. Milligray (mGy): A unit of measurement that refers to the dose of radiation a patient received during an examination/treatment. (1 Gy=1000 mGy). Peak skin dose (Dskin, max): The maximum absorbed dose to the most heavily irradiated localized region of skin (i.e., the localized region of skin that lies within the primary x-ray beam for the longest period of time during an FGI procedure). Potentially-high radiation dose procedure: An FGI procedure for which more than 5% of cases that procedure result in Ka,r exceeding 3 Gy or PKA exceeding 300 Gy cm2. Rad (Radiation Absorbed Dose): A unit of measurement that refers to the dose or radiation that a patient received during an examination/treatment. (1 rad = 10 mGy; 1 Gy = 100 rads). Reviewable Sentinel Event: According to The Joint Commission a reviewable sentinel event is one that involves a radiation overdose involving prolonged

Substantial Radiation Dose Management for Fluoroscopically-Guided Procedures 7 fluoroscopy with a cumulative dose of more than 15 Gy (1,500 rads) to a single field/organ within 6-12 months. Reviewable sentinel events also require patient follow-up. Substantial radiation dose level (SRDL): An appropriately-selected reference value used to trigger additional dose-management actions during a procedure and medical follow-up for a radiation level that might produce a clinically-relevant injury in an average patient. There is no implication that radiation levels above an SRDL will always cause an injury or that radiation levels below an SRDL will never cause an injury. Systeme Internationale (SI): The International System of Quantities and Units as defined by the General Conference of Weights and Measures in 1960 and periodically revised since. These units are generally based on the meter/kilogram/second units, with special quantities for radiation including the Becquerel, gray and sievert. "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."


Imaging Services, Mammography

Policy Number: IS 7.02 Date Created: 02/01/1996 Document Owner: Carla Hernandez (Administrative Assistant)


Approvers: Board of Directors (Administration), Carla Hernandez (Administrative Assistant), Daniel Hightower (Radiology), Gordon Ah Tye (Dir Imaging & Radiation Svcs), Renee Lauck (Dir OP Rad Onc & Imaging Svcs)

Communication of Mammography Results to Patients Printed copies are for reference only. Please refer to the electronic copy for the latest version. Policy: Mammography patients can expect to get results in a timely manner. Procedure: I. Patient is informed with a letter stating the following

A. Normal B. Additional imaging required C. Short term follow-up required D. Biopsy recommended

II. If patients have not received the results of their mammogram within three to four (3-4) weeks of their examination, they will be told to call their referring physician for results.

III. The mammographer or registrar will hand the patient a written reminder to that effect. IV. Dense tissue notification:

If a patient has dense tissue it is stated in the patient’s letter: Your mammogram shows that your breast tissue is dense. Dense breast tissue is very common and is not abnormal. However, dense breast tissue can make it harder to evaluate the results of your mammogram and may also be associated with an increased risk of breast cancer. This information about the results of your mammogram is given to you to raise your awareness and to inform your conversations with your doctor. Together you can decide which screening options are right for you.

Related Documents: NONE References: NONE "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

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

Policy: In accordance with MQSA regulation, KDHCD is obligated to release a copy of original films and the original digital images to a patient, either hard copy or CD or if authorized by the patient, a representative acting in their behalf. Procedure: I. Process

A. If there is a request to have a patient’s original films or digital images permanently released, the patient or their representative must sign a release form. (Addendum A) This form states that the films are no longer the property or responsibility of KDHCD. All images obtained digitally, will be either printed or put on a CD and given to the patient.

B. Copies of the original digital mammograms films can be made for KDHCD

file, but patient may not be charged. II. Documentation

A. The signed release form is to be scanned into Imnet. Related Documents: NONE References: NONE "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."





Mammography Infection Control Printed copies are for reference only. Please refer to the electronic copy for the latest version. Policy: The following procedure shall be followed when cleaning the Mammography equipment. Procedure: After each patient use: 1. Before a new patient is positioned for mammography, the image receptor is wiped with

isopropyl alcohol and low lint cleaning wipes. a clean with an antibacterial soap and water solution.

2. If any blood spill or breast secretion occurs, the image receptor is additionally cleaned

with Super Sani-Cloth Germicidal Disposable wipes, Germicidal wipe or Omega detergent, then re-cleaned with isopropyl alcohol and low lint cleaning wipes.antibacterial soap and water solution.

3. After each use, the plastic localization compression paddle, biopsy compression paddle

and/or biopsy probe guide is taken to the deep sink and washed with water then cleaned with the Super Sani-Cloth Germicidal Disposable wipes.antiseptic soap

4. Employees will wash their hands after cleaning and prior to each patient handled. Related Documents: NONE References: NONE "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."





Mammographic Localization Printed copies are for reference only. Please refer to the electronic copy for the latest version. Policy: When performing Mammography Localizations, staff will adhere to the following procedure. Procedure:

I. At the time of the request for this procedure, the patient’s mammograms are to be retrieved from the facility where they were taken, and placed in the file box in the Radiologist’s office.

II. The Radiologist will review films and determine if any additional work-up should be obtained prior to the localization exam.

III. Review in #2 will also assess the need for such a procedure. This is especially applicable to those studies done elsewhere.

IV. A KDDH radiologist must review outside films that will be used for the localization, before the examination can be scheduled.

V. A minimum of 1 hour should be set aside for the procedure.

VI. Technologist sets up supplies using sterile technique, under the direction of the

Radiologist. A. Sterile 3x4 sponges B. Package sterile towels C. 1 cc syringe D. 3 cc syringe E. Small vial of methylene blue F. Lidocaine 1% G. Betadine swabs

G. Chlora Prep H. Localization wire I. Sterile Gloves J. Affirm needle guides I.K. Sterile med. labels

Formatted: Indent: Left: 1", No bullets ornumbering

Mammographic Localization 2 VII. Fill out the Radiology Procedure Record (See Addendum 11 A) and document the

following:

A. Explain the basics of procedure to patient. B. Patient assessment by RN if necessary. C. Allergies and medications. D. Two Identifiers checked E. Contrast Used and amount F. Reactions

VIII. Once the procedure has begun, the patient is not to be left alone in the department, until the patient has been transferred to a vehicle of the care of surgery personnel or to a family member, to be driven to either the hospital or Surgery Center where the surgery will be performed.if the biopsy is to be performed at another facility.

IX. Fill out Pathology requisition with the patient information including the Radiologist’s name to insure that biopsy results will be returned to Kaweah Delta Imaging Center District Hospital, Breast Center Mammography Department, for follow-up.






Mammography Stereotactic Biopsy Printed copies are for reference only. Please refer to the electronic copy for the latest version. Policy: When performing a Stereotactic biopsy at the Breast Center, the staff will adhere to the following procedure. Procedure: I. Supplies:

A. Table cover Multicare Platinum Biopsy table only B. Auto guide drape Multicare Platinum Biopsy table only

C. Biopsy chair, sheet, pillow, chux Affirm onlyTubing

D. Biopsy paddle

E. Suros Bx Holder

F. Clip marker

G. Suction container

H. Bag of 250 ml Sodium chloride

I. 911 ga. Probe Guide

J. Biopsy tray

K. Epi with Lidocaine(under 60 years only) and/or Lidocaine

L. Autoguide Multicare Platinum Table, Affirm upright biopsy chair

M. 911 ga. Suros Probe

II. Preparation

Mammography Stereotactic Biopsy 2

1. Cover on table and autoguide drape under biopsy paddle

2. Cover seat of chair and have chux for patient’s lap, for AffirmAutoguide drape under biopsy paddle

3. Set up Radiologist/Surgeon tray

4. Set up Tech tray

5. Set up Suros probe, system, and prep tubing

6. Place patient prone on table, breast through biopsy hole or sit patient on biopsy chair

7. Compress breast, lesion in center of biopsy paddle

8. Take scout-save

9. Take stereo pairs-save

10. Set up Autoguide-cover with drape Multicare Platinum Biopsy table only

11. Place probe in Trigger mechanism attach to Autoguide or Affirm

12. Turn on suros

III. Biopsy Procedure

1. Radiologist targets lesion

2. Program Autoguide

3. Radiologist/Surgeon

a) Cleans skin

b) Numbs area with Lidocaine and Epi with Lidocaine

c) Small incision

d) Probe placement

e) Stereo pairs- save

f) Specimen retrieval

g) Stereo pairs- save (If calcs, take X-ray on regular mammo machine)

h) Clip placement

i) Stereo pairs- save; Rest of filming –save

Mammography Stereotactic Biopsy 3

4. Take patient out of compression- hold pressure- bandage

5. Take post biopsy X-rays on mammo machine

6. Pressure bandage- ice pack- post instructions. Related Documents: NONE References: NONE "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

Policy Manuals – AP38

Appendix D


Manual Name: Imaging Services Date: September 28, 2017 Support Staff Name: Carla Hernandez


#

Status (New, Revised,

Reviewed, Deleted)

Name and Phone # of person who wrote

the new policy or revised an existing policy

Contrast/Medication – Procurement, Storage, Control, Distribution, Administration and Monitoring of Radiographic Contrast Media

IS 18.2 Revised Renee Lauck, ext. 3208

Contrast/Medication – Outpatient Radiology Narcotic Control

IS 11.01 Reviewed Renee Lauck, ext. 3208

Pediatric Contrast Dose IS 19.6 Reviewed Renee Lauck, ext. 3208

Contrast/Medication, Imaging Services



Approvers: Board of Directors (Administration), Medical Executive Committee, Pharmacy and Therapeutics, Carla Hernandez (Administrative Assistant), Daniel Hightower (Radiology), Gordon Ah Tye (Dir Imaging & Radiation Svcs), Renee Lauck (Dir OP Rad Onc & Imaging Svcs)

Contrast/Medication - Procurement, Storage, Control, Distribution, Administration and Monitoring of Radiographic Contrast Media

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

I. Formulary Management

A. The formulary system described in Pharmacy Manual Policy 3.10.0 “Formulary System: Drug Product Selection” will be followed.

II. Radiographic contrast is procured by filling out an appropriate supply requisition and sending it to the pharmacy department. A pharmacy department buyer places the order.

III. Contrast Media Storage

A. The contrast media are stored in the Imaging areas in which it is used: Diagnostic Radiology, C.T., MRI, Kaweah Delta Imaging Center, and Interventional Radiology.

B. Contrast media will be stored:

1. In a segregated manner in accordance with the intended route of administration.

2. In a secure area.

3. Under necessary conditions to ensure stability.

C. Use of contrast warmers

1. Clinical experience indicates that it is desirable for iodinated or non-ionic contrast media to be at body temperature (98.6F or 37C) prior to intravascular injection, and contrast warmers are

Contrast/Medication - Procurement, Storage, Control, Distribution, Administration and Monitoring of Radiographic Contrast Media 2

often used for this purpose.

2. The contrast warmer temperature should not exceed 98.6F (37C). Contrast media should be stored as specified on the package insert, and should not be kept in the warmer for any period of time longer than that reasonably needed to reach body temperature or to assure that a supply of properly warmed media is readily available for use in ongoing radiological procedures.

3. The “First In, First Out” method of inventory control will assure that the time each container remains in the warmer is relatively uniform.

4. Manufacturer states there is data to support allowing Isovue to remain in the contrast warmer not exceeding 98.6 F (37C) for less than one month when the product has at least 6 months remaining on labeled expiration date, and otherwise appears suitable for use. Bottles or vials of Isovue should be maintained in an upright position while in warmer.

3.5. Contrast bottles will be placed in the warmer at the beginning of the day for that days use and will be used on a first in first out basis. Bottles will not be stored in warmer for more than 24 hours. Warmer will be emptied at the end of each day to assure bottles are not left overnight. Any unused vials will be disposed of.

IV. The technologists in the aforementioned Imaging areas monitor usage and place orders appropriately.

V. Once an order is placed, contrast media are distributed to the appropriate Imaging area.

VI. Contrast Media Ordering

A. The order basics described in Patient Care Manual Policy CP 19 “Medication: Administration” are followed.

B. Contrast media are administered to patients by order of the Radiologist performing the exam or the prescriber ordering the exam.

VII. Contrast Media Administration

A. The administration basics described in Patient Care Manual Policy CP 19 “Medication: Administration” are followed.

1. Exception: IV contrast media orders do not require a review by the pharmacist. The licensed independent practitioner (LIP) is in control of the ordering, preparation, and administration of

Contrast/Medication - Procurement, Storage, Control, Distribution, Administration and Monitoring of Radiographic Contrast Media 3

contrast media.

a) In the radiology setting, LIP control of these processes does not require he/she be at the bedside or personally administering the contrast media.

b) In the radiology setting, LIP control does require the LIP to be within the department in close proximity and readily available in the event of an adverse reaction during IV contrast administration.

2. Exception: Oral and rectal contrast media orders do not require a review by the pharmacist. Prior to administration, orders for oral and rectal contrast media are reviewed for appropriateness by the radiologist.

A. Prior to radiographic contrast media administration, the patient is screened by the radiology technologist for any allergies or drug interactions, which would preclude product use. Pertinent information will be brought to the attention of the radiologist who will determine how to proceed.

B. A RN or a Radiographer may inject contrast media. Those Radiographers who possess an IV certification may start IV if needed.

C. Each patient, who receives iodinated or non-ionic contrast media, has

the amount, type and any reactions recorded on the Radiology Procedure Record.



Manual Name: Renal Services Date: 10/6/17 Support Staff Name: Nicole Rhodes Routed To: Approved By:

(Name/Committee – Date) Department Director Medical Director (if applicable) Medical Staff Department (if applicable) Patient Care Policy (If applicable) Pharmacy & Therapeutics (if applicable) Interdisciplinary Practice (if applicable) Executive Team (if applicable) Medical Executive Committee (if applicable) Board of Directors

Jon Knudsen Roger Haley


#


Reviewed, Deleted)

Name and phone number of person who wrote the new policy or revised an

existing policy Hepatitis Testing in Renal Patients for Acute Dialysis

RS-L.34 Revised Darrell Chudej 559-624-3601 Cathy Gage-Ivers 559-624-2504

Initiating and Discontinuing Hemodialysis using a Central Venous Catheter

RS-L.10 Revised Darrell Chudej 559-624-3601 Cathy Gage-Ivers 559-624-2504

Patient No Call/No Show: Patient Failure to Attend Treatment/Appointment

RS-E.02 Revised Darrell Chudej 559-624-3601 Cathy Gage-Ivers 559-624-2504

Acute Dialysis

Policy Number: RS-L.34 Date Created: 10/07/2009 Document Owner: Nicole Rhodes (Database Reporting Analyst)


Approvers: Board of Directors (Administration), Jon Knudsen (Dir of Renal & Oncology Svcs), Nicole Rhodes (Database Reporting Analyst), Roger Haley (Nephrology), Tariq Javed (Nephrology)

Hepatitis Testing in Renal Patients for Acute Dialysis Printed copies are for reference only. Please refer to the electronic copy for the latest version. Policy: Dialysis patients are at significant risk to contract Hepatitis B.

A. Identify hepatitis B status for all acute dialysis renal patients. in a designated high-risk group who may have contracted hepatitis.

B. To initiate appropriately infection prevention procedures. care for patients

whose hepatitis profile lab test is positive. C. This policy applies to all patients undergoing hemodialysis, either

intermittent (IHD), continuous (CRRT) or extended (SLEDD)’ B.D. The policy is initiated for the first hemodialysis treatment.

Acute patients receiving hemodialysis meeting the criteria defined below will have baseline screening, serum hepatitis profile test, performed.

Procedure:

A. The registered nurse (RN) will obtain an place an order for forthe ainitiation of protocol for Hepatitis/Immunodeficiency Control – Acute Dialysis. a serum hepatitis profile test when a patient requiring renal service meets the following criteria.

A.B. Hepatits B surface antigen results from external sources (outpatient dialysis facility, etc.) if available, can be used as sufficient Hepatitis B screening if the result is within the last 30 days.

B. If Hepatitis B status is not known, and If not already ordered, tThe RN will place an order for a stat Hepatitis B Surface Antigen (HBsAg).lab determination, to be drawn as far in advance of the dialysis treatment as possible, such that results may be known prior to initiation of the treatment.

1. The patient is initiating dialysis treatments, either temporarily or ongoing.

Formatted: List Paragraph, No bullets ornumbering



Hepatitis Testing in Renal Patients for Acute Dialysis 2 C. Hepatitis status is returned 1. Surface antigen will be ordered per this policy. a. New initiates 2. Patient is a known chronic dialysis patient and results are not available. a. results are not available b. results are > 30 days

2. The patient has come from another facility and past hepatitis

screening results are not available. 3. The lab results are greater than 30 days old before a newly diagnosed

patient is transferred to an outside chronic facility.

B.D. The serum hepatitis profile test will be ordered per this policy

C.E. Patients at high risk for hepatitis B (e.g. known drug abusers) or evidence of hepatic dysfunction (jaundice, elevated liver enzymes) will have an HbAgs run as a “stat” lab request.

D.F. Attending physician and nephrologist will be notified of positive results. G. Patients dialyzing with unknown or positive hepatitis B status will:

a. Dialyze in patient’s room or other isolated room b. The dialysis machine used will remain in patient’s room until status

known

c. Staff caring for patients with unknown hepatitis B status, must be hepatitis B immune and will not simultaneously care for multiple patients

d. Room door will be closed during initiation and discontinuation of

dialysis

e. Separate and isolation equipment is required (blood pressure cuff, stethoscope, etc.)

f. Once hepatitis B status is confirmed:

i. Positive – machine will be isolated, bleached, and red bag

applied

Formatted: Bullets and Numbering











Hepatitis Testing in Renal Patients for Acute Dialysis 3

ii. Negative – machine will be disinfected per policy and returned to regular usage

References: Gordon, C. (2008) KDOQI US Commentary on KDIGO Clinical Practice Guidelines for the Prevention, Diagnosis, Evaluation, and Treatment of Hepatitis (AJKD volume 52 November 2008, pp 811-820) Finelli, L. (2002) National Surveillance of Dialysis-Associated Diseases in the United States (CDC archive Special Article pp 52-60) Center for Medicare and Medicaid (CMS) Conditions for Coverage (2008)

Hepatitis Testing in Renal Patients for Acute Dialysis 4 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

Acute Dialysis, Chronic Dialysis

Policy Number: RS-L.10 Date Created: 06/02/1997 Document Owner: Nicole Rhodes (Database Reporting Analyst)


Approvers: Board of Directors (Administration), Jon Knudsen (Dir of Renal & Oncology Svcs), Nicole Rhodes (Database Reporting Analyst), Roger Haley (Nephrology)

Initiating and Discontinuing Hemodialysis using a Central Venous Catheter Printed copies are for reference only. Please refer to the electronic copy for the latest version. Policy: To provide hemodialysis using a Central Venous Catheter. Indwelling

Central Venous Catheters will only be accessed and discontinued by a Registered Nurse/LVN.

Equipment: Supplies for Initiating Dialysis: • 2-10ml syringes • 1-absorbent pad • 4 antimicrobial pads • 1-package toppers • 1-pair clean exam gloves • Dialyzer as prescribed * refers to 10ml-15ml syringe as available Supplies for Discontinuing Dialysis(not sure this caveat is needed) • 2-10ml syringes • 2-3ml syringes with prescribed anticoagulant flush • 2-sterile catheter caps • 2 antimicrobial pads • 1-absorbent pad • 1-pair clean exam gloves Procedure: Note: If patient has TEGO Cap refer to TEGO policy RS-L.33 for assessing and care. I. Initiating Hemodialysis Using a Central Venous Catheter

A. Apply face mask, Wwash hands, apply face mask, don appropriate gown, and put on gloves


Initiating and Discontinuing Hemodialysis using a Central Venous Catheter 2

B. Place absorbent pad and sterile topper under port of patient’s catheter and untape catheter connections. Wrap outside of caps with antimicrobial pad.

C. Cleanse outside of venous port cap with antimicrobial pad. Remove

venous port cap and cleanse port with a new pad. Attach sterile *10ml syringe to the end of the venous port and aspirate 5ml’s of blood. This will clear the catheter of heparin.

D. Cleanse the outside of the arterial port cap with antimicrobial pad. Remove the venous arterial port cap and cleanse port with a antimicrobial pad. Attach sterile *10ml syringe and aspirate 5ml of blood from port.

E. Connect arterial blood line from dialysis machine to arterial port.

Secure luerlock connection.

F. If the patient is not to receive the prime, clamp Normal Saline inlet with clamp supplied on the line and double clamp with plastic scissor clamp. Turn blood flow to 100ml/min. Blood will flow from arterial catheter port through inverted dialyzer. When the venous chamber on the dialysis machine becomes pink, clamp venous blood line and turn blood flow off. If patient is to receive prime proceed to “HG” before initiating blood flow (“H” below is deleted – should this read “proceed to G”?

G. Connect venous blood line to venous port. Secure luerlock

connection.

H. Connect venous blood line to venous port. Secure luerlock connection.

II. Discontinuing Dialysis using a Central Venous Catheter

A. Take patient’s vital signs; notify RN if medications are to be given.

B. Refer to RS-L.44 Rinseback Technique

A.C. Document in patient’s electronic medical record

B. Spread limits on arterial, venous and TMP monitors.

C. Turn blood flow off.

D. Clamp arterial line to the right of the normal saline inlet port.



https://kdhcd.policytech.com/docview/?docid=8350

Initiating and Discontinuing Hemodialysis using a Central Venous Catheter 3

E. Compress Normal Saline bag until the line is cleared of blood, clamp arterial blood line and clamp arterial port.

F. Remove clamp from right side of the Normal Saline inlet port and move

clamp to the left side of the inlet port. Turn blood flow on to 100-150ml/min. This will clear the blood through the dialyzer through the venous blood chamber. When clear, turn blood flow off.

G. Clean the Central Venous Catheter ports with new antimicrobial pads.

Flush each port with 5-10ml (I would not have a range of flush amount, just choose one – eliminates the question of “how does the nurse choose”) of Normal Saline.

H. Registered Nurse ONLY will connect predrawn anticoagulant flush in

amount and concentration prescribed. Use a flush and clamp technique to instill. (The “ONLY” part is unclear. I get that only a RN will do this, not the LVN. Yet the top of the policy says this is for RN/LVN; however, that is misleading if there are parts of this process that the LVN is not allowed to do.)

I. Place sterile catheter caps on ends; apply a bridge tape around caps for

extra added security.

J. Take patient’s blood pressure, standing and sitting. Assist patient to the weight scale to weigh and discharge if patient is stable.

K. Document in patient’s electronic medication record.

Initiating and Discontinuing Hemodialysis using a Central Venous Catheter 4 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

Chronic Dialysis, Peritoneal - Outpatient

Policy Number: RS-E.02 Date Created: 10/20/2004 Document Owner: Nicole Rhodes (Database Reporting Analyst)


Approvers: Board of Directors (Administration), Jon Knudsen (Dir of Renal & Oncology Svcs), Nicole Rhodes (Database Reporting Analyst), Roger Haley (Nephrology), Tariq Javed (Nephrology)

Patient No Call/No Show: Patient Failure to Attend Treatment/Appointment Printed copies are for reference only. Please refer to the electronic copy for the latest version.

Policy: In the event of a no call/no show for a scheduled appointment or

dialysis treatment, t. To safeguard the health and safety of clinic patients, t. The dialysis clinic will attempt to determine the patient’s whereabouts and status in order to, as outlined in this policy.

I. As stated in the “Patient Rights & Responsibilities”, patients are to notify the

dialysis facility(s) in case of emergency or if unable to make their scheduled appointment/dialysis treatment time.

II. A no call/no show means the patient did not provide the facility prior notification and has not come to their appointment/treatment.

III. Staff will attempt to contact patient to determine patient’s plan related to scheduled dialysis treatment. or patient’s status.

IV. StaffCharge Nurse will follow up related to patient’s whereabouts within 1 hour. within 30 to 45 minutes.

V. Staff will attempt to contact patient per contact information as listed in patient’s record.

VI.A. Staff will check with hospital, or search hospital census if available in/and, to attempt to locate patient.

VII.B. Staff will call the transport company if patient utilizes transport services..

VIII.C. If patient does not have history of missed treatments, no call/no show and the above actions have been unsuccessful, law enforcement will be contacted and a patient safety check will be requested. If the patient has a history of no call/no show, the law enforcement may be called as determined by the Charge Nurse or Social Worker.

IX.V. If a pattern of no call/no show for dialysis appointments/treatments is noted.

Formatted

Patient No Call/No Show: Patient Failure to Attend Treatment/Appointment 2

A. The licensed nurse will re-educated the patient related to health care compliance and benefits of treatment and possible complications of missed treatments.

B. Patients Rights and Responsibilities may be reviewed with patient C. The nephrologists will be notified as appropriate D. The Renal Care Coordinator will be notified. Another interdisciplinary team

(IDT) member may assist in problem-solving. E. If the problem persists, the IDT team will reassess the patient and plan of care

meeting will be scheduled

Patient No Call/No Show: Patient Failure to Attend Treatment/Appointment 3 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."


Manual Name: Respiratory Care – South Campus Policies Date: 7/27/17 Support Staff Name:


#

Status (New, Revised, Reviewed w/no

Revision, Deleted)

Name and Phone # of person who wrote the new policy or

revised an existing policy

Therapeutic Gas, Storage, Handling and Quality Control 2009 Revised Steve Hensley/Wendy Jones

Mechanical Ventilation 3001 Revised Steve Hensley/Wendy Jones

Bagging 3008 Revised Steve Hensley/Wendy Jones

Transport of Ventilator Patients 3009 Revised Steve Hensley/Wendy Jones

Aerosol Therapy 4001 Revised Steve Hensley/Wendy Jones

Metered Dose Device (Inhaler) 4002 Revised Steve Hensley/Wendy Jones

Sputum Induction 4004 Revised Steve Hensley/Wendy Jones

Oxygen Therapy 5001 Revised Steve Hensley/Wendy Jones

Non-Rebreather Mask 5002 Revised Steve Hensley/Wendy Jones

Assuring Oxygen Purity, Availability, and System Integrity 5003 Revised

Steve Hensley/Wendy Jones

Pulse Oximetry 5004 Revised Steve Hensley/Wendy Jones

Oxygen Cylinder Use 5005 Revised Steve Hensley/Wendy Jones

Airway Management 6001 Revised Steve Hensley/Wendy Jones

Requirements for Initiation Weaning from Continuous Mechanical Ventilation 6004 Revised

Steve Hensley/Wendy Jones

Extubation Policy 6005 Revised Steve Hensley/Wendy Jones

Peak Flow Determination 6006 Revised Steve Hensley/Wendy Jones

Tracheostomy Care – South Campus 6007 Revised Steve Hensley/Wendy Jones

Routine Tracheostomy Tube Change 6008 Revised Steve Hensley/Wendy Jones

Postural Drainage and Percussion 6009 Revised Steve Hensley/Wendy Jones

Suctioning 6011 Revised Steve Hensley/Wendy Jones

Use of Passy-Muir Valve (PMV) 6013 Revised Steve Hensley/Wendy Jones

Continuous Positive Airway Pressure 3003 Deleted Steve Hensley/Wendy Jones

Bilevel Positive Airway Pressure “BIPAP” 3004 Deleted Steve Hensley/Wendy Jones

Intermittent Positive Pressure Breathing (IPPB) 3005

Deleted Steve Hensley/Wendy Jones

Incentive Spirometry 6010 Deleted Steve Hensley/Wendy Jones

Respiratory South Campus

Policy Number: RT South Campus - 2009 Date Created: 10/01/2000 Document Owner: Kristy Samuels (Administrative Assistant)


Approvers: Board of Directors (Administration), Board of Directors (ENDO/PF/IC/RT), Dept of Critical Care, Harjoth Malli (Pulmonary/Critical Care Medicine), Kristy Samuels (Administrative Assistant)

Therapeutic Gas, Storage, Handling and Quality Control

Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: To guide safe handling of therapeutic gases. Policy: It is the policy of Kaweah Delta .Medical Center to comply with all

standards set forth by governing agencies regarding the safe use, storage, handling and procurement of liquid oxygen and the handling of portable compressed gas cylinders.

Procedure: I. Procurement

A. Kaweah Delta South Campus is supplied with both a primary and secondary oxygen source. The bulk oxygen system as well as all cylinder gases are supplied to this institution by Air Liquide America Corporation.

B. Records concerning delivery, purity and quantity are maintained by Plant

Operations staff.

C. Cylinder gases are procured from Airgas Liquide Corp. on an as needed basis and are stored in accordance to JCAHO, and DPHS and NFPA 99 regulations at this facility.

II. Storage

A. The storage area must be permanently posted.

B. Cylinders are grouped by content.

C. Full and empty cylinders must be segregated in the storage area. when possible.

D. Storage room must be dry, cool and well ventilated.

E. The storage facility should be fire resistant where practical.

F. Cylinders must not be stored near flammable substances.

G. Large cylinders must be stored in an upright position. H. Valves should be kept closed on empty cylinders at all times.

III. Transporting

A. If protective valve caps are supplied, they should be utilized whenever cylinders are in transport and until they are ready for use.

B. Cylinders must not be dropped, dragged, slid or allowed to strike each

other violently.

C. Cylinders must be transported on an appropriate cart secured by a chain strap or fitted design.

IV. Use

A. Before connecting equipment to a cylinder, be certain that connections are free of foreign materials.

B. Turn valve outlet away from personnel and crack cylinder valve to

remove any dust or debris from cylinder valve outlet.

C. Cylinder valve outlet connections must be American Standard or CGA Pin indexed and low-pressure connections must be CGA diameter indexed.

D. Outlets and connections must be tightened with appropriate wrenches

and must never be forced on.

E. Equipment designed for one gas will never be utilized on another.

F. Cylinder valves should be closed at all times except when they are in use.

G. Never lubricate valve outlets or connecting equipment (oxygen and oil

under pressure may cause an explosive oxidation reaction).

H. Position the cylinder so that the label is clearly visible.

I. Check label before use; it should always match the color code.

J. Cylinder carts must be of self-supporting design with appropriate casters and wheels. Those intended for use in surgery must be grounded.

Therapeutic Gas, Storage, Handling and Quality Control 4

K. Cylinder contents must be identified before use by reading the label,

which should not be defaced, altered or removed.

L. Safety-release mechanisms, non-interchangeable connections and other safety features shall not be removed or altered.

M. Control valves on equipment must be closed both before connection

and when not in use. V. Nursing Staff Education:

A. Proper oxygen use, storage, and handling will be provided by:

1. Patient Care Provider Orientation (New Employees).

2. Annual Nursing Competency

3. Annual Safety Testing (Computer testing), by all District employees.






Mechanical Ventilation Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: To establish safe, effective and consistent management of mechanical

ventilatory support. Policy: Respiratory Care practitioners will safely establish and maintain

mechanical ventilatory support resulting in respiratory homeostasis. Procedure: I. General Description:

A. Mechanical ventilation is the application of ventilatory support via mechanical means in patients whose normal physiologic respiration is compromised by disease, function or trauma.

II. Complete The Physician Order:

A. See Attachment: Admissions Orders for Kaweah Delta Sub acute

III. Therapy Objectives:

A. To augment, support and sustain alveolar ventilation resulting in adequate oxygenation with carbon dioxide elimination.

IV. Indications:

A. There are generally four accepted categories used as guidelines for the implementation of mechanical ventilation:

1. Apnea: cessation of respiration from any cause.

2. Acute ventilatory failure; decompensation of pulmonary function

yielding the following ABG’s: pH less than 7.25, PaCO2 greater than 60, PaO2 less than 50 or the imminent threat of deterioration to this level.

Mechanical Ventilation 2

3. Acute hypoxemic respiratory failure: the inability of the pulmonary system to maintain a PaO2 greater than 50 mmHg at an FiO2 of .50 or greater or PaO2/FiO2 <200-300.

4. Impending failure: indicated by a steady rise in PaCO2 and drop in pH with increased work of breathing. This would also apply to patients with progressive neuromuscular weakness with vital capacities of less than one liter.

V. Patient Education Applicable To Therapeutic Procedure:

A. In the alert, cooperative patient, it may be beneficial to explain that augmentation of ventilation is necessary for a time until the patient’s own pulmonary system can again support their physiologic need. This may be valuable in reducing anxiety associated with mechanical ventilatory support.

VI. Methodology Of Procedure:

A. Check physician orders for Vt, f and FiO2, etc. B. Prior to initiation of ventilation, check respirator for proper assembly

and operation.

1. Alarms (Pressure, Volume, and Oxygen)

2. Pressure Manometer.

3. Humidification systems.

C. Adjust Ventilator parameters as specified by physician.

1. Tidal volume is adjusted as specified.

2. Set the flow rate in accordance with the respiratory rate and tidal volume. The flow rate must be adjusted to keep an inspiratory to expiratory ratio of 1:2 - 1:4. Allow more expiratory time (lower ratio) if airway obstruction is severe.

3. Adjust normal pressure alarm limits to 10-15 cm H2O pressure

above the pressure necessary to deliver the specified tidal volume but not to exceed 50cm H2O. Adjust low pressure alarm to 5 cm below peak inspiratory pressure.

4. Attach ventilator to the patient and immediately check the tidal

volume and peak inspiratory pressure for acceptable values.

5. Make adjustments in volume and flow if necessary.


6. Check and adjust all alarms for proper position.

7. Adjust inspiratory temperature to approximately 31-33 degrees

C at the level of the tracheostomy tube. VII. Delivery Of Aerosol Medication If Applicable:

A. Aerosolized medications may be administered by either the nebulizer or MDI. This is accomplished by placing a nebulizer/spacer in-line at approximately 6-12 inches from the patient “Y” connector on the inspiratory limb of the circuit. When administering aerosol therapy the nebulization “block” is utilized to drive the nebulizer. The desired volume is administered for approximately 10 -20 minutes. Patient parameters and monitoring will be carried out just as they would with routine aerosol administration, (refer to Aerosol/MDI Procedure).

B. Metered dose inhalers may also be used via the Aerovent or

equivalent spacer. VIII. Monitoring (Bedside Measurements):

A. Ventilator checks shall be completed routinely every six hours with the following parameters monitored and recorded.

1. Mode of ventilation, i.e. A/C, SIMV, Pressure Control 2. Alarms: Alarm volume shall remain on maximum setting at all

times. This will be checked and documented each vent check.

a. Low Vt Volume alarm: Set at 20% below delivered Vt setting.

b. Pressure alarms: Peak pressure alarm will be

maintained at 10-15cm H2O pressure above peak pressure but not to exceed 50cmH2O. Low-pressure alarm will be maintained at 5cm H2O pressure below peak inspiratory pressure.

c. Oxygen delivery alarm: Will be set at 10% below

prescribed FiO2.

d. Minute volume alarm: Will be set at 50% above calculated minute ventilation (prescribed Vt x RR).

3. Cuff pressure.

4. Inspired temperature: (Ideally maintained at 31-33 degrees 0C


5. Delivered tidal volume.

6. Calculated minute volume.

7. Respiratory rate:

a. Continuous (set rate)

b. Spontaneous

c. SIMV

8. Peak inspiratory pressure.

9. Static pressure (Plateau pressure).

10. PEEP

11. FiO2

12. Pulse

13. Sputum production, (results of suctioning).

14. Evaluation of arterial blood gases (when available). 15. Tracheostomy tube position, ties/tape appropriately

applied/secured, maintain lack of tension or torque on airway. Montgomery straps should be considered on all high risk or highly “mobile” residents.

Note: Formal ventilator checks will be monitored q6 hours however RCPs will round q2 hours providing a limited respiratory

assessment/airway management including monitoring proper tube position, tension, torque and security on all ventilator and non-ventilator dependent patients with tracheotomy tubes.

IX. Record Keeping:

A. Online ventilator documentation is designed to record all pertinent ventilatory parameters. In the comment section, space is provided for patient evaluation to be made at the end of each check. This evaluation should include any information that may be helpful in the management of the patient. Describe adverse events, patient distress, ventilator malfunction, results of suctioning, breath sounds, evidence of infection, etc.

X. Complications Related To Mechanical Ventilators

A. Barotrauma


1. Subcutaneous emphysema (seen on x-ray and palpated under the skin)

2. Pneumomediastinum.

3. Pneumopericardium

4. Pneumothorax

B. Inadequate oxygenation and/or ventilation

1. Oxygen deficiency: Generally, PaO2 , <60 or SpO2 < 90%

2. Ventilation deficiency: PaCO2 high enough to result in pH <

7.25. C. Excessive oxygenation and/or ventilation, (generally FiO2 > .60 or

PaCO2 <30mmHg)

D. Excessive or inadequate humidification. (Excessive or inadequate temperature of humidified gas). Excessive need to suction copious watery mucus versus presence of thick, dry, secretions

E. Intubation of right mainstem bronchus may lead to left lung atelectasis

and right-sided pneumothorax.

F. Accidental extubation. Extreme risk if patient paralyzed.

G. Apnea (due to accidental disconnection from ventilator). Extreme risk if patient paralyzed.

H. Atelectasis

I. Infection. Ventilator associated pneumonia, tracheostomy infection,

sinusitis and otitis (especially in nasotracheal intubation).

J. Hypotension (shock) K. Cuff related problems.

L. Alarm found off (not with present generation ventilators.

XI. Recognition Of Complications:

A. Mechanical (related to equipment)


1. Apnea secondary to accidental disconnection’s from ventilator or mechanical ventilator failure.

a. Recognized by alarm activation b. Response of therapist to complication: The therapist or

nurse will immediately go to the bedside and initiate bag and mask ventilation while observing breathing pattern and cardiac rate. Once patient stabilization is complete the therapist will then determine the origin of the problem and rectify it.

2. Cuff related problems: Cuff related problems are generally

related to under or over inflation.

a. Under inflation is recognized by:

i. Possible drop in peak pressure with obvious mouth leak

j. Possible activation of volume or low pressure

alarm

k. Audible air leak from oro- or nasopharynx

b. Response of therapist to complication: Inflate cuff with manometer and syringe until initial audible leak is eliminate or tidal volume is achieved.

c. Response to overinflation: Routinely check and record

cuff pressure a minimum of q 6 hours, ensuring the pressure is 18-25cm H2O. or document reason for higher pressure.

3. Alarm found off: Recognized by checking alarms for proper

function and assuring alarm is on at all times.

a. Response of the therapist to alarm off: Turn alarm back on

4. Filters plugged, resulting in expiratory air flow obstruction.

B. Clinical (related to patient)

1. Barotrauma (pneumothorax, pneumopericardium,

pneumomediastinum, interstitial emphysema).

a. Recognition may be made by the following:


i. Auscultation indicating markedly decreased breath sounds on one side could indicate possible pneumothorax.

j. Marked increase in peak inspiratory pressure

along with decrease in compliance may indicate the presence of pneumothorax

k. If patient vitals are deteriorating call Code Blue..

2. Therapist response to complications:

a. Place patient on 100 % oxygen and notify nurse. b. Call attending physician immediately. c. If patient vitals are deteriorating call Code Blue and

activate EMS (call 911).

3. Inadequate oxygenation and/or ventilation

a. Recognition may be made by the following:

i. Oximetry will indicate SpO2 < 90%

j. The patient may show signs of cyanosis, restlessness, convulsions, tachycardia, or bradycardia. Any of these may indicate the possibility of decrease oxygenation and/or ventilation.

k. The therapist will routinely observe ABG’s and will

know that reduced PaO2 (less than 60 torr) or increased PaCO2 (greater than 50 torr) are indicative of inadequate oxygenation and decreased ventilation

4. Response of therapist to complication:

a. Notify physician and discuss appropriate ventilator changes

5. Excessive oxygenation and/or ventilation:

a. These are generally recognized with routine monitoring of ABG’s. FiO2 > .60 mmHg or greater might be indicative of excessive oxygenation while PaCO2 of less than 30


mmHg might be indicative of excessive ventilation. b. Response of the therapist to this complication: notify

attending and discuss appropriate ventilatory changes.

6. Excessive or inadequate humidification:

a. The therapist will routinely observe the nature of bronchial secretions. When copious and thin secretions are observed, it may be concluded that excessive humidification is likely, when they are thick, it can be concluded that humidification may be inadequate.

b. Action to be taken would simply be close monitoring of

inspired temperatures with ideal temperature being between 31-33 degrees centigrade.

c. Instillation of 3 cc’s of sterile saline prior to suctioning may help loosen these secretions.

7. Accidental extubation:

a. Obvious recognition by tube being displaced from the

trachea b. Action to be taken by the therapist:

b. Re-insert tracheostomy tube

i. Provide resuscitation with bag and mask while

nurse immediately contacts physician.

j. If patient is in arrest situation call Code Blue while activating EMS. The intubation certified therapist may reintubate (refer to intubation procedure).

c. Call for MD assistance.

8. Infection:

a. Purulent secretions are easily recognized by their thick

green character. b. Action to be taken should include proper charting of

secretion character. The physician should be notified by the nurse with the suggestion that a sputum culture be obtained for analysis.

c. Inspect tracheostomy wounds on q-shift for evidence of

infection.

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9. Hypotension (shock):

a. With the initiation of mechanical ventilation, close (q 5-10 minute) monitoring of patient vitals is essential. There is usually a slight decrease in blood pressure. However, if the systolic blood pressure drops below 100 mmHg, hypotension is present.

b. Action to be taken should include immediate physician

contact with the suggestion that either ventilatory parameters be adjusted or administering vasopressive medications or volume expanders be considered.

10. Atelectasis:

a. Auscultation of the chest may reveal decreased or

bronchial breath sounds. b. Chest x-ray may show atelectasis c. ABG’s may indicate a drop in PaO2 d. Peak inspiratory pressure will increase with a

corresponding decrease in compliance e. Action to be taken would include:

i. Frequent lavage and suctioning

j. Use of Ballard (Closed Suction system)or standard

coude’ catheters.

k. Discuss other possible therapeutic procedures with physician to include PD&P, aerosolized bronchodilators and/or mycolytics and in unresolved cases, bronchoscopy may be indicated.

XII. Contraindications:

A. Always check ventilator parameters and function prior to attaching patient to ensure proper calibration. This will avoid excessive ventilation, oxygenation, etc.

B. Always attach ventilator to an outlet that will be supplied by emergency

power (red plugs) in the event of an electrical power failure.


XIII. Automatic Stop Order:

A. Not applicable






Bagging Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: To augment or support ventilation via resuscitation bag. Policy: The Respiratory Care Practitioner will provide augmentation to

spontaneously breathing patients to prevent atelectasis or sustain normal ventilation by artificial means utilizing a resuscitation bag.

Procedure: I. General Description:

A. Bagging is the application of ventilatory support or assistance with a manual resuscitation bag. The applications may consist of complete ventilatory support in such instances as cardiopulmonary arrest or simply as a manual sigh administered to prevent atelectasis.

II. Complete Physician Order: A. The physician shall specify the frequency, repetitions and oxygen utilization during the bagging procedure.

NOTE: If the physician does not specify the utilization of oxygen, it is generally understood that if the patient is receiving supplemental oxygen, it will be administered during bagging. If the patient is not receiving oxygen, then the bagging procedure will be carried out using room air only.

III.II. Therapy Objectives:

A. To provide ventilation when apnea is present.

B. To assist ventilation when pulmonary dysfunction will not support physiologic need.

C. To supply occasional deep breaths (sighs) to prevent atelectasis in patients with monotonous shallow breathing patterns.

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Bagging 2

D.C. For transportation of ventilator dependent individuals.

IV.III. Indications:

A. To correct emergency apnea and hypoventilation. Examples:

1. Pulmonary dysfunction secondary to neurological disease.

2. Pulmonary dysfunction secondary to anesthetics or other respiratory depressant medications.

3. Apnea.

B. To inflate and aerate diseased lungs:

1. Pneumonia 2. Obstructive airway disease.

V.IV. Patient Education Applicable to Therapeutic Procedure:

A. In the alert, coherent patient, it should be explained that deep breathing will be accomplished periodically with the resuscitation bag. Full explanation of the procedure and its purpose may be valuable in reducing anxiety associated with ventilatory dependency.

VI.V. Methodology of Procedure:

A. Check physicians order for frequency and duration of therapy.

B.A. Bring resuscitation bag to bedside and explain procedure to patient (refer to 5).

C.B. When possible, elevate patient’s head and trunk as high as their

physical condition will allow. This will provide better lung expansion.

D.C. If patient is receiving supplemental oxygen, supply resuscitation bag with oxygen. In Code Blue procedure, use 100% oxygen. If patient is on mechanical ventilation with PEEP apply PEEP valve to resuscitation bag.

E.D. Connect patient to bag and begin compression using two hands for

maximum inflating volume. F. If the duration of bagging is not specified, a minimum of 20 breaths will be sufficient.

G.E. If suctioning is necessary, it should be performed during the therapy to



Bagging 3

allow for re-oxygenation with the resuscitation bag. H.F. After completing therapy, the equipment should be stored in a plastic

bag and made available for the next procedure. VII. Delivery of Aerosol Medication, If Applicable: A. Not applicable. VIII. Monitoring (Bedside Measurements): A. Depending on the purpose of the therapy, the following parameters should be evaluated:

1. Respiratory rate and depth before and after therapy.

2. Breath sounds before and after therapy.

3. Secretion production:

a. Color

b. Volume

c. Consistency IX.VI. Record Keeping:

A. This procedure will be documented online in the respiratory therapy section of the patient’s electronic chart. Parameters essentially for patient evaluation are:

1. Date and times.

2. Number of compressions and/or length of therapy

3. Respiratory rate and depth before and after procedure.

4. Secretion production:

a. Volume b. Color

c. Consistency

5. Breath sounds

6. Patient’s tolerance to procedure






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Bagging 4

X.VII. Possible Complications Listed:

A. Respiratory depression secondary to carbon dioxide depletion.

B. Respiratory depression in patients with COPD due to hyper oxygenation.

C. Mechanical malfunction of resuscitation bag.

1. Action to be taken in the event of complications:

a. Check for leaks reposition patient and continue to bag.

b. Replace resuscitation bag.

XI.VIII. Contraindications:

A. Not applicable

XII.IX. Safety Precautions If Applicable:

A. Not applicable XIII.X. Automatic Stop Order:

A. Not applicable






Transport of Ventilator Patients Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: When the need arises to mobilize the ventilatory dependent patient,

the Respiratory Care Practitioner will support ventilation with either a portable ventilator or bag ventilation to assure optimal respiratory homeosttsis (ventilation/oxygenation).continuous ventilatory homeostasis is maintained.

Policy: Patients will be provided sustained continuity in continuous mechanical

ventilatory support during internal and external transports. Procedure: I. Ventilator dependent patients requiring transport will be accompanied by a

Respiratory Care Practitioner Practitioner and RN who will support ventilation at prescribed settings utilizing a transport ventilator to emulate current CMV orders. Transport oxygen, suction, cardiac monitor, oximeter and bagging equipment will accompany all patients during transportbe made available as needed..

II. During transport, the patient will be “bagged” with 100% oxygen and “PEEP”

at the setting ordered while on the ventilator if applicable. RN will be in attendance as needed.

I. When patients require special therapeutic or diagnostic procedures, a

portable volume ventilator will be set-up and utilized to support ventilation during procedure with all current ventilator parameters.

II. The Respiratory Care Practitioner (RCP) will accompany all CMV patients

requiring transport. The Respiratory Care Student may assist with transport u only in the presence and under the direct supervision of the RCP.

III. An RCP will remain with the ventilator dependent patient during all therapeutic

and diagnostic procedures while being maintained on portable CMV. Once complete, the patient will be returned to their unit.

IV. Pulse oximetry will be monitored continuously while the patient is transported,

Transport of Ventilator Patients 2

supported and returned to the unit. SpO2's will be maintained at 92% or greater at all times during the transport process.

V. Patients requiring paralytics, i.e., pancuronium or vercuronium, will not be transported without attendance of the anesthesiologist, Emergency Department Physician or Critical Care M.D.






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

Purpose: To deliver therapeutic aerosols via hand held nebulization Policy: The Respiratory Care Practitioner will administer therapeutic

aerosols via hand held nebulizer by mouthpiece, mask, “T” tube and or ventilator circuit.

Procedure: I. General Description of Therapy:

A. Aerosol therapy is defined as the administration of bronchodilators, mucolytics, antimicrobials, anti-inflammatories, and vasoactive medications by a simple hand-held nebulizer. These devices are very effective in delivering therapeutic doses of the aforementioned drugs and are generally well tolerated by the patient.

II. Complete Physician Order:

A. The physician must specify:

1. Type Dose of active medication 2. Dose of Medication 3. Mode of Therapy 4. Frequency of Therapy

2. Dose of diluent (saline or water). The dose of diluent does, in fact, control the length of each aerosol treatment and, therefore, specification of the diluent dose will be taken to mean that the physician in this hospital has also specified duration of the treatment. For example, a 2 cc volume of saline implies a treatment of 5 minutes duration where a 5 cc volume of saline implies a treatment duration about twice as long.



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Aerosol Therapy 2

2.The physician must also specify the frequency of therapy.


A. To facilitate delivery of therapeutic bronchodilating aerosols for the purpose of achieving bronchodilation.

B. To facilitate delivery of therapeutic aerosols for the purpose of

mobilization and expectoration of secretions. C. Delivery of mucolytics for the purpose of thinning or liquefying

secretions to promote mobilization and expectoration.

D. Delivery of certain antimicrobials (gentamicin, tobramycin) to decrease endobronchial infection.

E. Delivery of vasoactive bronchodilators to reduce mucosal edema.

F. Delivery of cromolyn to block bronchospasm secondary to the

release of inflammatory mediators mediators of bronchospasm from the bronchial inflammatory cells.

G. Delivery of hypertonic saline for the purpose of obtaining

secretions for diagnostic evaluation.

H. To deliver high doses of Albuterol to rapidly treat critical hyperkalemia

IV. Indications:

A. Any of the following diseases or diagnosis:

1. Chronic obstructive pulmonary disease (including asthma, emphysema, chronic bronchitis).

2. Expiratory rhonchi, wheezing, or other evidence of airway

obstruction.

3. Atelectasis

4. Bronchiectasis

5. Cystic Fibrosis

6. Pneumonia

7. Laryngotracheitis



Aerosol Therapy 3

8. Laryngeal edema

9. Stridor

10. Renal failure

B. Inability to productively cough when sputum is needed for diagnostic purposes, i.e. for sputum induction.

V. Patient Education Applicable to Therapeutic Procedure:

A. Patient education and cooperation are essential in achieving effective therapeutic doses of aerosolized medication. The patient is instructed to take slow deep breaths through his mouth, pause at the end of maximal inspiration for a few seconds, and then exhale slowly. This breathing pattern and breath hold will allow for enhance deposition. In the patient whose sensorium is compromised, aerosol therapy may be of benefit but therapeutic effectiveness will be somewhat reduced.

VI. Methodology of Procedure:

A. After receiving the order, verify on physician’s order sheet and write your last name in block letters on the right hand side of the order sheet under the physician’s order. Also write the time using the 24-hour system.

A. Prepare the proper medication.

B. Identify patient (using two patient identifiers).

C. Reaffirm the procedure to the patient.

D. If possible, place the patient in an upright or sitting position to

allow expansion of all pulmonary segments.

E. Administer therapy:

1. Assemble equipment and attach to patient. Adjust flow rate to allow adequate nebulization of medication to meet the inspiratory demand of the patient.

2. Check patient’s pulse at beginning, during and after

therapy. If the pulse increases more than 1/3, stop the treatment and notify the nurse of the increase. Chart the increase and put a note on the face of the chart explaining the problem to the physician. It may be necessary to telephone the doctor. If the patient is receiving frequent


Aerosol Therapy 4

treatments, the order should be changed or at least reviewed by the physician prior tot he next treatment.

3. Listen to breathe sounds before, during and after therapy.

4. The patient’s subjective experience from his/her treatment is very important to note. If the patient complains of being nervous or jittery after a treatment, this should be charted, explained to the nurse and a note should be left for the physician on the face of the chart. Again, it would be preferable to have the physician review his order prior to the following treatment. It is most important that the physician be made aware of any reaction the patient has to the treatment or the medication. Also, chart if the patient feels better or worse as a result of the treatment.

5. When giving aerosol in the pediatric patient, the pulse precaution will be slightly different. The attending physician will be notified when the pediatric patient’s pulse exceeds 150 per minute.

6.5. Continue to administer aerosol until the medication is

exhausted. If, in your opinion, the duration of the treatment is excessively long or excessively short, discuss this with the physician.

7.6. After the therapy is completed, ask the patient to cough. If

the patient is productive, ask patient to repeat effort, emphasizing a strong cough to facilitate cough effectiveness.

F. Note the color, consistency and amount of sputum. If sputum is

not produced, chart this also. Always ask at the time of the following treatment about any sputum that was raised between treatments and inspect the sputum sample. We do encourage the use of sputum cups routinely to make such observations easier.

G. Document all relevant information in patient’s electronic chart. A

progress note must be written following the documentation policy at the end of each shift or completion of each practitioner/patient intervention.

H. If the patient refuses a treatment, notify the nurse and document

the reason for refusal. If in any 24-hour period the patient refuses more than one treatment, the physician must be notified at the time of the second refusal. It will be the responsibility of the therapist to personally call the physician in this instance though


Aerosol Therapy 5

he/she should also inform the nurse that he/she is doing this.

VII. Delivery of Aerosol Medications:

A. Medication Orders:

1. The practitioner and nurse will share the responsibility of picking up written orders. Verbal orders may be given directly to the nurse or the practitioner who will write the order.

2. The practitioner and nurse will sign off the order after assuring themselves that the order for aerosol medication is complete. See #2 above.

3. Retrieve the medications from the locked box in the Respiratory Department. Prior to giving the medications to the patient, verify the label and concentration with the written order.

B. Measurement and Dilution of Medications:

1. Use syringes for dispensing both medication and diluent utilizing aseptic technique when Non-unit dose medications are prescribed. C. Patient Education:

1. When the patient is getting ready to go home and it is known that the patient will be self-administering aerosol medication, it is appropriate for the therapist to begin teaching the patient how to place medications in the nebulizer and operate the aerosol delivery device. The therapist, at his/her discretion, may teach the patient to use the drop counting method of dispensing medication and diluent. When this is done, assume that there are 16 drops per ml or cc. The patient should demonstrate this by doing so himself/herself. The therapist should record the patient’s ability to do this. If the patient is unable to self-administer medication, it may be appropriate to teach a family member or some other responsible person how to do this.

2. The patient may take medication home with him/her if the physician writes an order for the pharmacist to re-label the medication for appropriate home use. VIII. Monitoring (Bedside Measurements):

See #6 above.

IX.VII. Record Keeping:

A. The therapist shall document a complete note online in the respiratory therapy section of the electronic chart., or multi disciplinary progress note following each treatment.

1. When the physician order is received:

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Aerosol Therapy 6

a. The therapist will document electronic record specifically the name of the medication, its dose, name of the diluent, its dose, and the frequency of therapy.

b. The patient’s respiratory diagnosis and objective of therapy are also documented.

B. Each progress note (documented following the treatment) shall contain

the following:

1. Date and times

2. Pulse before and after therapy (if the pulse is difficult to feel or rapid and irregular, an apical pulse should be taken with the stethoscope).

3. Respiratory rate before and after therapy.

4. Presence or absence of sputum production with description of

character of sputum (mucoid, purulent, consistency and amount).

5. The therapist’s written comment about the treatment should

include tolerance of therapy and patient’s impression of treatment (is breathing easier, able to cough better, etc.) EXTREMELY IMPORTANT.

X.VIII. Possible Complications Listed:

A. Tachycardia

B. Tremors

C. Anxiety

D. Bronchospasm (associated with administration of mucolytics).

E. Cross contamination.

XI.IX. Action To Be Take in the Event of Complication:

A. Tachycardia: If pulse increases 1/3 the baseline value in the adult patient, therapy should be terminated and the physician contacted and made aware of this complication. At that time, a dose change in medication should be discussed with the physician.

B. Tremor: In cases where the patient complains of nervousness following



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Aerosol Therapy 7

aerosolized bronchodilator administration, the physician should be made aware of the complication.

C. Anxiety: Anxiety is an unfortunate side effect the sympathomimetic

drugs. When demonstrated clinically, the physician should be notified.

D. Bronchospasm: Therapy should be stopped and the physician notified. The addition of a bronchodilator should be discussed.

XII.X. Contraindications: A.Those patients who are unable to achieve deep sustained breaths may not be candidates for aerosol therapy. This form of therapy works best when the patient is able to cooperate and follow simple commands. Nevertheless, it may still be useful in obtunded and uncooperative patients. XI.Safety Precautions: Not applicable. XIII.XI. Automatic Stop Order:

A. Patient intolerance.If at any time during treatment the pulse increases more than 1/3 of baseline, the treatment is automatically stopped and the physician is contacted.




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Metered Dose Device (Inhaler)

Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: To administer therapeutic aerosols via metered dose inhalers Policy: The Respiratory Care Practitioner, RN or LVN may administer, monitor and assess

patient administration of therapeutic aerosols via metered dose inhaler. The following guidelines are for the RCP’s.


A. The purpose of this therapy is to use a simple device to deliver bronchodilators, steroids, antibiotics,nibiotic or medications with anti-inflammatory properties.


A. The physician shall specify the frequency and dose of medication to be delivered (usually prescribed in 1 or 2 puffs up to 4 - 8 puffs per Rx).


A. Promote bronchodilation

B. Mobilize secretions

C. Reduce mucosal edema IV. Indications

A. Any of the following diagnosis or conditions

1. Chronic obstructive pulmonary disease (including asthma, emphysema or chronic bronchitis).

2. Expiratory rhonchi, wheezing or other evidence of airway obstruction.


A. Patient education is the essential factor in the success of this mode of therapy. To

effectively use a metered dose devise, the patient must be capable of coordinating their his breathing while activatingcompressing the metered dose device. The therapist will be responsible for instructing the patient in the proper self-administration technique as well as follow-up evaluation of the patient’s ability to effectively perform therapy. Use of a spacer can simplify the coordination problem for the patient as well as improve aerosol deposition.

1. Introduction: The practitioner will inform the patient that they are from the

Respiratory Therapy Department and that their physician has ordered aerosol therapy by metered dose device to help their breathing.

2. Especially during the first two or three treatments, the practitioner will review the

following points with the patient before allowing the patient to perform therapy:

a. The patient will understand that maximum benefit from this form of therapy can only be achieved by coordinating the inspiratory phase of breathing with the activationcompression of the metered dose device. Strong emphasis should be placed on the compression of the canister after approximately 1/3 of the inspiratory phase.

b. A relaxed slow deep inspiration should also be emphasized. (If the patient

breathes in quickly, the medication will be drawn into the back of the throat and deposited there). A slow breath will allow the particles to be drawn deeply into the airways for maximum benefit.

c. The patient should finally be instructed to hold this deep breath for 10

seconds if possible. It should be explained that this will allow medication to deposit optimally thereby providing maximum therapeutic benefit.


A. After receiving physician order, verify by writing your last name in block letters on the right-hand side of the order sheet under the physician’s order.

A. The metered dose device (MDI) is assembled for use and taken to the bedside.

B. Explain the procedure to the patient:

1. The metered dose device is to be shaken vigorously prior to use.

2. The patient is instructed to exhale to functional residual capacity (FRC).

3. Instruct the patient to place the open end of the metered dose device into his/her

mouth past the teeth.

4. Do not allow closure of the lips; this allows more air to be inhaled through the mouth to aid in carrying medication deep into the air passages.

5. While taking a slow deep breath, instruct the patient to press down firmly

on the cartridge to release medication. (The compression should take place after approximately 1/4 to 1/3 of the inspiration to allow for opening of the small airways for access of inhaled medication).


6. After complete inspiration is achieved, have the patient hold his/her breath (10

seconds if possible) to allow medication to deposit in distal airways.

7. Routine use of spacers are encouraged in general and essential if steroid inhalers other than Azmacort are used.

VII. Delivery of Aerosolized Medication:

A. The metered dose inhaler is a form of aerosol therapy. VIII. Monitoring:

A. Observe patient for objective/subjective response, i.e. patient anxious, tremors, pale or flushed.

B. Check pulse before and after treatment.

C. Listen to breath sounds before and after therapy

D. Respiratory rate before and after therapy

E. Sp02 before and after therapy

F. Sputum production during and after therapy

IX. Record Keeping:

A. The practitioner shall document a complete note in the respiratory therapy section of the patient’s electronic chart following completion of therapy.near the end of each shift.

1. When the physician’s order is received:


a The practitioner will date, time and sign the order noting medication, its dose and frequency of treatment.

a The patients respiratory diagnosis and the therapeutic objective of

will also be documented. 2. Each progress entry shall contain the following:

a. Date and times of treatment(s) b. The patient’s subjective/objective experience(s) related to treatment

c. Heart rate before and after therapy, (if pulse is difficult to feel or rapid

and irregular, an apical pulse should be taken with a stethoscope). d. Change in breath sounds, nature of breath sounds. e. Presence or absence of sputum production with description of

character of sputum (mucoid, purulent, thickness, consistency and amount). Ask about sputum prior to each treatment.

f. The therapist’s online entry about the treatment is to always include

tolerance of treatment and patient’s impression of treatment. It is very important to state whether or not the patient feels he/she was improved, or not improved, or made worse by the treatment.

A. Adverse effects of aerosols (refer to section on Aerosol Medication)

1. In general, appreciate the fact that bronchodilators may cause systemic side

effects and these are usually tachycardia, arrhythmias, and nervousness. Sometimes tachyphylaxis (decreasing responsiveness to the medication) may occur particularly with frequent use. Some medications seem to cause a sore throat and this can be largely prevented or minimized by gargling or rinsing the mouth after treatments.

B. Action to be taken in the event of complication

1. When it is determined that a particular aerosol preparation is causing an adverse effect, the physician should be made aware of this prior to the next treatment, and be given the opportunity to change the order.

X. Contraindications:

A. In general, the primary contraindications to metered dose devices are patients who do not have either the mental or physical capability to effectively use the device. The problem being coordination in activatingcompressing the canister resulting in effective interventions. Some patients simply cannot perform this simple maneuver.

B. Inform the physician of the patient’s inability to be treated by this modality if that is

the case. Suggest other modalities such as spacer, hand-held nebulizer, etc. XI. Safety Precautions:

Not applicable XII. Automatic Stop Order

A. If at any time during the treatment, the pulse rate rises more than 30 %, the treatment is automatically stopped or interrupted and the physician is contacted prior to the


Metered Dose Device (Inhaler) 5

next treatment. A telephone call to the physician may be necessary.






Sputum Induction Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: To facilitate sputum production. Policy: The Respiratory Care Practitioner shall administer hypertonic saline to

facilitate sputum production via aerosol if patients cannot spontaneously produce an adequate samples for analysis.


A. The purpose of inducing sputum is to obtain a sputum specimen for diagnostic purposes in the patient who is unable to spontaneously produce sputum. Inducement is achieved by the administration of hypertonic saline by an aerosol generator.


A. The physician shall specify the desire for sputum induction by the Respiratory Therapy Department.

B. The type or types of diagnostic procedures should be specified

(cytology, AFB, C&S).

C. The type of aerosol generator should be specified. (When unspecified, it is generally accepted that 10% hypertonic saline will be administered by a hand-held nebulizer). Administration over a 30 minute period is usually necessary. A bronchodilator should be considered as part of the induction procedure if there is likelihood of bronchospasm (asthma history, COPD, etc.).

III. Therapy Objective:

A. To stimulate cough and sputum production for diagnostic purposes. IV. Indications:

Sputum Induction 2

A. A sputum induction will be performed only in those patients who are unable to spontaneously produce sputum.


A. The patient is made aware that therapy is being initiated to aid in secretion production. He/she will also to be instructed to cough frequently throughout the aerosol treatment, and informed that any secretion produced will be expectorated in designated containers. Importance should be placed on specimen production from the lungs and NOT SALIVA.


A. It is generally accepted that all sputum specimens will be obtained between 5:00 am and 7:30 am. If necessary, breakfast should be delayed and the patient should avoid eating until the specimen is collected unless otherwise ordered by the physician.

1. After receiving order, verify in doctor’s order sheet and write your last name in block letters under the physician’s order including date and time.

1. Draw up the proper medication making sure to check the bottle

label.

2. Assemble equipment and check for proper function.

3. Administer therapy:

B. As indicated previously, sufficient 10% hypertonic saline with hand-held nebulizer is routinely administered for sputum inducement. The induction period should last for approximately 30 minutes.

1. The patient should be placed in high Fowlers or sitting position if

possible.

2. The patient is attached to the aerosol device with straps adjusted for comfort.

3. Breath sounds should be monitored before, during and after

therapy.

4. Therapy will continue for 20-30 minutes or until adequate sputum specimen are collected.

5. After completion of therapy, the patient is asked to vigorously

coughed once again.


Sputum Induction 3

6. When the patient produces a suitable specimen, have them

deposit specimen into an appropriate specimen container, avoiding all contact by either the patient or the technician with the inside of the container or lid.

7. The container will be labeled with the patient’s name, room

number, time collected, diagnostic test to be performed, and collected by Respiratory Care.ratory Therapy.

8. The specimens are taken immediately to the nursing station and

handed to the registered nurse in charge of the patient. The specimens will then be taken to the clinical laboratory.

9. The procedure is then charted in the electronic medical

record.on the respiratory therapy progress note. This note should include the character, consistency and amount of sputum and the specimens collected as well as any reactions or side effects of the induction procedure.

10. If the patient is unable to produce a specimen, this will be

charted and the nurse notified. VII. Delivery of Aerosol Medication if Applicable

A. If the patient is subject to bronchospasm for any reason, it might be well advised to obtain an order for a bronchodilator prior to sputum induction to prevent bronchospasm.

VIII. Monitoring:

A. Check the patient’s pulse before, during and after treatment.

B. Listen to breath sounds before and after treatment.

C. Cough the patient and observe effectiveness.

D. Note color, consistency, and the amount of sputum, if any, to be included in charting notes. If sputum is not produced, chart this also. Always ask at the time of the following treatment about any sputum that was raised between treatments.

IX. Record Keeping:

A. The therapist shall document a complete note in the electronic chart following each treatment.

B. When the physician order is received:

Sputum Induction 4

1. The practitioner will document it in electronic record specifically

the solution aerosolized and the frequency of therapy.

2. The patient’s respiratory diagnosis and also the objective of therapy.

C. Each progress noted (recorded following the treatment) shall contain

the following:

1. Date and time

2. Pulse before and after therapy

3. Presence or absence of cough

4. Presence or absence of sputum production with description of character of sputum (mucoid, purulent, consistency, amount).

5. The practitioner’s written comment about the treatment is to

always include tolerance and effectiveness of treatment. It is extremely important to state success or failure of the induction and relay the information to the Registered Nurse.

X. Possible Complications Listed:

A. Bronchospasm

1. Recognition of complications:

a. Bronchospasm - Recognized by wheezing upon auscultation of the chest or, in more severe cases, increased work of breathing and paroxysmal coughing may be demonstrated.

2. Action to be taken in the event of complication:

a. Bronchospasm - Therapy should be stopped and the

physician notified, suggest the addition of a bronchodilator if appropriate.

XI. Contraindications:

Not Applicable. XII. Safety Precautions If Applicable

Follow established procedure will eliminate any possible precaution.

Sputum Induction 5


Not Applicable. XIV. Addendum

A. If an order for sputum induction by RCP is received, it is first checked and verified in the physician’s orders.

B. The type of equipment used is up to the discretion of the RCP unless

specified by the physician.

C. The hand held nebulizer is used to administer saline.

D. All secretions are collected in a sputum cup except those for cytology which are collected in a cup containing ethanol.

F. If you are unable to get a sample, be sure to notify nursing.

G. Cytology samples must be collected first thing in the morning before

the patient has eaten. These are usually done on three consecutive mornings.






Oxygen Therapy Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: To safely guide delivery of oxygen. Policy: The Respiratory Care Practitioner will initiate, monitor and assess

oxygen therapy. Procedure: I. General Description of Therapy:

A. Oxygen therapy is administered for the purpose of correcting existing hypoxemia in-patients with cardiac and/or pulmonary dysfunction.


A. The physician shall specify the exact liter flow or oxygen percentage and delivery device required to meet physiologic needs of the patient. Monitoring of arterial blood gases should be used as a guide for initial oxygen administration. Additionally, pulse oximetry will be utilized to assess continuing efficacy of therapy q-shift and PRN change in patient status.


A. To increase arterial oxygenation for the purpose of correcting hypoxemia.

IV. Indications:

A. Decrease the work of breathing in patients compromised by cardiopulmonary disease or conditions with resultant hypoxemia.

B. Decrease the work of the myocardium in the face of cardiac ischemia

or increased cardiac demand. C. Hypoxias:

Oxygen Therapy 2

1. Hypoxic hypoxia: Associated with a decrease in atmospheric partial pressure of oxygen or impairment of oxygen transfer through the cardiopulmonary system resulting in reduced arterial oxygen content.

2. Anemic hypoxia: Decreased oxygen content secondary to diminished blood volume, reduced hemoglobin concentration, ineffective hemoglobin (carbon monoxide poisoning) or hemoglobinopathy.

3. Circulatory hypoxia: Reduced blood flow with resultant tissue

hypoxia secondary to either cardiac dysfunction or inappropriate distribution of blood flow secondary to vascular disease.

4. Histotoxic hypoxia: Occurs with carbon monoxide inhalation or

cyanide poisoning. V. Patient Education Applicable to Therapeutic Procedure:

A. Patient should be informed that oxygen is a drug and that it is being prescribed to aid in their recovery. It should be explained that the doctor feels it necessary for them to have oxygen until such time that they no longer need it.


A. The therapist will review and initial the physician order.

B. Proper equipment (flowmeter and humidifier - depending on liter flow) will be assembled and brought to the patient’s bedside.

C. Introduce yourself and explain therapy, answer pertinent questions the

patient may have.

D. Attach the oxygen system to the wall outlet.

E. Dial in specified liter flow ensuring that the humidifier is bubbling and flow is exiting the delivery device (when humidifier required).

F. Attach oxygen delivery device to patient and adjust for comfort.

It should be noted that if mask oxygen is ordered, it is necessary to have the mask fit snugly for optimum therapeutic benefit. This will decrease ambient air entrainment and ensure delivered FiO2.

VII. Delivery of Aerosol Medication, if Applicable:

A. In view of the fact that many aerosol delivery devices are powered by oxygen, a fundamental knowledge of the indications and complications

Oxygen Therapy 3

of each modality is absolutely essential (refer to Aerosol Procedure). VIII. Monitoring (Bedside Measurement)

A. Pulse oximetry should be performed on room air and after O2 initiation to optimize oxygen administration. Pulse oximetry will be performed a minimum of q-shift to assess continued efficacy and optimal therapeutic deliver of oxygen.

B. Record Keeping:

C. Complete online documentation following respiratory assessment q-

shift

D. Fill in all parameters which include date, time, liter flow

E. Always document exact physician order with every progress note.

F.E. Document patient diagnosis and therapeutic objective with every

progress note.

G.F. Oxygen rounds will be completed q-shift to include assessment of proper equipment function, system integrity, liter flow/concentration and continued therapeutic benefit.

H.G. Possible Complications Listed:

I.H. Recognition of Complications

1. Oxygen induced hypoventilation: Patient usually demonstrates

mental dullness which may lead to lethargy and coma. Ventilation is markedly depressed. Blood gases show rising PaCO2 and falling pH. The PO2 is inappropriately elevated.

2. Oxygen Toxicity: Excessive oxygen administration at high FiO2

(60%) could have a detrimental effect on the pulmonary lining cell (Type I pneumocyte). This leads to lung injury causing edema, hemorrhage, and pulmonary exudate. This, in turn, decreases the PaO2. Recognition is generally made by chest x-ray indicating increasing diffuse pulmonary infiltrate. Increased FiO2 has no effect on PaO2. In fact, PaO2 usually continues to decline. Breath sounds may be diminished throughout but are usually not helpful in recognition of this problem.

3. Absorption Atelectasis: It is theorized that increased oxygen

concentrations in inspired air, once passing an obstruction, becomes trapped on exhalation. This volume of gas, being rich in oxygen and void of nitrogen, will readily be absorbed by the


Oxygen Therapy 4

pulmonary circulation leaving a collapsed pulmonary unit. Recognition is generally made by decrease or bronchial breath sounds with chest x-ray demonstrating atelectasis. ABG’s may indicate a decreased PaO2.

4. Retrolental Fibroplasia: In premature infants, oxygen concentrations over 40% (250mmHg) lead to constriction of the retinal artery. This causes unstable shunt vessels to form which do not supply adequate circulation for proper development. This in turn, leads to fibrotic tissue development with subsequent blindness. Recognition can only be made by the ophthalmologist well after irreversible damage has occurred.

5.4. Accidental Disconnection: Patients who are very mobile may

accidentally disconnect their oxygen delivery device from the flow meter. Hospital personnel may forget to reconnect tubing after treatments, patient transport, etc.

6.5. Inadequate humidification: This results in drying and crusting of

the mucosa. Recognition is generally made from the patient’s complaining of nasal congestion.

7.6. Insufficient Liter Flow: Is associated with oxygen administered

by simple mask at less than 5 liters which is not sufficient to rinse the mask of expired CO2.

8.7. Excessive Liter Flow: Are sometimes ordered erroneously.

Recognition is usually made by patients complaining of nasal congestion or air swallowing. The therapist should be aware that the liter flows in excess or 6 lpm via nasal cannula are usually not well tolerated.

B. Action to be taken in the Event of Complications:

1. Oxygen induced hypoventilation: The oxygen liter flow should be

immediately reduced in conjunction with contacting the physician. Attempts should be made to physically arouse the patient with repeated commands to breathe deeply. Do not discontinue oxygen in this situation.

2. Oxygen toxicity: Close physician monitoring is essential. Decisions may include intubation with the administration of CPAP or PEEP in an attempt to decrease toxic oxygen levels while maintaining PaO2.

3. Absorption atelectasis: Once atelectasis has occurred,

therapeutic procedures such IPPB or incentive spirometry should be discussed with the physician and a decision as to the


Oxygen Therapy 5

best course of action for resolution should be made.

4. Retrolental fibroplasia: Once the process has occurred, it is irreversible. However, with appropriate monitoring and intervention, this complication can be prevented by the use of CPAP or PEEP in an attempt to minimize toxic oxygen levels.

5.4. Accidental disconnection from humidifier: Securely connect

oxygen delivery device to humidifier.

6.5. Inadequate humidification: When making oxygen rounds, the therapist will always check the disposable humidifier for adequate water levels. If the water level is one-half inch from being empty, it should be replaced. Also, the therapist should understand that liter flows in excess of 6 lpm via nasal cannula are not well tolerated and the humidity achieved with standard disposable humidifiers is probably inadequate at high liter flows. Humidification, however, is usually not necessary if flows are <_ 3 lpm.

7.6. Insufficient liter flow: It is common knowledge that liter flows less

than 5 lpm are usually not adequate when using mask oxygen delivery devices. Therefore, if an oxygen order is received for mask oxygen at less than 5 lpm, the physician should be notified and a request for a nasal cannula should be made.

8.7. Excessive liter flows: Liter flows greater than 6 lpm are generally

not tolerated using a nasal cannula. The physician should be contacted with the suggestion that a simple mask be used instead.

IX. Contraindications:

A. There are no relevant contraindications to oxygen therapy when appropriately administered. It should be remembered that oxygen is a drug and it has very specific therapeutic effects when properly administered. Along with beneficial effects, there are detrimental effects as well; it is therefore essential that an understanding of this drug be had by all therapists responsible for its administration.

X. Safety Precautions, If Applicable:

A. No electrical appliances are to be used in the presence or immediate area of oxygen administration. All electrical devices must be evaluated by the Clinical Engineering Department prior to patient use.

XI. Automatic Stop Orders: Not Applicable.


Oxygen Therapy 6






Non-Rebreather Mask Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: To define the use of a Identify patient that requires Non-Rebreatheingr

oxygen mask (NRB) which is capable of delivering 90-100% oxygen, and putting into action steps that must be taken once this mode of oxygen delivery has begun.

Policy: The need for a NRBnon-rebreather (NRB) oxygen mask often serves

as a marker of acute respiratory deterioration. The intent of this policy is to identify respiratory patients who are unstable and evaluate the need for transferring them to a higher level of care.

Procedure: I. The registered nurse will contact the Respiratory Care Practitioner for initial

set up of the NRB mask after receiving an order from the physician. If there is sudden cardio-pulmonary compromise resulting in oxygen saturations that cannot be maintained above 90% by other modes of oxygen delivery, the RN/RCP may set-up oxygen delivery by NRB mask prior to receiving a physician order.

II. Stat ABG’s will be performed after the NRB is in place for 20 minutes. Results

will be called to the physician. At that time the registered nurse will discuss potential need for transfer to Acute Care.

III. If the NRB is used at the end of life for comfort care only, measures, this

policy does not apply. "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."





Assuring Oxygen Purity, Availability and System Integrity Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: To ensure purity of oxygen. Policy: To assure oxygen purity the following processes will be continuously moMonitored:

a. Oxygen purity testing validated by AirgasAir Liquid prior to filling our bulk oxygen vVessels.

b. Continuous oxygen analysis performed by our ventilators

c. Continuously monitored line pressure monitoring alarms

Procedure: I. Gas Purity

A. Maintaining oxygen purity is accomplished by the following mechanisms that are routinely monitored to ensure assure purity of our oxygen supply.

1. Every oxygen delivery to our bulk liquid oxygen reservoircylinder

must be analyzed when refilling. These checks are completed and verified by written invoice at the time of each delivery by our medical gas provider.

2. Whenever a percentage of oxygen is prescribedspecified by the

physician, it is our policy to analyze and deliver specific oxygen concentrations which confirms purity oxygen delivered. Additionally, (we continuously monitor oxygen delivery by our ventilators which have maintain built in continuous oxygen analyzers built-in that analyze oxygen percentages continuously.). This, in our opinion, identifies the purity and integrity of concentrationour oxygen supply and nature of oxygen.

Assuring Oxygen Purity, Availability and System Integrity 2

3. Our current bulk oxygen delivery provider is:

Liquid Air Corporation 2121 N. California Blvd. Walnut Creek, CA 94586 Emergency Telephone: 1-800-889-2793

Standard Telephone: 559-445-1756 3. **The integrity of our oxygen delivery system is inspected

annually. This annual certification of integrity is provided by a licensed independent certifying agency which includes along with mechanical checks of all pressure alarms, and outlets and medical gas purity. This annual certification service is coordinated by our Maintenance Department.









Pulse Oximetry Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: To guide accurate assessment of oxygen saturation. Policy: The Respiratory Care Practitioner will accurately assess SpO2 by

technically proficient pulse oximetry. Procedure: I. General Description of Therapy:

A. Pulse oximetry is a non-invasive assessment of the adequacy of oxygenation. It does not measure the partial pressure of arterial CO2 or O2, however, it measures light absorption that is converted into an SaO2 reading.

II. Theory of Operation:

A. For the purpose of understanding the functioning of pulse oximetry, the assumption is made that hemoglobin exists in two principle forms in the blood: oxygenated (with O2 molecules loosely bound) and reduced (with no O2 molecules bound). Arterial oxygen saturation (SaO2) is defined as the ratio of oxygenated hemoglobin (HbO2) to total hemoglobin [HbO2 + Hb (+ other forms of hemoglobin present in arterial blood)]:

SaO2 = HbO2 Total Hemoglobin

B. An SaO2 of 90% is roughly equal to an arterial PO2 (PaO2) of 60.

C. An oximeter measures the absorption of selected wave lengths of light passed through a living tissue sample. Because oxygenated hemoglobin and reduced hemoglobin absorb light at known wavelengths, the relative percentages of these two constituents, and thus SpO2, can be calculated. The central problem in translating oximetry theory into an effective medical device, however, is to

Pulse Oximetry 2

differentiate between the absorption due to oxygenated and reduced hemoglobin and the absorptions due to all other tissue constituents.

D. The oximeter solves this problem with a two wavelength, pulsatile

system. The principle is straight-forward: The pulsation of arterial blood flow present at a particular test site modulates the light emitted from the oximeters probe. Since other fluid and tissues present at the test site do not pulsate, they do not modulate the light passing through the test site area. Therefore, the attenuation of light energy due to arterial blood flow can be detected and isolated providing for the necessary calculations.

E. The light source consists of two wavelengths of light: red and infrared which are used to gauge the presence of oxygenated and reduced hemoglobin. The light, partially absorbed and modulated as it passes through the tissue sample, is converted into an electronic signal by the probes photo detector. Because HbO2 and Hb allow different amounts of light to reach the photo detector at the selected wavelengths, the electronic signal will vary depending on which light source is “on” and the oxygenation of the arterial hemoglobin. The resultant electronic signals are passed to the oximeter whether the signals are amplified. Analog and digital signal processing is then employed to convert the light intensity information into SpO2 values and the eventual display of such.

III. Complete Physician Order:

A. The physician shall specify the desire for pulse oximetry to include frequency and parameters for acceptable values for monitoring the patient’s SpO2. Ideally, these orders will include:

1. Action to be taken when SpO2 falls below an acceptable

percentage and:

2. The trending of delivered oxygen to maintain a desired SpO2.

a. To monitor oxygen therapy:

i. Physician order for pulse oximetry implies O2 will be discontinued for 15 - 30 minutes prior to oximetry.

ii. The physician may request oximetry without O2

discontinuation.

3. To monitor mask CPAP:

a. Continuous use (must be specified in order).

Pulse Oximetry 3

b. Intermittent use (take reading q 2 hours at time of routine

monitoring of CPAP). Do this unless continuous is specified.

4. To monitor mechanical ventilation. 5. To assess need for oxygen therapy.

6. To assess oxygen desaturation while walking:

a. Physician order will request ambulation of patient with or

without O2 and simultaneous oximetry. b. Ambulate patient at his own comfortable pace until SpO2

stabilizes or until patient unable to comfortable continue. IV. Therapy Objectives:

A. The purpose of pulse oximetry is to monitor SpO2 while providing optimal oxygen support as indicated. It must be remembered that wide fluctuations in SpO2 may be experienced in patients with low perfusion and/or decreased cardiac outputs. Therefore, it must never be solely utilized for evaluating the oxygen requirements for the clinically unstable patient. However, it is very effective in trending SpO2 with a realized and accepted variance with ABG’s of + 2%, i.e., if ABG SpO2 is 90%, oximetry should show 88 - 92 % saturation provided perfusion and pulse pressures are adequate.

V. Indications:

A. Evaluation of adequate oxygenation by passive oxygen delivery systems.

B. Trending of oxygen delivery by CPAP and continuous mechanical

ventilation.

C. Documenting transient and episodic hypoxemias.

D. Checking for hypoxemia secondary to exercise. VI. Performing Spo2 Measurements:

A. Prior to performing oximetry, the RCP or RN must perform a baseline respiratory assessment. This assessment should include the patient’s history, ABG’s (if available), vital signs and current oxygen therapy orders.

Pulse Oximetry 4

B. Normal Operating Procedure: Prior to operation, the practitioner/RN

must select which type of probe to use. In most situations, either the finger probe or earprobe will be equally effective. If the patient has very small earlobe or poor ear circulation, the finger may be a better site. If significant hand or finger movement is expected, the earprobe is recommended.

C. Turn on power by depressing the power switch.

D. Finger probe: To determine an accurate SpO2 when utilizing the finger

probe, you will need to ensure that perfusion is adequate. A capillary refill should be checked and must be less than 3 seconds. If the patient has an indwelling arterial line, I.V. line or has had a mastectomy, an alternate site may be required for accuracy.

E. Position the probe:

1. Ear probe: Proper positioning of the ear probe is of utmost importance. When it is in the closed position, it must be centered on the fleshy lower part of the lobe. It should not be positioned where cartilage is present nor should it press against the side of the head. Ensure that the photo detector window is fully covered. If the patient does not have an acceptable earlobe, either use the finger probe or attach the ear probe to the pinna of the patient’s ear.

2. Finger probe: Insert the patient’s index finger into the finger

probe until it contacts the raised finger stop of the finger probe. If the patient’ index finger is too large or too small to obtain a proper fit, any of the other fingers or the thumb may be used.

3. Read SpO2 and pulse rate measurements from digital displays:

allow 10 seconds after the probe is positioned for reading to stabilize.

Note: Monitor patient pulse to ensure accuracy (Pt pulse must equal pulse oximetry determination to ensure accuracy of monitoring).

VII. Record Keeping:

A. All observed SpO2's will be documented in the Respiratory Care section of the electronic record. This will include the date, time, delivered oxygen, and SpO2.

VIII. Preventative Maintenance:

A. The pulse oximeter requires very little maintenance and is not generally affected by environment. Considerations in the following

Pulse Oximetry 5

three categories will ensure optimal and lasting performance:

1. Environmental Requirements.

a. The pulse oximeter is designed to operate in an environment where the ambient temperature is between 0 and 45 degrees C (32 - 155 degrees F) with relative humidity of 100% or less. The storage temperature of the oximeter and probes should not exceed 55 degrees C (130 degrees F).

2. Visual Inspection.

a. The following procedure should be performed to assure

proper operation of the oximeter:

i. Periodically examine the oximeter enclosure for the possibility of loose hardware and loose or broken exterior features. Tighten loose hardware.

j. Examine the power cords for signs of strain,

deterioration or other damage. Repair or replace damaged wiring.

k. Examine probes for foreign material such as tape or

cotton and remove these obstructions. Observe the opening and closing action of the probes for unevenness and variations in closing force. Replace probes if any such defect is observed.

3. Cleaning:

a. Pulse Oximeter: The oximeter exterior surfaces should be

cleaned periodically with a soft cloth dampened with a mild soap and water solution and/or sprayed/wiped with and wiped with manufacturer approved disinfectantdisinfect spray. Do not allow water to accumulate. Make sure all surfaces have dried completely before using the oximeter.

b. Probes: The probes should be cleaned periodically with a

soft cloth dampened with a mild soap and water solution. Disinfection wll be performed per manufactuer recommendation.

It is recommended that the surfaces of the probe be swabbed with alcohol before and after each patient’ use. Do not immerse probe in water or alcohol. IX.Helpful Tips For Maintaining Accuracy:



Pulse Oximetry 6

A. When utilizing pulse oximetry, three factors may allow for decrease in accuracy: 1) Optical shunting; 2) ambient light; and 3) venous pulsation.

1. Avoid erroneous readings secondary to optical shunting. Be

certain that the probe being used is optimal for the chosen test sight. This light emitting diode must cover the test sight completely to avoid optical shunting.

2. Ambient light may affect the performance of the oximeter

therefore, it should never be used in an area where infrared elements are in use or direct overhead lighting is intense. To rectify these situations, simply cover the probe with a sheet or towel when sampling.

3. Avoid erroneous saturation readings secondary to venous

pulsation, be sure the perfusion in the sampling sight is uninhibited by restrictive bandaging or compromised positioning either of which will increase venous pressure and provide a “false low” saturation reading.

B. These units must not be used to determine oxygen saturation in

patients with high carboxyhemoglobin concentrations. Because of the functional characteristics of the pulse oximeter, it will not be capable of sensing the amount of saturated hemoglobin with carbon dioxide and will only detect the oxyhemoglobin present. This will, of course, read a higher than present SaO2 which will not reflect the patient’s true oxygen saturation.

IX. Safety Precautions:

A. This unit should never be used in the presence of flammable or explosive gases.

X. Automatic Stop Order: As standard procedure, continuous pulse oximetry will require re-evaluation for efficacy every 48 hours. If not reordered by the physician, monitoring will be discontinued "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."





Oxygen Cylinder Use Printed copies are for reference only. Please refer to the electronic copy for the latest version. Policy: The Respiratory Care Department will be responsible for the supply of

oxygen cylinders in the District. All patient care providers are responsible for safe handling and utilization of.oxygen within their scope of practices. .

Purpose: To define proper use and handling to assure optimal patient care and

environmental safety.maintain adequate supplies and insure safe and proper function. Cylinders are to be clearly labeled as to content, if not clearly labeled, return to supplier unused.

Process: The Respiratory Care Department will replace and manage cylinders

PRN. as they are used. Patient care providers will exchange empty cylinders for the empties for full when cylinder regulators indicate the cylinder has less than 500 pounds per square inch remaining. Additionally, and placing the pressure regulators on each tank prior to its next use. The patient care providers may retrieve a cylinder ready for use from the “Cylinder Room” if the respiratory care practitioner RCP is not available.

Note: All patient care providers are in- serviced on oxygen cylinder use during their new hire orientation, along with annual District environmental safety testing and annual nursing competency fair.

Procedure: I. Use:

A. Adjust the flow to prescribed level.

B. Attach appropriate oxygen delivery device.

C. Monitor the patient’s for Oxygen SpO2 and pulse as per policy.

D. Oxygen, tank use is limited to:

Oxygen Cylinder Use 2

1. Emergency transportUse to support a patient during a time of distress and if use should be determined to be continuous then the patient is to be promptly transferred to a room that has piped Oxygen or transported out of facility if we cannot meet the needs of the patient here.

2. Out of room or in room activities that require the patient to be

away from the wall oxygen outlet.outlet Oxygen.

3. Patient transport in or out of facility on an as needed basis.

4.3. Care of the terminally ill.

E. All cylinders are to be properly secured at all times. "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

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Airway Management Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: Description of combined respiratory care service requested by a

physician when airway management is required. Policy: Airway management consists of an intensive respiratory assessment

with specific interventions designed to support and/or improve pulmonary function.

Procedure: I. Complete Physician Order:

A. Airway management will be provided q 4 hours and documented in conjunction with specific interventions and concomitant therapies necessary to provide comprehensive respiratory care as prescribed. The parameters assessed/interventions provided, consist of:

1. Oxygen Therapy

a. Oxygen by protocol

a. Specific delivery device b. Liter flow/FiO2 c. Humidity

d. Inspired temperature

2. Respiratory Assessment

a. Respiratory rate

b. Pulse

c. SpO2




Airway Management 2

d. Breath sounds

e. Sputum production (volume/color/consistency) f. Work of breathing

g. ABG analysis

3. Naso, oro, endotracheal suctioning

4. Endotracheal/tracheostomy tube care and maintenance.

II. Therapy Objectives:

A. To provide comprehensive Respiratory assessments with specific interventions designed to support, maintain and improve pulmonary functions.

III. Indications:

A. In general, airway management is designed to support patients with marginal pulmonary function secondary to:

1. Respiratory failure/compromise (acute or chronic)

2. Ventilatory failure/compromise (acute or chronic)

a. COPD b. CVA

3. Post-op thoracic or upper abdominal surgery

4. Neuromuscular impairment (disease or trauma)

B. Ineffective secretion clearance

IV. Patient Education:

A. Patient education will focus on the specific modality(s) prescribed to achieve therapeutic goals. The patient will be instructed on each detail of therapy, its objective, desired outcome, and the patient’s role in active participation to optimize their care.

V. Methodology:

A. Upon receipt of the airway management order, the Respiratory Care Practitioner will:

Airway Management 3

1. Review, sign, date and time the order

2. Obtain necessary equipment and supplies

3. Proceed to the bedside and complete the following:

a. Introduce yourself to the patient

b. Provide patient education

c. Perform a respiratory assessment

4. Implement therapeutic interventions

5. Complete required documentation

VI. Delivery of Aerosol Therapy if Applicable:

A. Quite often, patients prescribed airway management have orders for conjunctive therapy. When ordered, the aerosol should be provided concomitantly with airway management.

VII. Monitoring:

A. Specific to prescribed interventions. VIII. Record Keeping:

A. Online documentation will be completed with each intervention documenting breath sounds, sputum production, brief assessment of therapeutic efficacy and progress.

IX. Possible Complication Listed:

A. Refer to intervention specific policy i.e. suctioning X. Contraindications:

A. Refer to intervention specific policy. XI. Safety Precautions:

A. Refer to intervention specific policy. XII. Automatic Stop Order:

A. Not applicable.


Airway Management 4






Requirements for Initiating Weaning from Continuous Mechanical Ventilation Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: To facilitate safe weaning from continuous mechanical ventilation. Policy: After meeting prescribed weaning criteria, the Respiratory Care

Practitioner will begin weaning from continuous mechanical ventilation. Definition: Weaning is the process of decreasing the level of ventilatory support and

and oxygenation leading to discontinuation of mechanical ventilation. Procedure: I. Requirements For Initiating Wean

A. The patient will be strong enough to maintain adequate spontaneous ventilation. The lungs will permit gas exchange adequately enough to maintain an acceptable level of oxygenation.

1. Discontinue all sedatives at least 4 hours prior to wean. Be

certain that sedation is not excessive. Discuss this with the physician. Sometimes appropriate sedation facilitates weaning by decreasing patient anxiety.

2. Physiologic parameters which suggest weaning feasibility:

a. Tests of mechanical capability:

i. Peak inspiratory pressure> -20 cm H2O (i.e. -30

preferred)

j. Vital capacity > 10-15 ml/kg body weight

k. Dynamic and static compliance > 25 ml/cm H2O.

b. Oxygenation: PaO2 > 60, SpO2 > 90% on FiO2 0.40

Requirements for Initiating Weaning from Continuous Mechanical Ventilation 2

c. Respiratory rate/tidal volume (f/Vt) is < 100 during 15 minute wean to T-piece or CPAP<_5 with pressure support <_ 7.

3. PaO2 is to be greater than 60 mmHg or SpO2 90% or greater

with the following:

a. Oxygen concentration delivered by the respirator is 40% or less

II. Techniques of Weaning

A. Initiate SIMV (Synchronized Intermittent Mandatory Ventilation)

1. Decrease respiratory rate as specified by the physician.

2. Observe the patient for ten minutes with each rate reduction, check spontaneous tidal volume, resume prior ventilator setting immediately at any sign of acute distress. If tolerated, then continue to decrease frequency until a rate of approximately 4 RPM’s is reached.

3. Pressure support ventilation in the 5-7 cm H2O range is usually

added during SIMV.

4. Place on T-piece to provide humidity and O2 once low rate SIMV (4 or less) is well tolerated with f/Vt < 100 for 30 minutes.

5. Use sufficient FiO2 to maintain SpO2 92 - 95%. 6.5. Do not remove tracheostomy tube unless physician order is

given and physician is in-house.

B. Trial wean from the Ventilator

1. Following medical prescription for progressive wean, remove patient from ventilator and place on blow-by oxygen at specified FiO2. The patient will be under the direct supervision of the respiratory care practitioner or registered nurse for 30 minutes to assure wean is tolerated. Continuous pulse oximetry will be provided along with direct assessment of work of breathing. The length of time the patient is off mechanical ventilation will be determined by the physician. The patient may remain on wean as tolerated with monitoring provided by the respiratory care practitioner and registered nurse every hour. Vital signs will be performed at initiation of wean (HR, RR, SpO2, WOB) and anytime patient appears to not be be not tolerating weaning process. If the patient does not appear to be tolerating wean vital signs will be immediately taken and the patient returned to

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the ventilator. The physician will be immediately notified of wean failure and provided with a complete assessment of the patient’s experience. During this time the ventilator remains at the patient’s bedside ready for immediate use as needed. When the physician order has been written to discontinue ventilatory support the ventilator may be removed from the patient’s bedside. The patient will continue on aerosolized oxygen at prescribed concentration to maintain SpO2 > 92%.

C. Factors indicating patient should be reconnected to ventilator.

1. Blood pressure: rise or fall (generally 20 mmHg systolic or 10

mmHg diastolic).

2. Pulse: Increase of 20/min or rate > 110 min

3. Respiratory rate: Increase of 10 /min. or rate > 30-35/min.

4. Tidal volume: <250-300 vol. (In adults).

5. Respiratory rate/tidal volume (in liters) > 100.

6. Significant EKG change (e.g. dangerous arrhythmias).

7. Deteriorating ABG’s with a fall in pH and PaO2 and increased PaCO2.

*One may accept a lower PaO2 and/or pH and a higher CO2 in patients with COPD, but pH < 7.25 is undesirable as is hypoxia (PaO2 < 60).

III. Special Precautions IV.III. Continue to suction, turn and deep breath after each IPPB/ Aero treatment as

well as PRN.

A. Nursing and Respiratory Therapy Personnel may discontinue wean anytime the patient demonstrates respiratory distress. Then notify the physician.

A. Do not remove tracheostomy tube without specific physician order and

physician in-house.

B. Weaning will not begin after 2000 hours (in the sense of attaching T-piece or initiating low rate SIMV) unless the physician is present.


V.IV. Documentation

A. All documentation regarding weaning will be done online in the patient’s electronic record. Record vitals at the beginning and end of wean, as well as comments pertaining to patient tolerance.






Extubation Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: To facilitate safe extubation. Policy: After successfully demonstrating self-supported ventilatory

homeostasis, the Respiratory Care Practitioner will remove the endotrqacheal/tracheostomy tube only after receiving physician order and only when physician is in-house.


A. Removal of an endotracheal/ tracheostomy tube occurs after comprehensive assessment of patient’s ability to maintain a patent airway without artificial adjuncts. Proper care planning between the physician, respiratory care preactitioner and registered nurse is an essential element to optimize patient care and safety. .


A. Physician will order endotracheal/tracheostomy tube removal. III. Therapy Objectives:

A. To progress through the overall weaning process ensuring that the patient has deomonstrated the capacityis capable too adequately breath f breathing without an artificial airway and can sustain adequate oxygenation and CO2 elimination.

IV. Indications:

A. In general, a patient who is breathing comfortably on their own without progressive rapid shallow breathing and deterioration in blood gases, is a candidate for extubation. It is the responsibility of the physician to assess the patient’s ability to cough effectively and support their own ventilatory requirements. The rapid shallow breathing index should be

Extubation 2

<_ 100 for at least 3010-15 minutes. V. Patient Education Applicable to the Therapeutic Procedure:

A. The Respiratory Care Practitioner (RCP)therapist will explain the plan of care and solicit feeback to assure the coherent patient fully understands the procedure.that he is going to remove the tube. The patient is suctioned immediately prior to extubation. The patient is instructed to take a repeated deep breaths and, when prepared, the tube is removed during an inspiratory effort. Immediately post-procedure the patient will be instructed to cough vigorously to clear the upper airway.

VI. Methodology Procedure: Note: a replacement endotracheal/tracheostomy tube will be immediately available for insertion should the patient demonstrate signs and symptoms of respiratory distress or difficulty breathing., hy

A. See #5.

VII. Delivery of Aerosol Medications:

A. Aerosol medication will be given as ordered by physician prior to extubation..

VIII. Monitoring:

A. The RCP/RN therapist should remain at or very near the bedside for 30 minutes after extubation.

B. Vital signs will be taken and assessed determined prior to extubation.

and at intervals after extubation. In general, these patients are being monitored directly. Pulse oximetry is in place. The patient will remain on continuous Sp02 monitoring and is to remain semi-fowler position for a minimum of one hour. Schduled narcotics and/or anxiolytics should be discussed during care planning between the physician, nurse and RCP and managed according to the established care plan. not excessively sedated. (See weaning policy.)

IX. Record Keeping

A. The RCPtherapist will document the intervention online in the patient’s electronic record. Most of the time this will be recorded with the patient’s continuous mechanical ventilation data in the electronic record. All ventilatory parameters including, respiratory rate, heart rate, BP, SpO2, and appearance of the patient tolerance will be recorded post-extubation.and upon development of post-extubation complicationat appropriate intervals online in the patient’s electronic record.

Extubation 3


A. Post-extubation laryngospasm

B. Retention of secretions leading to progressive respiratory failure.

C. Aspiration

D. Hypoxia

E. Hypoventilation

F. Congestive heart failure

G. Stenosis of the airway above or below the cuff area. XI. Recognition of Complications:

A. Laryngospasm: Development of stridorous breath sounds in conjunction with an increased respiratory rate, increased work of breathing and apprehension.

B. Secretion Retention: Indicated by adventitious breath sounds (rales

and rhonchi) with moist cough.

C. Aspiration: Notice difficulty swallowing, record any events of vomiting (after any episode of vomiting, worry about aspiration), suggest follow-up blood gases, chest film, auscultate chest frequently.

D. Hypoxia: Observe decrease PaO2 on arterial blood gas or decreased

SpO2 on oximeter.

E. Hypoventilation: Follow-up routine arterial blood gas should be obtained to detect this.

F. Fatigue: Appearance of exhaustion, progressive rapid shallow

breathing (RR > 30-35)

G. CHF: Progressive unexplained respiratory distress. Increase in wedge pressure. Chest x-ray indicating congestion.

XII. Action to be Taken in the Event of Complication:

A. Laryngospasm: Suggest administration of aerosolized racemic epinephrine in attempt to relieve spasm. If unsuccessful, reintubation may be required.

B. Secretion Retention: Nasotracheal suctioning may sufficiently clear

airway. If not, suggest appropriate therapy to aid in secretion

Extubation 4

mobilization. IPP.B, or postural drainage and percussion.

C. Aspiration: Do appropriate suctioning: nasopharyngeal or nasotracheal. Airway management, nasogastric suction, and NPO status are all appropriate follow-up procedures.

D. Hypoxia: Administration of appropriate oxygen therapy. An SpO2 90%

or less while on O2 > 50% suggests the need for reintubation.

E. Hypoventilation: Suggest bi-level ventilationfrequent IPPB and/or incentive spirometry, breathing exercises, etc., for the purpose of increasing minute ventilation. BiPAP ventilation may be helpful in selected instances.

XIII. Safety Precautions, If Applicable: (see VI above)

A. Be sure cuff is completely deflated prior to extubation and adequate respiratory muscle strength has been assessed ensuring self-ventilatory support (see weaning policy).

XIV. Automatic Stop Order:

A. Not applicable. "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."





Peak Flow Determination Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: Defines & describes the Peak Flow Meter and how it is used within the

District. Policy: Upon receipt of physician ordermedical prescription, the Respiratory

Care Practitioner will perform peak flow determination assuringobtain maximum patient effort times 3 attempts.in obtaining peak flow rates.


A. Peak flow determination is utilized to evaluate degree of airflow obstructionthe effects or of airway obstruction and the improvement and/or reversibility of acute and chronic air flow obstruction as seen in the asthmatic patient.. Peak flows provide objective data that can be utilized to guide therapeutic management in acute exacerbation. Once a baseline is established, patient education of the value of such self-assessment is completed and periodic patient initiated/practitioner supervised peak flow measurements can be made. Peak flows are not usually helpful in non-asthmatic patients with non-reversible airway disease..


A. The physician shall prescribe the performance of peak flow determination. The order should indicate the desire for patient education as it applies to continued utilization of the peak flow meter as a tool for self-assessment.

III. Therapeutic Objective:

A. Peak flow determination is is a tool utilized to monitor monitor the management of airflow obstructionthe progress of the asthmatic patient and to assessevaluate the effectiveness of bronchodilator and anti-inflammatory therapy in reversing air flow obstruction. This objective

Peak Flow Determination 2

data can be very useful in determining patient compliance and proper medical disease management.the benefits of such therapeutic interventions and guide patient support and maintenance. The patient is to become able to monitor the efficacy of his continuing post-discharge asthma program.

IV. Indications:

A. Peak flow determination in patients exhibiting signs of respiratory distress secondary to pulmonary compromise associated with bronchospasm can be utilized to assess degree of pulmonary compromise and guide therapeutic interventions.


A. Patient education as to the necessity for cooperation and maximum performance of the peak flow maneuver are essential in determining the degree and appropriateness of therapeutic interventions. The patient will understand that baseline values for their peak k flow can be evaluated routinely to determine the status of their pulmonary condition and alert them to necessities for adjustment in medication as prescribed by their physician. During the education phase, the RCP will instruct the patient and a significant other (parent, spouse, care provider), if applicable, to the proper performance of the peak flow maneuver. A brief description of the peak flow meter, along with any maintenance requirements, will be reviewed. Once a baseline has been established, the patient will be instructed to utilize this value as a benchmark to determine the effectiveness of their current therapeutic regimen. The patient should be encouraged to monitor peak flow if chronic maintenance therapy is necessary.

VI. Methodology of Procedure: A. After receiving the order, verify the physician order and write your last name in block letter form on the right hand side of the physician order sheet. Also note the time using 24 hour system when the order was received.

A. Review the patient’s chart to gather helpful data so that a patient assessment can be made. Information of importance should include:

1. Diagnosis

2. Assessment of current status or condition / pertinent medical

history

3. Current medication

4. ABG’s



5. Pulse Oximetry

6. Radiographic findings

7. Respiratory Rate

8. Breath sounds

B. Proper equipment should be brought to the bedside.

C. Complete explanation of the procedure/patient education as required.

D. Have the patient perform the peak flow maneuver.

1. The patient should be instructed to sit upright in a chair or at bedside.

2. Inhale as deeply as possible and place their mouth firmly

around the mouthpiece, making sure their lips form a tight seal.

3. Blow out as hard and fast as possible. This will cause the indicator to move up the scale. The final position of this indicator will represent the peak flow.

Note: Be sure not to have the patient perform a forced vital capacity maneuver! Once the initial blast of air is forced out, the patient should be instructed to stop actively exhaling.

4. The peak flow maneuver should be repeated approximately

three (3) times to insure maximum flow is determined.

5. Once complete, the peak flow meter should be stored ready for re-use.

E. Record Keeping:

1. Upon completion of three (3) peak flow maneuvers, the

practitioner should document the following:

a. Date b. Time c. Patient cooperation

d. Patient effort

e. Ratio of observed flow versus predicted flow*


f. Patient education/instruction: (include patient’s ability to comprehend importance of monitoring, ability to consistently perform maneuvers, ability to identify worsening pulmonary function requiring physician contact).

*Refer to table of predicted peak flows for men, women and children of different ages.

NOTE: All documentation should be recorded online in the patient’s electronic record.

VII. Complication:

A. The deep breath and hard puff can cause paroxysmalset off asthmatic coughing and aggravate bronchospasm. This is rarely a problem, but should be documented and communicated to the physician if observed.






Tracheostomy Care –South Campus Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: To ensure proper airway patency, tracheostomy tube function and

patient safety. Policy: The patient requiring tracheostomy can expect a properly functioning

and well-maintained airway established and monitored to ensure airway patency, facilitate ventilation, oxygenation, nutrition and patient comfort.

Procedure: I. Following tracheostomy tube insertion, the Respiratory Care Practitioner will:

A. Evaluate tube position ensuring it is midline in the trachea without torque or tension.

Note: Tension on the tracheostomy tube must be prevented at all times. Whenever possible, a Montgomery strap will be used on the patient’s chest to secure the ventilator circuit midline to the trachea preventing pulling, tugging, or tracheal deviation.

B. Measure the cuff pressure to determine proper inflation pressure is maintained at all times (cuff pressure should never exceed 22 mmHg/30cm H2O pressure in the properly sized tube).

C. Perform tracheal suction to ensure airway patency.

D. Check trach ties to ensure that they are snug with only one pencil

width between ties and patient neck.

E. Monitor prescribed humidification/oxygenation per physician’s order.

F. When oxygen is prescribed, SPO2 monitoring will be provided.

G. Auscultate breath sounds.

Tracheostomy Care –South Campus 2

II. Expected Outcomes:

A. Tracheostomy tube will remain in correct position.

B. Cuff pressure will be kept at a minimum level to maintain a seal between the cuff and tracheal wall (ideally 18-25 cm H2O pressure).

C. Cuff will remain intact with properly maintained tube stability.

D. Adequate hydration, oxygenation and secretion management will be sustained.

E. Patient comfort will be supported.

III. Unexpected Outcomes:

A. Extubation or tube dislodgment secondary to ineffective restraints, improper tube securing, inadequate sedation, incorrect tube size, cuff under inflation, or prolonged intubation.

B. Mucosal ischemia secondary to high cuff inflation pressures (usually

>25 mmHg/34 cm H2O pressure).

C. Airway occlusion from overinflation of cuff.

D. Hypoxia secondary to inadequate oxygenation/ventilation, inadequate secretion removal, obstruction/occlusion, or improperly maintained hydration delivery system.

IV. Monitoring: The Respiratory Care Practitioner will assess the following

parameters a minimum of Q12 hours:

A. Tube position

B. Tube stability (properly maintained trach ties).

C. Appropriate cuff pressure.

D. Adequate hydration/oxygenation/SPO2.

E. Secretion production (volume, consistency, color).

F. Breath sounds. V. Documentation: The Respiratory Care Practitioner will document the assessment outlined under IV above (Monitoring). All documentation will be made in the patient’s online electronic record. Unexpected outcomes will be reported to the Registered Nurse and Primary Care Physician.

Tracheostomy Care –South Campus 3






Routine Tracheostomy Tube Change –South Campus Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: To assure proper airway patency, tracheostomy tube function and

patient safety. Policy: The patient requiring tracheostomy can expect a properly functioning

and well maintained tracheostomy tube which will assure airway patency, facilitate ventilation, oxygenation and patient safety. The tracheostomy tube is typically changed every 8 weeks to prevent mucus build-up, maintain patency and cleanliness. This may vary depending on individual patient secretion production, excessive patient mobility/activity which may require more frequent tube changes secondary to wear. Check with the patient’s physician for frequency of tube changes. It is understood that patients maintained in our sub-acute unit have mature tracheostomy sites and tracheostomy replacement is considered a routine intervention provided by Respiratory Care Practitioners assigned to this unit. Initial and sustained competency will be established and maintained by policy review and successful tube change under direct supervision of Medical Director, Supervisor, or Lead Tech.

Note:

Routine Tracheostomy tubes will always be changed with two practitioners or a respiratory therapist and other qualified nursing staff adept at routine airway management.

Routine tracheostomy tube changes will be performed before

feeding or at least 2 hours after feeding.

Initial tracheostomy tube changes for all new patients will only occur when a physician is present on the unit and immediately available to assist with airway management if required. This consideration applies to all new patients and those who are known to have a history of difficult tracheostomy tube change/management.

Routine Tracheostomy Tube Change –South Campus 2

Supplies: Emergency supplies to be kept at bedside.

Same size trach tube with obturator Size smaller tube with obturator Trach ties (commercially constructed with Velcro) Small blanket or towel roll Sterile water soluble lubricant Suction O2 blow-by (if ordered) Good light source Resuscitation bag Suction Catheter

Procedure: I. Routine Tracheostomy Tube Change

A. Provide the patient with a detailed review of the tracheostomy change process along with calming reassurance.

B. Wash hands C. Utilizing strict aseptic technique, inspect the new tracheostomy tube for

expiration date, cracks, tears or decreased flexibility before use. For cuffed tubes, always inflate cuff to check for leaks (deflate completely before insertion).

D. Insert obturator into new tube; be sure it slides in and out easily. The

obterator helps to guide the tube, and the rounded tip adds protection to the stoma during insertion.

E. Place a small amount of sterile water soluble lubricant (surgilube or K-Y

jelly) on the end of the new trach tube and place the tube in the sterile container or sterile surface until ready to insert.

F. Have suction and oxygen available G. With the patient in supine position, place a small blanket or towel roll

under his/her shoulders to help with hyperextension of tracheostomy site for maximum exposure of the stoma.

Note: Some patients with mature tracheostomys may prefer to have their tracheostomy tube changed while in sitting position.

H. Administer oxygen if ordered. I. Gently remove the old trach tube (follow angle of the tube, on an

upward and outward arc).


J. Inspect old tube for integrity, mucous plugs or odor, then discard following removal of trach tube, assess stoma for skin irritation, breakdown and signs of infection. Report any of these findings to the assigned RN immediately.

K. Insert the new tube in a smooth curving motion directing the tip of the

tube toward the back of the neck in a downward arc (like inserting a suction catheter). DO NOT FORCE THE TUBE!

L. Remove the obturator immediately while holding the tube securely in

place with your other hand.

M. Apply tracheostomy tube tie and secure tube. to one pencil width. Once the ties are properly adjusted, secure velcro with pink plastic adhesive tape to maintain proper tube position

II. Following tracheostomy tube insertion, the Respiratory Care Practitioner will:

A. Evaluate the tube position ensuring it is midline in the trachea without torque or tension.

B. Measure the cuff pressure to determine proper inflation pressure is

maintained at all times (cuff pressure should never exceed 25 mmHg/34cm H2O pressure in the properly sized tube).

C. Perform tracheal suction to ensure airway patency.

D. Check trach ties to ensure they are snug with only one pencil width

between ties and patient neck.

E. Monitor prescribed humidification/oxygenation per physician’s order.

F. When oxygen is prescribed, SPO2 monitoring will be provided.

G. Auscultate breath sounds III. Techniques for a Difficult Trach Change

A. The obturator helps make insertion easy and trauma free. Always keep an obturator on hand should the tube need emergent re-insertion following un-planned or planned extubation.

B. If easy re-insertion is not accomplished, repositioning the patient may

facilitate insertion.

C. If the tube cannot be completely inserted promptly, hold the tube in place, remove the obturator to allow the patient to breath, and then


continue to gently insert the tube.

D. If still unable to insert tube, remove the tube, re-lubricate and try again.

E. If this is unsuccessful, try to insert the one size smaller tube.

F. If needed, insert a suction catheter through the tracheostomy tube and guide the suction catheter through the stoma into the trach. Then slide the trach tube over the suction catheter and into the stoma. Remove the suction catheter following successful tube insertion.

Note: Slight stoma irritation with minimal trauma is often experienced during successful tube change. This may result in minimal bleeding which should be noted. If bleeding persists or becomes significant contact physician immediately.

G. If all else fails, cut a section of the suction catheter to place in the

stoma in order to keep the stoma open and maintain an airway. Be sure to cut the catheter long enough so that it cannot be aspirated! Secure the catheter and immediately call for medical assistance.

H. Give supplemental oxygen by blow-by or at low flow through the

catheter if needed to maintain SpO2 > 92%.

I. If you absolutely cannot get any tube or catheter into the stoma and the patient is breathing fairly comfortably (through the stoma or through the mouth and nose), contact the doctor for immediate assistance if on site or transfer immediately to emergency department.

J. If insertion is not possible and patient is demonstrating signs of

respiratory distress activate EMS and provide necessary cardio-pulmonary support.

IV. Documentation: The Respiratory Care Practitioner will document:

A. Patient tolerance and ease of insertion

B. Size Trach tube inserted

C. Verification of proper tube placement

1. Trach mid-line 2. Breath sounds 3. Oxygen saturation

4. Physically feel air movement from trach during expiration

5. No visible signs of respiratory insufficiency or distress


D. Minimal or significant bleeding following successful tube change.

E. Success or failure of procedure.

F. Complication communication and resolution (if required).






Postural Drainage & Percussion Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: To define postural drainage & percussion, along with its therapeutic

objectives, indications and how it will be administered. Policy: The Respiratory Care Practitioner will demonstrate technical skill in the

application of postural drainage and percussion techniques that result in maximum patient cooperation and effective secretion removal.


A. Postural drainage and percussion is defined as therapeutic posturing with the application of vibrational energy for the purpose of mobilizing retained pulmonary secretions. Postural drainage and percussion is generally administered to facilitate pulmonary clearance when physiological pulmonary compromise has resulted in secretion retention, atelectasis or pneumonia.


A. The physician must specify:

1. The pulmonary aspects requiring clearance. 2. The physician must also specify the frequency of treatment, i.e.,

QID, etc. 3. It is desirable but not mandatory for the physician to specify the

therapeutic objective (see below). III. Therapy Objectives: To facilitate mobilization of retained pulmonary secretions.

A. To promote secretion removal by expectoration or suctioning.

Postural Drainage & Percussion 2

B. To prevent and/or correct atelectasis secondary to secretion retention.

C. To prevent pooling of secretions (to avoid the possibility of pulmonary

infection/pneumonia) D. To decrease energy expenditure in patients compromised by chronic

respiratory disease who have viscid secretions and are unable to cough or expectorate efficiently.

IV. Indications: A. Pneumonia B. Obesity

C.A. Disease or conditions which cause an increase in pulmonary secretion production (chronic bronchitis, bronchiectasis, cystic fibrosis).

D.B. Neuromuscular insufficiency such as Guillian-Barre Syndrome,

Amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), muscular dystrophy (MD), etc.

E.C. Inability to cough effectively and mobilize secretions (CVA, comatose

patient, etc.).

F. Prophylactically in patients needing mechanical ventilation, who because of injury, have limited ability to move.

G. Pre-operative patients with excessive secretions.

H.D. Post-operative patients who because of pain, will not cough effectively or ventilate adequately. Generally incentive spirometry and/or IPPB are better.


A. It is extremely important that the therapist explain the purpose of therapy in an attempt to gain the confidence of the patient. This can simply be done by conversing with the patient about his daily activities and physical capabilities with frequent reassurance that this treatment modality will be helpful.

B. It is of utmost importance that the therapist review the patient’s history so that they may fully understand the scope of their needs and discuss these points with the patient. This will not only give the patient a feeling of security and trust, but will also give the therapist an opportunity to visually evaluate the patient’s condition and determine possiblehis physical limitations prior to initiation of therapy.







1. The patient is to understand that he will be placed in positions which will probably initially be uncomfortable for him/her, but as therapeutic goals are accomplished, he will realize less discomfort. It will be understood that if the patient feels too compromised, posturing of less compromise can be assumed with the same therapeutic effectiveness. 2. Reinforcement is essential with frequent reminders that once the goals are achieved, these procedures can be carried out by family members in the home on a continual therapeutic regimen if beneficial.

1.B. Pursed lip breathing should be encouraged throughout the procedure. Satisfactory explanation should be made so that the patient understands its beneficial effects in improving ventilation while in compromising positions.

2.1. The importance of good coughing will be reviewed. Coughing will

be encouraged after each segment is percussed for approximately one to two minutes.

3.2. Patient should finally be asked if they have any questions about

the objectives of therapy. These questions should be answered tactfully and with positive overtones to reinforce the patient’s confidence and collaboration.

V. Methodology of Procedure:

A. After receiving the order, verify it in the electronic medical record.it on the physician order sheet and write your last name in block letter form on the right hand side of the order sheet under the physician’s order. Also, write the time using the 24 hour system (military time) when this order is received.

B. Identify patient (using two patient identifiers per HIPAA guidelines).

C. Review the patient’s chart to gather helpful data to properly asses the

patient. Information of importance should include:

1. Pulmonary diagnosis, history of current problems, quality and consistency of secretion production.

2. Assessment of current physical status. The patient may be too ill to tolerate this form of therapy.

3. Insight into his physician’s treatment goal. 4. Arterial blood gases. **

5. Pulmonary function studies. **







6. Radiologic findings. **

** All may aid in the assessment of PD&P. Hypoxia may worsen in certain positions therefor oximetry monitoring to assure adequate oxygenation may be desirable during therapy.

7. Blood pressure records. High or low blood pressure should

prompt caution in the use of PD&P. 8. Cardiac status and history. PD&P should not be employed in

patients with hypotension, congestive failure, etc.

9. Medications presently being administered. IV lines may impede PD&P Rx or be lost if caution is not used.

10. Concomitant conditions which may affect the treatment plan i.e.,

fractures, gastric distension, NG tube, severe dyspnea, hemodynamic instability.

C. Proper equipment should be brought to the bedside.

D. Complete explanation of the procedure (refer to patient education, V)

E. Administer Therapy:

1. The therapist should note any apparent respiratory distress:

a. Respiratory rate

b. Quality of respirations.

c. Hypoxia (oximetry)

2. Careful observation of speech patterns (such as patient

breathing between every two to three words).

3. Observation of patient’s habitually assumed posturing provides initial clues to excessive use of accessory muscles of respiration.

4. Patient interview to determine:

a. Attitude towards illness.

b. Understanding of condition.

c. Motivations and expectations from therapy.


5. It is important to establish an atmosphere of hope and

encouragement to gain the patient’s trust and cooperation. After these have been successfully accomplished, administration of therapy is generally accepted more readily.

6. Postural drainage and percussion should not be performed within

60 minutes after meals. Do not employ trendellenberg position in patients receiving nasogastric feelings.

7. Check patient’s pulse before, during and after therapy. If pulse

rate fluctuates more than 20 to 30 beats per minute, therapy should be discontinued and the nurse/physician notified.

8. Blood pressure should be monitored before and after therapy as

well. If a rise or fall of 20 mm of mercury occurs, the therapy should be discontinued and the nurse/physician notified.

9. Listen to breath sounds before and after therapy. 10. Note patient color during procedure. 11. Place patient in designated position.

12. Use either mechanical or manual percussion to specified

segments times one to two minutes.

13. Have patient take deep inspirations and exhale slowly through pursed lips while vibration is being applied after one to two minutes of percussion.

14. Cough patient (chart effectiveness).

15. Repeat procedures 10 through 13 until all designated segments

are drained. 16. Document in the electronic record color, consistency and amount

of sputum produced.

17. Document a comprehensive progress note each shift. Include the physician order, objective of therapy, regions of the chest percussed and positions attained.

18. If the patient refuses his treatment, notify the nurse and chart the

reason for refusal. If in any 24-hour period the patient refuses more than one treatment, the physician must be notified at the time of the second refusal. It will be the responsibility of the RCP to personally call the physician in this instance though he shall


also inform the nurse that he is doing this. VI. Delivering of Aerosol Medications if Applicable:

A. It is generally understood that patients who have concurrent aerosol therapy orders with postural drainage and percussion will receive the postural drainage and percussion immediately after aerosol administration to maximize the effectiveness of therapy.

VII. Monitoring (Bedside Measurement)

A. Should consist of careful patient evaluation throughout procedure. Breath sounds as well as sputum production should be evaluated and recorded with each treatment. (Refer to VI above).

VIII. Record Keeping:

A. With the initiation of therapy, a respiratory care online progress note should be completed. This should include:

1. Diagnosis

2. Therapeutic objective

3. Exact positions attained (i.e., “All segments,” “RLL,” etc.)

4. Date and time of each treatment

B. All subjective reports from the patient should be documented.

C. All objective information should be documented. (Vital signs, sputum

production, etc.)

D. Assess the response to therapy.

E. State future plan to continue or modify Rx as appropriate.

IX. Possible Complications:

A. Recognition of complications:

1. Mechanical (related to equipment). Look for bruises and chest soreness.

2. Clinical (related to patient).

a. Improper percussion technique leading to bruising.

b. Increase of pain or dyspnea.


c. Decrease or increase in blood pressure secondary to

position changes.

d. Hypoxia (cyanosis) or decreased SpO2 (oximetry).

e. Decrease or increase in pulse secondary to posturing.

f. Spontaneous pneumothorax in patients with advanced bullous disease (recognized by pain, decreased breath sounds, acute respiratory distress).

B. Action to be taken in the event of complications:

1. Clinical (Related to patient). Prevention:

a. Use proper cupping techniques

b. Monitoring patient’s vital signs closely throughout

therapy.

c. Contact physician if patient complains of pain, dsypnea or excessive work of breathing with decreased SpO2 during therapy.

X. Contraindications: A. None of these are absolute contraindications but their presence should prompt caution and probably physician discussion.

1. Head injury 2. Congestive heart failure. 3. Pulmonary edema 4. Cardiac arrhythmia 5. Shock 6. Vomiting 7. Dyspnea 8. Gastrointestinal hemorrhage, gastric distention, ileus, bowel

obstruction 9. Patient unable to tolerate procedure.

Formatted: No bullets or numbering, Widow/Orphan control


10. Seizures

11.10. Bullous disease

12.11. Fractures over area to be percussed or unstable fractures remote to chest, traction, etc.

B. If complications occur:

1. If chest is bruised and sore, discontinue treatment if agreeable with

physician.

2.1. Evaluate severity of pain. If pain makes treatment impractical, discuss with physician.

3. Modify position if position not tolerated for any reason. Be sure

physician is informed if optimal positioning is not possible.

4.2. Notify physician immediately if pneumothorax suspected. XI. Safety Precautions if Applicable:

None XII. Automatic Stop Orders: A. Stop therapy after 15 days if not renewed by physician.

A. Stop therapy immediately if poorly tolerated and notify physician. "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

Formatted: Indent: Left: 0.92", First line: 0.5", Numbered+ Level: 1 + Numbering Style: 1, 2, 3, … + Start at: 1 +Alignment: Left + Aligned at: 0.04" + Tab after: 0.5" +Indent at: 0.5", Tab stops: 1.42", List tab + Not at 0.5"

Formatted: Indent: First line: 0.5", No bullets ornumbering, Widow/Orphan control

Formatted: Indent: Left: 0.96", First line: 1", Numbered +Level: 1 + Numbering Style: 1, 2, 3, … + Start at: 1 +Alignment: Left + Aligned at: 0.04" + Tab after: 0.5" +Indent at: 0.5", Tab stops: 1.46", List tab + Not at 0.5"

Formatted: No bullets or numbering, Widow/Orphan control





Suctioning Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: A clarification on suctioning issues and how it will be applied. Policy: The Respiratory Care Practitioner will provide airway management by

performing suctioning via natural or artificial pathways. Procedures: I. General Description of Therapy:

A. Suctioning is defined as the application of negative pressure through a suction catheter to the upper airway for the purpose of stimulating cough and removing secretions.


A. The physician shall specify the frequency of suctioning and route. In cases where suctioning if performed for diagnostic purposes; the physician shall specify the test required, for example, culture and sensitivity, etc. In emergency situations, oral and endotracheal suctioning may be performed without the physician’s order.


A. Removal of secretion from the upper airway in tracheotomized or intubated patients.

B. Prevent atelectasis from secretions stasis

C. Prevent ventilation / perfusion mismatching from secretion retention.

D. Promote cough for secretion removal.

E. Obtain sputum for diagnostic purposes.

F. Prevent/treat aspiration of solids or liquids in-patients with impaired

Suctioning 2

upper airway function.

IV. Indications:

A. Intubation or Provide mechanical removal of retained secretions in those patients who have impaired mucociliary function secondary to disease processes or placement of artificial airways.tracheotomized patients who, because the intubated upper airway has been bypassed, will require a means of secretion removal.

B. Patients, who because of disease or injury are incapable of coughing

effectively and therefore, may allow secretions to accumulate.

C. Pooling of secretions secondary to:

1. Neuromuscular weakness.

2. CVA

3. Inhibited cough maneuver from abdominal or thoracic surgery.

4. Excessive secretion production and/or retention.

5. Oral surgery V. Patient Education Applicable to Therapeutic Procedure:

A. In the alert, coherent patient, it will be explained that the suctioning procedure will be uncomfortable but necessary for the improvement of the patient’s condition. The patient should understand that the suction catheter is much smaller that the airway and that they will be capable of breathing around the tube at all times. The patient should also understand that coughing during the procedure is expected and that ventilation and oxygenation can occur in spite of the cough maneuver.


A. Appropriate equipment is brought to the bedside and assembled.

1. Suction equipment

2. Oxygen equipment

3. Resuscitation bag

B. The patient will be placed in high Fowlers position.

C. Wash hands with antimicrobial preparation except in emergencies.

Suctioning 3

D. Select type of catheter: Standard, Ballard, Ballard Coude’, Standard

Coude’. E. Open catheter package

F. Hyper oxygenate the patient with six or seven breaths of 100%

oxygen, (if needed)

G. Glove one hand with sterile glove

H. Pick up tip of catheter with gloved hand; attach to vacuum connecting tube.

I. Introduce catheter into the orifice during inspiration without suction

applied.

J. Entrance into the trachea can be recognized by paroxysmal coughing.

K. Continue advancing the catheter until resistance is felt, the catheter should not be forced any further.

L. Apply suction while rotating the catheter, withdraw the catheter

approximately one inch with the suction off, reapply suction and rotate once again. Continue this process until catheter is withdrawn.

M. Suction for no longer than 15 seconds.

N. Even though all secretions may not have been removed in the

specified length of time, the patient should be hyper oxygenated again before any additional suctioning is performed. Wrapping the suction catheter around the fingers of the gloved hand as the catheter is removed also helps to prevent contamination of the catheter. As long as it has not been contaminated, it may be reinserted for additional suctioning. Turning the head from side to side may facilitate selective catheterization, particularly of the left main stem bronchus.

NOTE: If the patient has tenacious secretions, 3 to 6cc’s of sterile normal saline for injection should be instilled at the beginning of the suctioning procedure. This should be followed by bag breathing and sighing before suctioning is attempted. After the patient has been hyperoxygenated, another 15 seconds of suctioning may be accomplished. If after suctioning this time, the patient seems to be free of secretions, the bag ventilation should be used to force the patient to sigh and to take several deep breaths which are held from 3 to 5 seconds, then released suddenly. Cough usually is induced, and this may help to mobilize secretions that were not within reach of the previous suction attempt.

Suctioning 4

O. Stop suctioning at this point if no further secretions are diluted. When the procedure is complete, the catheter is wrapped around the fingers of the gloved hand. Taking the glove off the cuff and removing it inside out keeps the catheter inside the glove and will minimize contamination of the patient’s surroundings. Once the catheter and glove have been disposed of, the vacuum connection tube should be rinsed with sterile water and the cup discarded. The oxygen and vacuum should be turned off, and the bedside should be checked to be sure that all supplies are at hand for the next suctioning procedure.

VII. Delivery of Aerosolized Medications if Applicable:

A. In the event of bronchospasm, it may be necessary to notify the physician and discuss the possibility of administering aerosolized bronchodilators to relieve bronchospasm.

VIII. Monitoring:

A. In the event that a cardiac monitor is not available, the patient’s pulse, respirations and blood pressure should be closely monitored before and after suctioning to safeguard against possible complications.

IX. Record Keeping:

A. The suction procedure will be recorded in the patient’s online electronic record. Parameters that should be noted are: date, time, and patient tolerance of therapy, secretion volume, color, consistency and any pertinent information.


A. Complications:

1. Hypoxia

2. Vagal stimulation

3. Trachitis

4. Damage to the mucous membrane

5. Occlusion of the airway with the catheter

6. Atelectasis

Suctioning 5

7. Laryngospasm

8. Sudden death

9. Infection

B. Recognition of complications:

1. Hypoxia: Recognized by marked reduction in SpO2; may also cause arrhythmias during suction procedure.

2. Vagal stimulation: Recognized by bradycardia; may lead to

cardiac arrest

3. Trachitis: Recognized by a dry, hoarse, hacking cough whenever trachea is stimulated.

4. Damage to the mucous membrane: Recognized by aspiration of

blood and/or tissue from the airway.

5. Occlusion of the airway with the catheter: Recognized by the inability of the patient to ventilate during the procedure. In extreme cases, retraction of accessory muscles of respiration may be note.

6. Atelectasis: Recognized by x-ray indicating collapsed pulmonary

segments.

7. Laryngospasm: Recognized by wheezing or stridor after the suctioning procedure. In severe cases, complete occlusion of the airway may occur.

8. Sudden death: Recognized by absence of vital signs.

9. Infection: Recognized by the onset of purulent secretion

production.

C. Action to be taken in the event of complications:

1. Hypoxia: Hyper oxygenate the patient before and after the suctioning procedure.

2. Vagal stimulation: If bradycardia persists, physician should be

notified. If cardiac arrest occurs, initiate CPR.

Trachitis: The patient should be encouraged to cough as vigorously as possible to mobilize secretions. If they cannot cough effectively, the installation of 5-10 ml of normal saline usually stimulates sufficient cough. After suctioning is complete,

Suctioning 6

instillation of one ml of 1% lidocaine every 2 to 4 hours PRN helps control the cough until the trachitis subsides. Topical steroids have also been used with good effect in this situation. Physician order, of course would be required.

3. Damage to the mucous membrane: No definitive action to be

taken. Best course is to minimize suction pressure and suction only when secretions are present.

4. Occlusion of airway with catheter: Immediately disconnect the

catheter. Use proper size catheter assuring that outside diameter is not greater than two thirds of the inside diameter of the airway being suctioned.

5. Atelectasis: Discuss with the physician appropriate therapy for

re-expansion of the collapsed lung, minimize suctioning pressure and length of suctioning procedure to prevent recurrence of complication.

6. Laryngospasm: In mild to moderate cases, the physician should

be notified and discuss with him the possibility of administering aerosolized bronchodilators. In severe cases, disconnect the suction from the connective tubing and allow the catheter to serve as an airway until help can be summoned.

7. Sudden death: Initiate CPR in an effort to revive the patient.

8. Infection: When purulent secretions are noted, notify the nurse

and physician with the request that a sputum culture be obtained.

XI. Contraindications:

A. Patient intolerance to procedure

B. Hemophilia

C. Cardiac instability

D. Hypersensitive vagal responsiveness

XII. Safety Precautions if Applicable:

A. Majority of all complications associated with suctioning procedure can be eliminated by using proper suctioning technique. Ideally, this should include:

1. Aseptic technique

Suctioning 7

2. Minimize the length of time allowable for suctioning to 15

seconds

3. Use proper suctioning pressure:

a. Adults: 120 to 150 mmHg

b. Pediatrics: 100 to 200 mmHg

c. Infants: 60 to 80 mmHg

4. Hyper oxygenation before and after the suction procedure

NOTE: The trauma of nasal introduction of a catheter into the airway may result in catecholamine release which, with attendant hypoxia, increase work of breathing, and vagal stimulation may result in arrhythmias.


A. Therapy should be terminated in patients who demonstrate marked bradycardia during the suction procedure.









Use of the Passy-Muir Valve (PMV) Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: The Passy-Muir Valve (PMV) is designed to provide complete power of

speech and swallowing for the tracheostomized patient. Policy: The Passy-Muir Valve Tracheostomy and Ventilator Speaking Valve

will be implemented following physician directed prescription by the Respiratory Care Practitioner and Speech or Occupational Therapist. Prior to implementation, it is essential that education regarding the PMV and its use be provided to all care providers working with the patient. This will help to ensure appropriate use of the PMV, maximize patient safety and optimize the patient’s communication and swallowing potential.

Procedure: Complete Physician Order:

A. The physician shall specify the desire for implementing the PMV. The initial order should include the objectives of the evaluation and establish the number and duration of implementations.

Therapy Objectives:

A. Improve speech

B. Improve swallowing

C. Facilitate secretion management

D. Facilitate weaning

E. Expedite decannulation

F. Promotes better hygiene Indications:

Use of the Passy-Muir Valve (PMV) 2

A. Awake and alert tracheostomized (ventilator or non-ventilator

dependent) patients may be considered candidates for PMV use if they meet assessment guidelines. During exhalation air passage must be sufficient around the trach tube and through the upper airway. A list of disease conditions or impairments for consideration include:

1. Ventilator Dependency

2. Neuromuscular Disease

3. Quadriplegia

4. Head Trauma

5. COPD

6. Tracheomalasia

7. Mild Tracheal and/or Laryngeal Stenosis

8. Bilateral Vocal Cord Paralysis without significant airway

obstruction.

9. Non-Obstructing Laryngeal Tumors

10. Sleep Apnea patients who are tracheostomized as an alternative to plugging.

I. Patient Education Applicable to Therapeutic Procedure:

A. To reduce anxiety and ensure successful transition to the PMV, the

patient, family and all personnel (all shifts) working with the patient should be instructed in the directions for use of the PMV including contraindications, cautions and warnings. Review all package inserts and labeling with patient, family and staff.

B. Education will be ongoing throughout the application period. If the PMV

will be utilized in the out-patient setting post-discharge, the patient and family/primary care provider will be provided with a complete PMV Kit along with home care instructions for care and maintenance of the PMV.

II. Methodology of Procedure:

A. Pre-placement Assessment Guidelines for Passy-Muir Tracheostomy

and Ventilator Speaking Valves.


1. For tracheostomized non-ventilator dependent patients: The PMV may be placed 48-72 hours after the tracheostomy is performed if the patient’s tracheal edema and/or secretions from the surgical site have decreased.

If the tracheostomy tube has been changed, PMV placement may be delayed 48-72 hours as this procedure may have induced tracheal swelling and/or bronchospasm.

2. Cognitive Status: Patient must be awake, responsive and

attempting to communicate. The PMV will not be used while the patient is sleeping unless specifically ordered by physician.

3. Medical/Pulmonary Status: Patients must have the appropriate

lung mechanics necessary to exhale around the tracheostomy tube and out of their nasal and oral cavities. Patient assessment should include but is not limited to:

a. Vital signs

b. Bedside oximetry and/or spirometry

c. Patient reaction/tolerance

d. Work of breathing

e. Airway patency

f. Breath sounds

g. Proper position of patient and tracheostomy tube

h. Patient psychological and motivational issues

4. Ability to tolerate cuff deflation: Cuff deflation is mandatory with

the PMV to allow exhaled air to pass around the tracheostomy tube and through the oro-nasopharynx. If it is determined that the patient cannot tolerate cuff deflation initially (i.e. due to risk of gross aspiration or need for intensive critical control of mechanical ventilation), the patient should be reassessed for cuff deflation as changes in his/her medical condition occur.

5. Secretion Management: Use of the PMV can facilitate

movement and oral expectoration of secretions by the patient. Over abundance, viscosity and/or ongoing infection affect secretions manageability. Ability to manage increased and/or different viscosities of secretions will vary with each patient. PMV use may need to be limited or deferred temporarily until secretions become manageable.


Warning: Patients with thick unmanageable secretions that

may cause airway obstruction should be carefully evaluated for use of the PMV.

6. Swallowing: The patient’s risk for aspiration should be evaluated

as this can influence the amount, thickness and manageability of secretions. Presence of gross aspiration can play an important role in determining a patient’s appropriateness for cuff deflation and PMV use. The safety and efficiency of the swallowing process can be negatively affected by the presence of a tracheostomy tube. While some tracheostomized individuals exhibit no swallowing difficulties, many will experience dysphagia and aspiration even though their primary diagnosis would not typically indicate swallowing problems. Use of the PMV can improve the safety and efficiency of swallowing and may reduce aspiration. The positive closure “no leak” design of the PMV restores the patient to a more normal closed system which improves swallowing as it facilitates increased pharyngeal/laryngeal sensation and restores positive subglottic air pressure.

WARNING: Although PMV use can improve swallowing and may reduce aspiration in some patients, the presence and/or risk of aspiration should be evaluated carefully with each patient to determine appropriate use of PMV in addressing swallowing function.

7. Airway Patency: The patient must be able to exhale efficiently

around the tracheostomy tube, up through the pharynx and out the nasal and oral cavities in order to wear the PMV.

a. Check diagnosis to ensure that there are no known

airway obstructions (e.g., tumors, stenosis, granulation tissue).

b. Tracheostomy tube size plays an important role in the

patient’s ability to exhale efficiently. The tracheostomy tube should be sized to allow for sufficient airflow around the tracheostomy tube to facilitate speech and effective use of the PMV. The cuff on the tracheostomy tube can also create an obstruction even when deflated and should be taken into consideration during airway patency assessment. The patient with a cuffed tracheostomy tube should be evaluated for a cuffless tracheostomy tube if medically appropriate to eliminate the need for cuff deflation with use of the PMV.

c. Besides assessment of airway patency:


d. Deflate tracheostomy tube cuff completely, if present.

e. Instruct the patient to inhale through the tracheostomy

tube.

f. Manually occlude the tracheostomy tube with a gloved finger as you instruct the patient to exhale through their mouth and nose to ensure adequate exhalation. This may be observed by having the patient blow on a tissue, mirror, feather, etc. Encourage the patient to vocalize, (e.g., say “Ah”, count, etc.) to determine pressure and quality of voicing. Although some patients may be able to exhale adequately, they may not be able to vocalize initially and may require voice assessment and/or retraining.

g. Some patients may require repeated attempts of steps a-

c to become accustomed to exhaling through the upper airway. Upon determination that the patient is able to exhale and/or voice adequately, you may consider PMV placement if other assessment criteria are met.

8. Lung Compliance: Critically ill and chronic pulmonary patients

have lungs with altered compliance. Therefore, PMV usage may be limited to short periods of time during the day with close monitoring. Severe lung disease causes a loss of lung elasticity and poor natural recoil. Exhalation is thus prolonged. Careful assessment for PMV use is needed to avoid potential complications associated with air trapping that can occur with non-elastic lungs. An appropriately sized trach tube is especially crucial for these patients when considering PMV use as it can facilitate exhaled air flow.

III. Non-Ventilator Dependent Application of PMV

A. After pre-assessment criteria have been met, PMV placement should

occur in conjunction with physician order.

1. Patient Assessment: The patient should be assessed before, during and after PMV placement for the following:

a. Vital signs (HR, RR, O2 saturation)

b. Breath sounds

c. Change in patient’s color and responsiveness d. Work of breathing


e. Tracheal and oral secretion status 2. Suctioning: It is recommended that both tracheal and oral

suctioning be performed as needed. This includes before and after deflating the trach cuff (if present).

3. Cuff Deflation: Slowly deflate cuff of the trach tube (if present).

The patient may need to be suctioned again following cuff deflation to remove secretions that were present on and/or above the cuff. The patient with a cuffed trach tube should be evaluated for a cuffless tube (if medically appropriate) to eliminate the need for cuff deflation with use of the PMV.

Warning: Tracheostomy tube cuff must be completely deflated before placing the PMV. Patient will be unable to breathe if the cuff is not completely deflated. PMV cannot be used with foam filled cuffed tracheostomy tubes. The PMV can be used with a cuffed tube if the cuff is completely deflated and the patient has sufficient airflow around the tracheostomy tube and bulk of the deflated cuff.

4. Tracheostomy Tube Size: Per physician direction, change to a

smaller tracheostomy tube or cuffless tube may be needed to provide sufficient exhaled airflow to allow appropriate use of the PMV.

5. Use of Warning Labels: Attach warning labels provided with

PMV to the pilot balloon of the patient’s cuffed tracheostomy tube and post at the patient’s bedside and in the patient’s chart to facilitate staff awareness, patient safety and proper PMV use.

6. PMV Attachment: Stabilize the trach tube with one hand while

attaching the PMV to the 15mm hub of the trach tube with the other hand using an approximate ¼ twist. The PMV has a friction fit for secure placement.

7. Patient Monitoring and Removal of PMV: Observe patient to

ensure that the diaphragm of the PMV opens during patient’s inspiration and remains closed during exhalation. Observe the patient with the PMV in place to ensure the patient has adequate airflow around the trach tube. If the patient exhibits signs of respiratory distress, remove the PMV immediately and reassess airway patency.

Warning: If the patient experiences difficulty utilizing PMV, the patient may have airway obstruction due to stenosis, tissue mass, Tracheomalasia, granulation, vocal cord paralysis in the midline position, secretions, or a tracheostomy tube that is


oversized for the patient’s trachea. With correction of the obstruction, the patient should be re-evaluated for PMV use.

Troubleshooting: If patient is unable to exhale adequately through the upper airway, the following may need to be considered for reassessment.

i. Cuff Assessment: Check to ensure that the tracheostomy

tube cuff is completely deflated. Although not required, a cuffless trach tube may provide optimal airway patency for use with the PMV and should be considered if the patient is an appropriate candidate.

j. Tracheostomy Tube Assessment: Evaluate tracheostomy

tube size to determine whether downsizing the tube is necessary due to the size of the tracheostomy tube or bulk of the deflated cuff to enable adequate exhalation.

k. Airway Obstruction: Physician assessment (e.g.,

bronchoscopy) for presence of unknown airway obstruction (e.g., stenosis, granulation, mass, vocal cord paralysis, etc.) should be considered.

l. Positioning: Reassess to ensure optimal patient trach

tube positioning.

m. Patient Anxiety: Tracheostomized patients may experience anxiety with initial PMV placement. Patient education prior to placement of PMV with explanation that the patient will experience sensation of airflow through the upper airway upon exhalation, and may initially experience movement of secretions through the airway and out the mouth, may help reduce some anxiety.

IV. Instruction for Ventilator Applications

A. All ventilator adjustments require a physician’s order.

B. Cuff Deflation. If the patient has a cuffed tube, ventilator adjustments may be required to compensate for leakage around the tube after deflation in order to meet the patient’s comfort and ventilatory requirements. The patient with a cuffed tracheostomy tube should be evaluated for a cuffless trach tube (if medically appropriate) to eliminate the need for cuff deflation with use of the PMV.

C. Ventilator Adjustments: If the PIP decreases significantly following cuff

deflation, inspired air may be escaping through the upper airway and not entering the lungs. To compensate, adjustments to tidal


volume/PIP may be necessary. When an increase in tidal volume/PIP is necessary, it should be made in small increments to avoid over compensation.

Warning: Do not exceed pre-cuff deflation value/peak inspiratory pressures Warning: Tracheostomy Tubes MUST be completely deflated before placing the PMV. Patient will be unable to breathe if cuff is not completely deflated. PMV cannot be used with foam filled cuffed tracheostomy tubes. The PMV can be used with a cuffed trach tube if the cuff is completely deflated and the patient has sufficient airflow around the trach tube and bulk of the deflated cuff.

D. PMV Attachment: PMV 007 with closed suction catheters will be attached to the hub of tracheostomy tube following complete deflation of cuff. Close monitoring with adjustments to tidal volume/PIP will be made to ensure adequate ventilation.

E. Monitoring and Removal of PMV: Observe PMV to ensure that the

diaphragm of the PMV opens during inspiration and remains closed on exhalation. Observe the patient to ensure adequate airflow occurs through the upper airway. If the patient exhibits signs of respiratory distress, remove the PMV immediately and reassess for airway patency.

F. Airway Pressures: Airway pressures may rise when patients use the

PMV due to exhalation through the oronasopharynx which creates physiologic PEEP. This is part of the natural physiology restored with a closed respiratory system created by the positive closure “no leak” design of the PMV. Consequently, mechanical PEEP may be reduced. When peak pressures are above allowable limits, the PMV needs to be removed immediately and assessment for upper airway patency performed. In addition, due to a slight increase in airway pressure experienced by some patients with PMV use, it is necessary as with any modification to the ventilator circuit to re-evaluate low pressure settings to disconnect to ensure that settings are appropriate.

G. Ventilator Alarm Settings: All alarms on ventilators need to be re-

evaluated for appropriate adjustments before, during and after use of the PMV.

Warning: Failure to re-evaluate and adjust ventilator alarms may compromise patient safety. When the PMV is placed in-line with the ventilator, the patient will no longer be exhaling into the ventilator circuit. Therefore, on most acute care ventilators, the high and low tidal volume, high and low minute volume and the apnea alarms must be reassessed. High and low pressure alarm settings on the ventilator must be reassessed at this time to ensure patient safety. Close patient


observation, patient monitoring and assessments must be consistently performed.

V. Delivery of Aerosolized Medications if Applicable

A. The PMV must be removed prior to nebulization of any medication. Under no circumstance will medications be aerosolized in conjunction with the PMV.

VI. Care of the PMV

A. Cleaning Procedure: Swish PMV in pure, fragrance free soap and warm (not hot) water. Allow PMV to air dry thoroughly before placing in storage container. Do not apply heat to dry PMV.

B. Do not use hot water, peroxide, bleach, vinegar, alcohol, brushes or Q-

tips to clean PMV. Do not autoclave.

C. Lifetime of PMV: Each PMV is guaranteed to last a minimum of two months. If the PMV should become sticky, noisy or vibrate prior to or after two months, the PMV should be replaced.

VII. Contraindications to the PMV

A. Unconscious and/or comatose patients.

B. Inflated tracheostomy tube cuff.

C. Foam filled tracheostomy tubes.

D. Severe airway obstruction which may prevent sufficient exhalation.

E. Thick and copious secretions.

F. Severely reduced lung elasticity that may cause air trapping.

G. This device is not intended for use with ET tubes.

VIII. Monitoring

A. Ventilator-dependent patients: Patients supported by CMV will have the following monitored with each ventilator check: 1. Vital signs

2. SpO2

3. Patient comfort/tolerance


4. Work of breathing

5. Airway patency

6. Breath sounds

7. Proper tube positioning

8. Secretion management

B. Spontaneously breathing patients: Spontaneously breathing patients bill be monitored with same parameters as indicated above. The frequency of monitoring will be determined by physician prescription.

IX. Documentation

A. Ventilator dependent patients will have complete respiratory assessments documented in the patient’s online electronic record.

B. Spontaneously breathing patients will have respiratory assessments

documented in the patient’s online electronic record. X. Automatic Stop Orders

A. Patient intolerance to PMV application.

B. Patient anatomy/physiology inconsistent with safe application.

C. Inadequate secretion management.



Manual Name: Rural Health Clinics Date:09/18/17 Support Staff Name: Maria Barba


#


Revision, Deleted)

Medication Storage And Security RCP.68 Revised Mary Jo Dyck (559)592-7314


Manual Name: Rural Health Clinics Date:10/10/17 Support Staff Name: Maria Barba


#


Revision, Deleted)

Kaweah Delta Woodlake Health Clinic Organizational Chart

WH.303 Revised Mary Jo Dyck (559)592-7314

Abnormal Results Follow-up RCP.39 Revised Mary Jo Dyck (559)592-7314

Patient Referrals RCP.38 Revised Mary Jo Dyck (559)592-7314

Hazardous Materials and Infectious Waste RCP.61 Revised Mary Jo Dyck (559)592-7314

Gases for Medical Use RCP.62 Revised Mary Jo Dyck (559)592-7314

Clinical Oversight RCP.88 Revised Mary Jo Dyck (559)592-7314

Admission Policy RCP.86 Revised Mary Jo Dyck (559)592-7314

Medication Storage and Security RCP.68 Revised Mary Jo Dyck (559)592-7314

Kaweah Delta Lindsay Health Clinic Organizational Chart

LH. 303 Reviewed Mary Jo Dyck (559)592-7314

Suspected Child Abuse Reporting RCP.42 Deleted Mary Jo Dyck (559)592-7314

Recall of Medical Devices or Supplies RCP.70 Deleted Mary Jo Dyck (559)592-7314

Child Abuse/Neglect Reporting MH.13 Deleted Mary Jo Dyck (559)592-7314

General Policies, Rural Health Clinic

Policy Number: RCP.68 Date Created: No Date Set Document Owner: Maria Barba (Administrative Assistant)


Approvers: Board of Directors (Administration), Board of Directors (Rural Health Clinics), Pharmacy and Therapeutics, David Garrett (Dir Outpatient Health Clinics), William Roach (Family Medicine)

MEDICATION STORAGE AND SECURITY Printed copies are for reference only. Please refer to the electronic copy for the latest version. PURPOSE: To ensure the safety of patients. POLICY: All medications used in the Clinic are to be secured from patient access and stored

appropriately. PROCEDURE: 1) Pharmaceutical products must be locked at all times unless authorized staff is immediately within

the medication area. All medication cabinets are locked at all times. The Medication Room door will remain closed and if any cabinets are left unlocked, the door must be locked. Cabinets in the medication rooms have locks to permit locking in the event of a temporary situation in which the door is unlocked, under the supervision of authorized staff whose scope of practice allows access to medications.

2) Only authorized staff will have access to the medication room.

i) Medication containers for articles or preparations intended for injectable administration shall: (1) Ccontain a preservative and/or be intended for multi-use by the manufacturer (2) ; Bbe entered only with a sterile needle or a syringe with a blunt plastic cannula upon

each use of the vial; (3) Bbe labeled with an expiration date when first opened; to be discarded no later than

28 days from the date first opened or at the manufacturer’s expiration date, whichever occurs first; and

3)(4) Bbe inspected for evidence of break in sterility before each use. 3) All multi-dose injectable medication vials shall be considered to expire in (28) twenty eight days.

4) Discarding or disposing of pharmaceuticals:

Empty or expired multi-dose vials are to be discarded in the Pharmaceutical Waste

bin located in the medication room. Identified medication products will be disposed in the black waste bin in the

medication room. 4) Unopened pharmaceuticals will be returned to KD pharmacy.

5) Licensed staff is responsible for medication storage. The Nurse Manager ensures compliance for

each area.

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MEDICATION STORAGE AND SECURITY 2

6) All medication removed from the medication storage area for administration will be documented in the electronic medical record and a log entry made for inventory control of pharmaceuticals by lot number. which will then adjust the electronic inventory.

7) If temperatures of medication refrigerators or freezers are out of range and power is out with an

unknown time of returned power, the Nurse Manager will contact KDHCD Pharmacy for further instructions.

MEDICATION STORAGE AND SECURITY 3


Rural Health Clinic, Woodlake

Policy Number: WH.303 Date Created: No Date Set Document Owner: Maria Barba (Administrative Assistant)


Approvers: Board of Directors (Administration), Board of Directors (Rural Health Clinics), David Garrett (Dir Outpatient Health Clinics), William Roach (Family Medicine)

KAWEAH DELTA WOODLAKE HEALTH CLINIC ORGANIZATIONAL CHART Printed copies are for reference only. Please refer to the electronic copy for the latest version.

ORGANIZATIONAL CHART


Senior Vice President/CFO

Director of Rural Health Clinics Medical Director

LVN Supervisor

Clinic Manager

Medical Assistant

Medical Business Office Assistant

Clinic Business

Office Manager

PA / FNP

Clinic Operations Manager

LVN

KAWEAH DELTA WOODLAKE HEALTH CLINIC ORGANIZATIONAL CHART 2 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."





ABNORMAL RESULTS FOLLOW-UP Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: Provision for appropriate follow-up on all significant laboratory and physical findings,

abnormalities and treatment complications. Policy:

A. Patients who are portal enabled have access to lab results as soon as results are posted in the electronic health record.

B. Patients with “Confidential” status will not have an email address entered in their demographics in order to prevent inadvertent release of results to the portal.

C. Critical lab results are followed up with the provider upon receipt, but minimally within 1 hour.

D. Abnormal laboratory and imaging results are flagged within the electronic health record to alert the provider.

E. Results of abnormal findings shall be communicated to the patient within 30 days or less as indicated by clinical judgement based on the patient condition, lab, and criticality of level.

F. Significant findings or conditions will be addressed by providers or their designee. Follow up is required for:

1. Abnormal laboratory tests 2. Abnormal Imaging study findings

3. Surgical complications 4. Contraceptive and other treatment complications 5. Significant abnormal exam findings or disease conditions

Procedure: A. Setting- KDHCD Rural Health Clinic site B. Supervision- Direct physician supervision not required although consultation/referral may be indicated per protocols. C. Patient Circumstances- Follow up required for: 1. Reported abnormal laboratory tests (patient notification of results) 2. Surgical complications 3. Contraceptive and other treatment complications 4. Significant abnormal exam findings or disease conditions as indicated PROTOCOL A. Processes for AProcedure for aAll follow-up

1. Respect patient’s request for confidentiality a. Review electronic health record for a global confidential alert or if responsible

party is the clinic before contacting the patient.

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ABNORMAL RESULTS FOLLOW-UP 2

b. If mailing a copy of the result for a confidential patient, mail in a plain envelope with the PO Box as return address Mail- (Plain envelope with P.O Box number as return address, if follow-up). Review chart and account for confidential address.

2. Document all contacts and attempts to contact in patient’s medical record. 3. When initial contact is not successful, a minimum of two or more follow-up attempts

shall be made, including . At least one of these attempts shall be by mail. When the patient has specified no contact by mail, additional phone attempts should be made to find the patient by phone list.

4. A certified letter is necessary if all other contacts are unsuccessful and the patient has any abnormal results.

5. Three attempts to contact the patient are sufficient. Contact Police Department if deemed necessary by practitioner. All contact must be documented in chart.

5. All patients shall be instructed by the practitioner during the visit regarding when to return for routine follow-up, when to return if not improving.

B. Procedure for Abnormal Lab Results

1. All abnormal lLab values shall be reviewed by ordering clinician and marked reviewed. and placed in a chart. All attempts to notify patient shall be documented in the chart with clinicians’ “plan” for follow-up.

C. 2. Abnormal Pap Smears

1. a. Note Pap smear in appropriate section of Abnormal Pap Follow-up Tickler File

2. b. Note abnormal Pap and date of repeat Pap on tickler card. 3. c. Contact patient by mail with Pap form letter or by phone. After two unsuccessful

attempts, send a certified letter. Be sure to use plain envelope. Chart phone calls and or letters on Progress Notes (unsuccessful attempts also).

4. d. Check “Abnormal Pap Follow-up” tickler cards at the end of each month to be sure

clients due for repeat Paps have been in. Send Pap letter to notify patient that pap is due/overdue or call clients that have not shown.

D. 3. Colposcopy Clients

a1. Refer clients who meet abnormal Pap smear protocol guidelines to a KDHCD Rural Health Clinic colposcopy clinic or to an outside colpo provider.

2b. Charts are returned to referring clinician between colloposcopy visits if necessary.

3c. A tickler file of colposcopy clients will be kept by the designated PAP follow-up person.

E.4. Infectious Diseases

1a. Clients with positive tests are called by the provider or provider’s designee with findings and recommendations. designated follow-up person and given follow-up instruction. (See appropriate protocols).

2b. Notation of positive test is made on Problem Record. 3c. Notation of communication or attempts with client are made in the

patient’s record. on Progress Notes. a1) If unable to reach client within 7 days, contact public health department to advise of failure to contact client and need for follow-up. b2) Notify KD Infection Practitioner Control Nurse regarding patient case. with follow-up information, including where and when client is to be treated.

c 3) Send CMR form to Public Health Department. F5. Urine Cultures

1a. After review of medical records and evaluation of treatment, clients with positive cultures are called by the provider or provider’s designee follow-up person or clinician and given treatment instructions. (See UTI protocol)

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ABNORMAL RESULTS FOLLOW-UP 3

2b. Negative culture reports are placed in client’s chart. If client calls for information, pull chart and give appropriate information.

G.6. Blood Tests for high risk oral contraceptive users

1a. Ordering provider clinician will at each site to review panel results and the patient’s client’s medical history and clinical findings.

2b. The provider will Clinician to discuss recommendation for oral contraceptive use o.c. use and when test is to be repeated with patient upon follow-up visit and note in the patient’s medical recordon Problem Record.

3c. Physician assistants and nurse practiioners will consult with the supervising physician as needed per For abnormal results referral to appropriate protocols and M.D. consult if indicated by protocol or clinician’s judgment.

7. All other lab results will be reviewed by clinician and managed per protocol or referred to staff physician.

HC. Contraceptive Complications

1. To be followed up by provider to include consult with supervising physician or specialist clinician.

2. Consult with staff physician as indicated.

ID. Other significant Findings or Conditions Follow-up of any other significant findings or conditions and the documentation of follow up is the responsibility of the ordering provider. belongs to the Ordering Clinician. Appropriate entries in the follow-up log and client record is required of all clinicians, as well as staff MD’s.










PATIENT REFERRALS Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: To provide appropriate referral methods for KDHCD Rural Health Clinic patients who

require care that is beyond the scope of the clinic. Policy: To continue to offer quality care and maintain preventative health outcomes by

providing a patient referral for further evaluation and or treatment.

Procedure: A list of names of physicians and their specialties is maintained in the clinic. The

case management staff at KDHCD will be utilized for assistance as needed. Indications for Referral:

• Laboratory testing or diagnostic testing beyond clinic scope of services. • Clinical conditions requiring further evaluation. • Patients requesting additional examination and evaluation. • Surgical complications or medical conditions or medication reaction requiring emergency care

beyond the clinic scope. Procedure for Medical Referrals:

• Further care may be requested by the provider as an order or a referral, depending on the type of service to be requested. A referral may be entered as STAT, urgent or routine.

1. STAT: addressed by clinic staff in 24-48 hours 2. Urgent: addressed by clinic staff in 72 hours 3. Routine: addressed by clinic staff in 7 days

• All diagnostic, radiological, laboratory, therapeutic and other physician services shall be

provided by the appropriate department within Kaweah Delta Health Care District, from the list of referral physicians maintained at the clinic, physicians or health facilities recommended by the Case Management staff at KDHCD or to the physician or facility of the patient’s choice.

• Complete referral form with name of referral source, patients name and date of birth, clinical findings or problem, and clinician signature. Include copies of pertinent data to include labs or X-Ray and pathology reports. If a reply is desired, indicate such on the referral form. Fax referral form and all pertinent data to the specialist for patient to be seen.

• • Prior authorizations, if required, will be obtained for medical referrals by the clinic and

provided to the referred service together with the patient medical information.

• The clinic will mMake the appointment for patient and document in the electronic medical record the name of referring medical provider, the name of the facility or provider the patient

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PATIENT REFERRALS 2

is being referred to, date, and time of appointment and that patient was notified and any instructions given to patient.

• Complete referral form with name of referral source, patients name and date of birth, clinical

findings or problem, and clinician signature. Include copies of pertinent data to include labs or X-Ray and pathology reports. If a reply is desired, indicate such on the referral form. Fax referral form and all pertinent data to the specialist for patient to be seen.

• If the referral specialist or clinic staff encounters difficulty in finding a resource for the patient,

he/she will contact their supervisor and the clinic manager for direction. The KDHCD case management staff will also be consulted to assist in finding a viable resource for the patient.

• If a STAT appointment is not able to be secured as ordered, In cases where the referring

Physician indicates that the referral is STAT the appointment will be made within a seven day time frame. The referral specialist will, upon receipt of the referral, start the referral process immediately. If the specialist is unable to make an appointment, after after all known resources up to three attempts have been made, attempting three times, the specialist will contact the referring physician to notify him/her of the referral status. This is to be done before the seven-day time frame to make the appointment has been reached.

• The referral specialist will document the outcome of all calls pertaining to the referral in the

electronic medical record and . She/he will follow up on all referrals to make sure the patient attended the appointment. If the patient does not keep the appointment as scheduled, the referral specialist will notify the referring Provider via telephone encounter and close the referral. The referring provider may reenter make a new referral for the patient at a later date if desiredthe patient.

• When transferring a patient for emergency care or for a follow-up of a procedure performed at the clinic, a clinic physician or clinician will call the M.D., hospital, E.D., etc. to alert them with pertinent medical data and to make the referral.

PATIENT REFERRALS 3 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."





HAZARDOUS MATERIALS AND INFECTIOUS WASTE Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: To ensure basic principles of Infection Control / Hazardous Materials Waste within the

clinic. Policy: All clinic personnel are responsible to adhere to the applicable Infection Control /

Hazardous Materials Waste Policies and Procedures per the Kaweah Delta Health Care District Infection Control and MSDS Manuals.

MaxCom manual is also located on computers throughout the clinic. Hazardous waste is anything with blood or body fluids, including known infectious waste.

Procedure: Infectious waste is defined as hazardous waste. A. CONTAMINATED MATERIALS AND WASTE COLLECTION

1. Contaminated waste materials will be placed in a RED biohazardous container. 2. Biohazard waste is collected each day by the environmental services staff and

transferred to a secure location for pick up by the contracted vendor. bag and placed in the soiled section of the utility room until removed by the contracted

biohazardous service. 3. 2. The dDisposable instruments will be disposed of as biohazard contaminated

material. Reusable instruments will be sterilized at KDHCD Sterile Processing Department. See Sterilization of Instruments policy.

43. Non-biohazard contaminated materials will be removed by Housekeeping. 5. Waste containers cans in the clinical areas exam rooms will have foot step on lever

to open the lid.

B. SYRINGES, AND NEEDLES AND SHARPS 1. SharpsThese shall be of disposable material and discarded in rigid, leak

proof containers labeled “Bbio-hazardous” sharps container” 2. Sharps buckets will be picked up by the environmental services staff when at the full

line and removed from service by the clinical staff. 3. Sharps buckets are transferred immediately by environmental services staff to a

secure location for pick up by the contracted vendor. C. STANDARD PRECAUTIONS 1. Standard precautions will be used for all patient care. All patients will be handled utilizing universal body substance precautions. For further reference, see Hazardous Materials and Waste Management Program Manual.

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HAZARDOUS MATERIALS AND INFECTIOUS WASTE 2

HAZARDOUS MATERIALS AND INFECTIOUS WASTE 3 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."





GASES FOR MEDICAL USE Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: To ensure the safe use of medical gases. Policy: It is the policy of the KDHCD Rural Health Clinics that only portable oxygen and

cryogenic agents will be maintained within the clinic. Procedure: Portable oxygen is available in the clinic for urgent/emergent use as ordered by a

provider, as well as for patient comfort as ordered by a providerwill only be used in an emergency situation to sustain life or provide comfort for ultimate transfer of the patient to a higher level of care and must be ordered by a Provider.

Oxygen tanks will be stored on an appropriate portable stand.

Full tanks will be stored separate from empty fultanks and there will be clear identification of empty and full containers.

Oxygen tanks in the clinic will be checked weekly by authorized staff to ensure appropriate storage and safety of containers and that an adequate amount is available in the clinic. Tanks will be replaced when oxygen level falls below 1/4¾. A full replacement tank will be kept on site at all times.

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GASES FOR MEDICAL USE 2 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

General Policies: Rural Health Clinic:

Policy Number: RCP. 88 Date Created: 07/07/2016 Document Owner: Maria Barba (Administrative Assistant)


Approvers: Board of Directors (Administration), Cindy Moccio (Board Clerk/Exec Assist-CEO), David Garrett (Dir Outpatient Health Clinics), William Roach (Family Medicine)

Clinical Oversight Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: To establish guidelines for the consistent and comprehensive oversight and management of clinic locations. Policy:

1. Each clinic location will be staffed with a licensed vocational nurse . 2. The back office staff at each clinic location will be supervised by a licensed vocational nurse

supervisor, other than the Visalia Family Medicine Center (FMC), which is co-managed with the onsite clinic manager.

3. Daily operational oOversight, management and inspections is the responsibility of the LVN supervisor of assigned clinical sites.

Procedure:

1. Each clinic location will have at least a monthly site visit by the supervisor to conduct inspections and observations. This includes the following locations:

a. Lindsay b. Woodlake c. Dinuba d. Visalia FMC e. Exeter pediatrics f. Exeter women’s health g. Exeter family practice

2. Inspections Monthly inspections will include the following:

a. Medication management i. Check medication logs – ensure completed properly

ii. Check expirations iii. Follow up on high profile and high use medications

1. Reconcile medication inventory with the paper and electronic logs 2. Audit a sample of each medication in the patient record for order

and documentation of administration 3. The high profile and high use medications to be reconciled include

those directed by the clinical manager toradol and depo-medrol

Clinical Oversight 2

iv. VFC management 1. Verify that the lot numbers in stock are entered into the electronic

log and into the California Immunization Registry (CAIR) 2. Run a report on administrations and follow up if there are any

abberanciesaberrancies in the reconciliation of the inventory counts 3. Audit at least 2 charts to verify documentation in the record and

CAIR 4. Check supply orders to assure that the quantities ordered are

appropriate to the clinic utilization needs v. E-kit management

1. Log completed each day or a notation that the clinic was is closed 2. Lock # match 3. Prior month lock # noted

b. Supply management i. Supplies are stored properly, off floor

ii. Observe stock levels to contain overstock or understock iii. Check expiration dates

c. Sterile equipment management i. Supplies stored properly

ii. Check logs for sign out to central sterile and return iii. Question staff on concerns re: availability of sterile supplies to meet

provider needs d. Lab management

i. Check lab log use for send out labs ii. Check expiration dates on reagents

iii. Check control logs 1. Verify daily controls completed, signed off, etc.

e. Refrigerator and freezer management i. Check the logs

1. Correct log used, daily readings, out of range documented, closed noted on days clinic is closed, prior month lock # on log form

f. Documentation management i. Check that prior month logs are filed in binders

ii. Question staff regarding scanning documents process, completion of SHA, PM160’s, Disability determinations, etc to assure that documents are being processed timely

3. If there are discrepancies or incomplete tasks found, issues will be addressed on site the date immediately with the involved staff and the issues will be remediated. If additional follow up is required, a plan will be documented on the checklist.

4. The oversight monthly checklist will be completed and returned to the clinical manager as each inspection is completed. by the end of the month. The clinical manager will follow up


on concerns as necessary, including if the issue is recurring with a specific staff. Follow up will be determined based on the severity and re-occurring nature of the concern.

Monthly On Site Checklist KD Rural Health Clinics, FMC

Clinical Oversight 4 Month/Year________________ Completed by _______________________________________ Clinic Site __________________ Date(s) of site visit ____________________________________

Medication Management Frequency Area OK Comments/Follow

up if needed Remediation complete

Manager review

2x/m Medication logs completed properly

1x/m Expiration dates checked 2x/m High profile / high use med

reconciliation • Reconcile with

electronic and paper logs

• Audit sample

1x/m VFC • Lot # entered in EMR,

CAIR • Administration entered

in EMR and CAIR • Run report – f/u

discrepancies in inventory

• Audit a sample

2x/m E-kit • Integrity secure • Log completed ea day

or note closed • Lock # match • Prior mo lock # noted

Supply Management Frequency Area OK Comments/Follow


Manager review

1x/m Proper storage Stock levels appropriate

Expiration dates checked Sterile Equipment Management Frequency Area OK Comments/Follow


Manager review

2x/m

Proper storage Packaging integrity OK Logs utilized

Lab Management Frequency Area OK Comments/Follow


Manager review

1x/m

Logs utilized Expirations dates checked

Refrigerator and Freezer Management Frequency Area OK Comments/Follow


Manager review

2x/m Daily readings completed


Out of range and f/u “Closed” noted when clinic closed High/Low documentation for closed dates f/u

No food, appliance clean Documentation Management Frequency Area OK Comments/Follow


Manager review

1x/m Prior month logs in binder Documentation process

• Scanning turned in • Processing PM160,s

SHA, etc • Disabilities

SUPERVISOR NOTES: MANAGER NOTES:

Monthly On Site Checklist KD Rural Health Clinics, FMC

Exeter FP Exeter Peds Lindsay Woodlake Dinuba FMC Formatted Table

Clinical Oversight 6 January

February

March

April

May

June

July

August

September

October

November

December

I. Related Documents: Insert hyperlink here or delete if no existing related documents exist. References: "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

General Policies: Rural Health Clinic:

Policy Number: RCP. 86 Date Created: 06/28/2016 Document Owner: Maria Barba (Administrative Assistant)


Approvers: Board of Directors (Administration), Cindy Moccio (Board Clerk/Exec Assist-CEO), David Garrett (Dir Outpatient Health Clinics), William Roach (Family Medicine)

ADMISSION POLICY Printed copies are for reference only. Please refer to the electronic copy for the latest version. PURPOSE To establish standards and processes by which a patient can be evaluated and accepted for admission and orientation of new patients to the practice in a Kaweah Delta Health Care District (KDHCD) clinic site. Policy: A. As a recipient of Federal financial assistance, Kaweah Delta Health Clinics do Exeter Health Clinic

does not exclude, deny benefits to, or otherwise discriminate against any person on the ground of race, color, or national origin, or on the basis of disability or age in admission to, participation in, or receipt of the services and benefits under any of its programs and activities, whether carried out by Kaweah Delta Health Clinics Exeter Health Clinic directly or through a contractor or any other entity with which Kaweah Delta Health ClinicsExeter Health Clinic arranges to carry out its programs and activities.

Kaweah Delta Health Clinics include: 1. Exeter Health Clinic 2. Dinuba Health Clinic 3. Lindsay Health Clinic 4. Woodlake Health Clinic 5. Visalia Family Medicine Center A.B. Patients will be accepted for care without discrimination on the basis of race, religion, age,

gender, sexual orientation, disability (mental or physical), communicable disease, or place of national origin.

B.C. Patients will be accepted for care based on the adequacy and suitability of organization

personnel, resources to provide required services, and the reasonable expectation that the patient’s medical, nursing, rehabilitative, and social needs can be adequately met in the patient’s place of residence.

C.D. The patient will be referred to other resources if the organization cannot meet his/her needs. D.E. Once a patient is admitted to service, the organization will be responsible for providing care

and services within its financial and service capabilities, mission, and applicable law and regulations.

Procedure:

A. Acceptance of New Patients Patients seeking to establish care with a Kaweah Delta Health Clinic the Exeter KDHCD Clinic will select a provider as follows:

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ADMISSION POLICY 2

1. Prospective patients are informed that Kaweah Delta Health Clinics are KDHCD Exeter Clinic is not accepting patients for purposes of pain management.

2. Patients not on a managed care plan: i. The patient may call the clinic and ask to establish care with a provider of

choice. ii. If the requested provider’s panel is not open, the patient will be offered other

available provider options. 3. Patients on a managed care plan:

i. The patient may select one of the KDHCD providers from a list of enrolled providers provided by the health plan.

ii. Some payers allow the patient to select the clinic site as the primary care clinic; patients will be offered available provider options with the next available openings offered first.

B. Orientation Process for New Patients A new patient chart packet will be used to orient new patients to the clinic. Contents are as follows:

1. Patient Information Forms a. Registration form b. Medical history form c. Authorization for Photo ID d. Conditions of Admission e. Patient Privacy Notice

2. Patient welcome letter 3. Patient Centered Medical Home Introduction 4. Clinic Brochure 5. For Pediatrics: Car Seat Information

Related Documents: Insert hyperlink here or delete if no existing related documents exist. References: "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."




Approvers: Board of Directors (Administration), Board of Directors (Rural Health Clinics), Pharmacy and Therapeutics, David Garrett (Dir Outpatient Health Clinics), William Roach (Family Medicine)

MEDICATION STORAGE AND SECURITY Printed copies are for reference only. Please refer to the electronic copy for the latest version. PURPOSE: To ensure the safety of patients. POLICY: All medications used in the Clinic are to be secured from patient access and stored

appropriately. PROCEDURE: 1) Pharmaceutical products must be locked at all times unless authorized staff is immediately within

the medication area. All medication cabinets are locked at all times. The Medication Room door will remain closed and if any cabinets are left unlocked, the door must be locked. Cabinets in the medication rooms have locks to permit locking in the event of a temporary situation in which the door is unlocked, under the supervision of authorized staff whose scope of practice allows access to medications.

2) Only authorized staff will have access to the medication room.

i) Medication containers for articles or preparations intended for injectable administration shall: (1) Ccontain a preservative and/or be intended for multi-use by the manufacturer (2) ; Bbe entered only with a sterile needle or a syringe with a blunt plastic cannula upon

each use of the vial; (3) Bbe labeled with an expiration date when first opened; to be discarded no later than

28 days from the date first opened or at the manufacturer’s expiration date, whichever occurs first; and

3)(4) Bbe inspected for evidence of break in sterility before each use. 3) All multi-dose injectable medication vials shall be considered to expire in (28) twenty eight days.

4) Discarding or disposing of pharmaceuticals:

• Empty or expired multi-dose vials are to be discarded in the Pharmaceutical Waste

bin located in the medication room. • Identified medication products will be disposed in the black waste bin in the

medication room. 4)• Unopened pharmaceuticals will be returned to KD pharmacy.

5) Licensed staff is responsible for medication storage. The Nurse Manager ensures compliance for

each area. 6) All medication removed from the medication storage area for administration will be documented in

the electronic medical record and a log entry made for inventory control of pharmaceuticals by lot number. which will then adjust the electronic inventory.

Formatted

Formatted




Formatted: Not Highlight







MEDICATION STORAGE AND SECURITY 2 7) If temperatures of medication refrigerators or freezers are out of range and power is out with an

unknown time of returned power, the Nurse Manager will contact KDHCD Pharmacy for further instructions.

MEDICATION STORAGE AND SECURITY 3 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

APPENDIX D

POLICY SUBMISSION SUMMARY

Manual Name: Lab General Date 9/15/2017 Support Staff Name: Lorrie Anderson Policy/Procedure Title: Policy/Procedure # Status

(New, Revised, Reviewed, Deleted)

Name & Phone # of Person who wrote new

policy or revised one Turnaround Time and Frequency for In-house Testing

LG-00032 Revised Lorrie Anderson x5027

Competency Assessment Policy

LG-00014 Revised Lorrie Anderson x5027

Novius Lab Computer Backup

LC00005 Reviewed Lorrie Anderson x5027

Lab Document Control Procedure

LG-00019 Reviewed Lorrie Anderson x5027

--Nursing--, Clinical Laboratory, Lab General

Policy Number: LG-00032 Date Created: No Date Set

Document Owner: Lorrie Anderson (CLS Analyst-

IT)



Turn Around Time and Frequency for Inhouse Testing


POLICY: In order to assure that work on critical patients is performed as quickly as

possible, the laboratory provides STAT testing, which is available to all physicians. Tests

are performeddone on a “first come, first served” basis. Time is measured from receipt of

the specimen in the laboratory to the release of results. Nursing Uunits will be called

in the event of testing delays.

I.

I. To establish lLaboratory testing expectations are set as follows:.

TEST NAME FREQUENCY CUT OFF TIME TURN-AROUND

ABO, RH DAILY 24/7 NONE 2-6 HOURS

ACETAMINOPHEN DAILY 24/7 NONE 2-6 HOURS

AFP –TUMOR MARKER DAILY 24/7 NONE 2-6 HOURS

ALBUMIN DAILY 24/7 NONE 2-6 HOURS

ALCOHOL DAILY 24/7 NONE 2-6 HOURS

ALK P-TASE DAILY 24/7 NONE 2-6 HOURS

AMMONIA DAILY 24/7 NONE 2-6 HOURS

AMYLASE DAILY 24/7 NONE 2-6 HOURS

AMYLASE URINE DAILY 24/7 NONE 2-6 HOURS

ANA SCREEN MWF BATCH 1X 1000 HRS NEXT DAY

ANTIBODY SCREEN DAILY 24/7 NONE 2-6 HOURS

APT FETAL HgB DAILY 24/7 NONE 2-6 HOURS

BACT AG GRP B ONLY (CIE) CSF DAILY 24/7 NONE 2-6 HOURS

BACT AG GRP B ONLY (CIE) SERUM DAILY 24/7 NONE 2-6 HOURS

BACT AG GRP B ONLY (CIE) URINE DAILY 24/7 NONE 2-6 HOURS

BACTERIAL AG (CIE) CSF DAILY 24/7 NONE 2-6 HOURS

BACTERIAL AG (CIE) SERUM DAILY 24/7 NONE 2-6 HOURS

BACTERIAL AG (CIE) URINE DAILY 24/7 NONE 2-6 HOURS

BASIC METABOLIC PANEL DAILY 24/7 NONE 2-6 HOURS

BILIRUBIN DIRECT DAILY 24/7 NONE 2-6 HOURS

BILIRUBIN TOTAL DAILY 24/7 NONE 2-6 HOURS

BLOOD CULTURE ADULT DAILY 24/7 NONE 5 DAYS

BLOOD CULTURE PEDIATRIC DAILY 24/7 NONE 5 DAYS

BLOOD CULTURE YEAST DAILY 24/7 NONE 14 DAYS

BLOOD GAS ARTERIAL DAILY 24/7 NONE 1-2 HOURS

BLOOD PARASITES DAILY 24/7 NONE 2-6 HOURS

BNP (BRAIN NATRIUPENIC PEPTID) DAILY 24/7 NONE 2-6 HOURS

BUN DAILY 24/7 NONE 2-6 HOURS

Turn Around Time and Frequency for Inhouse Testing 2


C DIFFICILE TOXIN A & B DAILY BATCH 1 X NONE NEXT DAY

CA 15-3 DAILY 24/7 NONE 2-6 HOURS

CA 19-9 DAILY 24/7 NONE 2-6 HOURS

CA 125 DAILY 24/7 NONE 2-6 HOURS

CALCIUM DAILY 24/7 NONE 2-6 HOURS

CALCIUM URINE DAILY 24/7 NONE 2-6 HOURS

CAPD FLUID CELL COUNT DAILY 24/7 NONE 2-6 HOURS

CAPD FLUID CULTURE DAILY 24/7 NONE 3 DAYS

CARBAMAZAPINE DAILY 24/7 NONE 2-6 HOURS

CARBON DIOXIDE DAILY 24/7 NONE 2-6 HOURS

CARBON MONOXIDE DAILY 24/7 NONE 2-6 HOURS

CBC W/DIFFERENTIAL DAILY 24/7 NONE 2-6 HOURS

CBC-HEMOGRAM DAILY 24/7 NONE 2-6 HOURS

CEA DAILY 24/7 NONE 2-6 HOURS

CHLAMYDIA/GC TUE/FRI 0600 HRS NEXT DAY

CHLORIDE DAILY 24/7 NONE 2-6 HOURS

CHLORIDE URINE DAILY 24/7 NONE 2-6 HOURS

CHOLESTEROL DAILY 24/7 NONE 2-6 HOURS

CKMB DAILY 24/7 NONE 2-6 HOURS

COCCI – CSF/ COCCI SERUM IgG, IgM MWF 0800 HRS 2-6 HOURS

COMPLEMENT C3 DAILY 24/7 NONE 2-6 HOURS

COMPLEMENT C4 DAILY 24/7 NONE 2-6 HOURS

CORD BLOOD – ABO, RH , D COOMBS DAILY 24/7 NONE 2-6 HOURS

CORONARY RISK/LIPID PANEL DAILY 24/7 NONE 2-6 HOURS

CORTISOL DAILY 24/7 NONE 2-6 HOURS

CPK DAILY 24/7 NONE 2-6 HOURS

C-REACTIVE PROTEIN DAILY 24/7 NONE 2-6 HOURS

CREATININE DAILY 24/7 NONE 2-6 HOURS

CREATININE URINE DAILY 24/7 NONE 2-6 HOURS

CREATININE CLEARANCE 12 HR DAILY 24/7 NONE 2-6 HOURS

CREATININE CLEARANCE 24 HR DAILY 24/7 NONE 2-6 HOURS

CRYPTOCOCCUS ANTIGEN QUAL DAILY BATCH 1 X YES STAT NEXT DAY

CRYPTOCOCCUS ANTIGEN TITER DAILY BATCH 1 X 1500 HRS NEXT DAY

CRYPTOSPORID/GIARDIA DFA DAILY BATCH 1 X 1500 HRS NEXT DAY

CRYSTAL ID DAILY 24/7 NONE 2-6 HOURS

CSF ANALYSIS = CELL CT, PRO, GLU DAILY 24/7 NONE 2-6 HOURS

CSF CELL COUNT DAILY 24/7 NONE 2-6 HOURS

CSF CULTURE DAILY 24/7 NONE 3 DAYS

CULTURE AEROBIC NO GRAM STAIN DAILY 24/7 NONE 3 DAYS

CULTURE AEROBIC WITH G/S DAILY 24/7 NONE 3 DAYS

CULTURE CAMPYLOBACTER DAILY 24/7 NONE 3 DAYS

CULTURE FUNGUS DAILY 24/7 NONE 4-6 WEEKS

CULTURE GENITAL DAILY 24/7 NONE 3 DAYS

CULTURE GRP B STREP GENITAL DAILY 24/7 NONE 3 DAYS

CULTURE QUANT LOWER RESP DAILY 24/7 NONE 3 DAYS

CULTURE RESPIRATORY DAILY 24/7 NONE 3 DAYS

CULTURE STOOL DAILY 24/7 NONE 3 DAYS

CULTURE STOOL E0157:H7 DAILY 24/7 NONE 3 DAYS

CULTURE THROAT BHS DAILY 24/7 NONE 3 DAYS

CULTURE THROAT-NASOPHARYNX DAILY 24/7 NONE 3 DAYS

CULTURE URINE DAILY 24/7 NONE 3 DAYS

D DIMER DAILY 24/7 NONE 2-6 HOURS



DIGOXIN DAILY 24/7 NONE 2-6 HOURS

DIRECT COOMBS DAILY 24/7 NONE 2-6 HOURS

DRUG SCREEN QUAL URINE DAILY 24/7 NONE 2-6 HOURS

ELECTROLYTES PANEL DAILY 24/7 NONE 2-6 HOURS

EOSINOPHIL SMEAR URINE DAILY 24/7 NONE 2-6 HOURS

FERRITIN DAILY 24/7 NONE 2-6 HOURS

FETAL FIBRONECTIN DAILY 24/7 NONE 2-6 HOURS

FIBRINOGEN DAILY 24/7 NONE 2-6 HOURS

FOLIC ACID DAILY 24/7 NONE 2-6 HOURS

FREE T-3 DAILY 24/7 NONE 2-6 HOURS

FREE T-4 DAILY 24/7 NONE 2-6 HOURS

FSH DAILY 24/7 NONE 2-6 HOURS

GAMMA GT DAILY 24/7 NONE 2-6 HOURS

GENERAL HEALTH PANEL DAILY 24/7 NONE 2-6 HOURS

GENTAMYCIN DAILY 24/7 NONE 2-6 HOURS

GLUCOSE DAILY 24/7 NONE 2-6 HOURS

GLUCOSE CSF DAILY 24/7 NONE 2-6 HOURS

GLUCOSE MISC FLUID DAILY 24/7 NONE 2-6 HOURS

GLUCOSE TOLERANCE MON - SAT OP 1100 HRS 2-6 HOURS

GLUCOSE URINE RANDOM OR 24 HR DAILY 24/7 NONE 2-6 HOURS

GR A STREP SCREEN DAILY 24/7 NONE 2-6 HOURS

GRAM STAIN DAILY 24/7 NONE 2-6 HOURS

H. PYLORI AB DAILY AM SHIFT NONE 2-6 HOURS

HA1C DAILY 24/7 NONE 2-6 HOURS

HC03 VENOUS DAILY 24/7 NONE 2-6 HOURS

HCG QUAL SERUM DAILY 24/7 NONE 2-6 HOURS

HCG QUAL URINE DAILY 24/7 NONE 2-6 HOURS

HCG QUANT/TUMOR MARKER DAILY 24/7 NONE 2-6 HOURS

HDL CHOLESTEROL DAILY 24/7 NONE 2-6 HOURS

HEPARIN ANTIBODY DAILY AM SHIFT 1200 HRS (NOON) < 24 HOURS

HEPATITIS A IgM M – F BATCH 1 X 1200 HRS (NOON) NEXT DAY

HEPATITIS B CORE IgM M - F BATCH 1 X 1200 HRS (NOON) NEXT DAY

HEPAPITIS B SURF AB - HBSAB M - F BATCH 1 X 1200 HRS (NOON) NEXT DAY

HEPAPITIS B SURF AG - HBSAG M - F BATCH 1X

STAT 2E - 24/7

1200 HRS (NOON) NEXT DAY

HEPATITIS C IgG M - F BATCH 1 X 1200 HRS (NOON) NEXT DAY

HEPATITIS PANEL M - F BATCH 1 X 1200 HRS (NOON) NEXT DAY

IMMUNOGLOBULIN IgA TU/FRI BATCH 1 X 1000 HRS NEXT DAY

IMMUNOGLOBULIN IgG TU/FRI BATCH 1 X 1000 HRS NEXT DAY

IMMUNOGLOBULIN IgM TU/FRI BATCH 1 X 1000 HRS NEXT DAY

INFLUENZA A & B ANTIGEN DAILY 24/7 NONE 2-6 HOURS

IRON DAILY 24/7 NONE 2-6 HOURS

IRON BINDING TOTAL/TRANSFERRIN DAILY 24/7 NONE 2-6 HOURS

KETONE (ACETONE) DAILY 24/7 NONE 2-6 HOURS

KLEIHAUER BETKE DAILY 24/7 NONE 2-6 HOURS

LACTIC ACID DAILY 24/7 NONE 2-6 HOURS

LDH DAILY 24/7 NONE 2-6 HOURS

LDH MISC FLUID DAILY 24/7 NONE 2-6 HOURS

LDL CHOLESTEROL DAILY 24/7 NONE 2-6 HOURS

LEGIONELLA ANTIGEN URINE BATCH DAILY 1X NONE NEXT DAY

LIPASE DAILY 24/7 NONE 2-6 HOURS

LITHIUM DAILY 24/7 NONE 2-6 HOURS



LIVER PANEL DAILY 24/7 NONE 2-6 HOURS

LUTEINIZING HORMONE (LH) DAILY 24/7 NONE 2-6 HOURS

MAGNESIUM DAILY 24/7 NONE 2-6 HOURS

MAGNESIUM MISC FLUID DAILY 24/7 NONE 2-6 HOURS

METABOLIC PANEL DAILY 24/7 NONE 2-6 HOURS

MICROALBUMIN URINE DAILY 24/7 NONE 2-6 HOURS

MISC BODY FLUID - CELL CT DAILY 24/7 NONE 2-6 HOURS

MIXING STUDY (LUPUS ANTICOAG) DAILY 24/7 NONE 2-6 HOURS

MONO TEST DAILY 24/7 NONE 2-6 HOURS

MONOCLONAL GAMMOPATHY (IEP) M/TH BATCH 1 X 0700 HRS NEXT DAY

MYCOPLASMA IGM AB SCREEN BATCH DAILY 1X 0500 HRS NEXT DAY

MYOGLOBIN SCREEN DAILY 24/7 NONE 2-6 HOURS

OCCULT BLOOD GASTRIC DAILY 24/7 NONE 2-6 HOURS

OCCULT BLOOD- STOOL DAILY 24/7 NONE 2-6 HOURS

OSMOLALITY SERUM OR URINE DAILY 24/7 NONE 2-6 HOURS

OVA & PARASITES PANEL BATCH DAILY 1 X 1500 HRS 5 DAYS

PCO2 VENOUS DAILY 24/7 NONE 2-6 HOURS

PFA – PLATELET FUNCTION ASSAY DAILY 24/7 NONE 2-6 HOURS

PH MISC FLUID DAILY 24/7 NONE 2-6 HOURS

PH VENOUS DAILY 24/7 NONE 2-6 HOURS

PHENOBARBITAL DAILY 24/7 NONE 2-6 HOURS

PHENYTOIN DILANTIN DAILY 24/7 NONE 2-6 HOURS

PHOSPHORUS DAILY 24/7 NONE 2-6 HOURS

PHOSPHORUS URINE RANDOM OR 24 HR DAILY 24/7 NONE 2-6 HOURS

POTASSIUM DAILY 24/7 NONE 2-6 HOURS

POTASSIUM MISC FLUID DAILY 24/7 NONE 2-6 HOURS

POTASSIUM URINE RANDOM OR 24 HR DAILY 24/7 NONE 2-6 HOURS

PREALBUMIN DAILY 24/7 NONE 2-6 HOURS

PRENATAL PANEL MWF BATCH 1X 1200 HRS NEXT DAY

PROCALCITONIN DAILY 24/7 NONE 2-6 HOURS

PROLACTIN DAILY 24/7 NONE 2-6 HOURS

PROTEIN CSF DAILY 24/7 NONE 2-6 HOURS

PROTEIN ELECTROPHORESIS (PEP) M/TH BATCH 1X 0700 HRS NEXT DAY

PROTEIN MISC FLUID DAILY 24/7 NONE 2-6 HOURS

PROTEIN, TOTAL DAILY 24/7 NONE 2-6 HOURS

PROTEIN URINE DAILY 24/7 NONE 2-6 HOURS

PSA DAILY 24/7 NONE 2-6 HOURS

PTH – PARATHYROID HORMONE DAILY 24/7 NONE 2-6 HOURS

PT – PROTHROMBIN DAILY 24/7 NONE 2-6 HOURS

PTT PARTIAL THROMBOPLASTIN TIME DAILY 24/7 NONE 2-6 HOURS

REDUCING SUBSTANCE DAILY 24/7 NONE 2-6 HOURS

RENAL PANEL I, BASIC METABOLIC

PANEL

DAILY 24/7 NONE 2-6 HOURS

RENAL PANEL II DAILY 24/7 NONE 2-6 HOURS

RETICULOCYTE COUNT DAILY 24/7 NONE 2-6 HOURS

RHEUMATOID FACTOR – RA DAILY 24/7 NONE 2-6 HOURS

RH TITER M - F BATCH 1X 1400 HRS NEXT DAY

ROTAVIRUS AG SCREEN BATCH DAILY 1X NONE NEXT DAY

RPR MWF BATCH 1X 0500 HRS NEXT DAY

RSV VIRUS DAILY 24/7 NONE 2-6 HOURS

RUBELLA IGG DAILY 24/7 NONE 2-6 HOURS

SALICYLATE DAILY 24/7 NONE 2-6 HOURS



SED RATE WESTERGREN DAILY 24/7 NONE 2-6 HOURS

SEMEN ANALYSIS APPT ONLY M-F 0730-1100 ONLY NEXT DAY

SGOT (AST) DAILY 24/7 NONE 2-6 HOURS

SGPT (ALT) DAILY 24/7 NONE 2-6 HOURS

SKIN TEST TB (PPD) BATCH DAILY 1X NONE 3 DAYS

SODIUM DAILY 24/7 NONE 2-6 HOURS

SODIUM MISC FLUID DAILY 24/7 NONE 2-6 HOURS

SODIUM URINE DAILY 24/7 NONE 2-6 HOURS

SPECIFIC GRAVITY MISC FLUID DAILY 24/7 NONE 2-6 HOURS

SYNOVIAL FLUID ANALYSIS – CELL CT DAILY 24/7 NONE 2-6 HOURS

T3 FREE DAILY 24/7 NONE 2-6 HOURS

T3 TOTAL DAILY 24/7 NONE 2-6 HOURS

T3 UPTAKE DAILY 24/7 NONE 2-6 HOURS

T4 DAILY 24/7 NONE 2-6 HOURS

T4 FREE DAILY 24/7 NONE 2-6 HOURS

TEG DAILY 24/7 NONE 2-6 HOURS

TESTOSTERONE DAILY 24/7 NONE 2-6 HOURS

THEOPHYLLINE DAILY 24/7 NONE 2-6 HOURS

THYROID PANEL (TSH, T4, FT4) DAILY 24/7 NONE 2-6 HOURS

THYROID REFLEX DAILY 24/7 NONE 2-6 HOURS

TOBRAMYCIN DAILY 24/7 NONE 2-6 HOURS

TRIGLYCERIDES DAILY 24/7 NONE 2-6 HOURS

TROPONIN I DAILY 24/7 NONE 2-6 HOURS

TSH DAILY 24/7 NONE 2-6 HOURS

TYPE AND CROSS MATCH DAILY 24/7 NONE 2-6 HOURS

TYPE AND SCREEN DAILY 24/7 NONE 2-6 HOURS

UREA NITROGEN MISC FLUID DAILY 24/7 NONE 2-6 HOURS

UREA NITROGEN URINE DAILY 24/7 NONE 2-6 HOURS

UREA REDUCTION DAILY 24/7 NONE 2-6 HOURS

URIC ACID DAILY 24/7 NONE 2-6 HOURS

URIC ACID URINE DAILY 24/7 NONE 2-6 HOURS

URINALYSIS COMPLETE DAILY 24/7 NONE 2-6 HOURS

VAGINITIS PANEL BY DIR. PROBE BATCH DAILY 1 X NONE NEXT DAY

VALPORIC ACID DEPAKOTE DAILY 24/7 NONE 2-6 HOURS

VANCOMYCIN DAILY 24/7 NONE 2-6 HOURS

VIRAL AB SCREEN (HIV) M-F BATCH 1 X 1200 HRS (NOON) NEXT DAY

VITAMIN B12 DAILY 24/7 NONE 2-6 HOURS

WET MOUNT – KOH DAILY 24/7 NONE 2-6 HOURS

WET MOUNT-SALINE DAILY 24/7 NONE 2-6 HOURS

Revised:2/6/2014

"These guidelines, procedures, or policies, herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

Clinical Laboratory, Lab General

Policy Number: LG-00014 Date Created: 02/01/2014

Document Owner: Lorrie Anderson (CLS Analyst-

IT)


Approvers: Board of Directors (Administration), David Hewitt (Pathology), Randall Kokka

(Director of Laboratory)

Competency Assessment Policy


Competency assessment shall be conducted for all staff performing testing to assure that each

individual performing testing receives regular in-service training and education appropriate

for the type and complexity of lab testing performed.

The frequency of competency assessment will be compatible with CLIA ’88 requirements,

which state that for non-waived testing, employees must be assessed at least semi-annually

during the first year of hire, 6 months after hire and then annually thereafter, to assure

theythat staff maintain their competency to perform test procedures and report test results

promptly, accurately and proficiently.

Evaluating the competency of all testing personnel and assuring that the staff maintain their competency to perform test procedures and report test results promptly, accurately and proficiently. The procedures for staff competency evaluation of the competency of the staff must include, but are not limited to, the following verification methods:—

1. Direct observation of routine patient test performance, including as applicable: patient

identification and preparation, and specimen collection, handling, processing and

testing.

2. Monitoring the recording and reporting of test results, including the reporting of

critical results.

3. Review of intermediate test results or worksheets, quality control records, proficiency

testing results and preventative maintenance records.

4. Direct observation of performance of instrument maintenance and function checks.

5. Assessment of test performance through testing previously analyzed specimens,

internal blind testing samples, or external proficiency samples.

6. Evaluation of problem-solving skills.

(i) Direct observations of routine patient test performance, patient preparation,

specimen handling, specimen processing and testing;

(ii) Monitoring the recording and reporting of test results;

(iii) Review of intermediate test results or worksheets, quality control records,

proficiency testing results, and preventive maintenance records;

(iv) Direct observation of performance of instrument maintenance and function

Competency Assessment Policy 2

checks;

(v) Assessment of test performance through testing previously analyzed

specimens, internal blind testing samples or external proficiency testing

samples; and

(vi) Assessment of problem solving skills; and

Evaluations must be performed at least annually unless test methodology or instrumentation

changes, in which case, prior to reporting patient test results, If test methodology, or

instrumentation changes, the individual's performance must be re-evaluated to include the use

of the new test methodology or instrumentation prior to reporting patient test results.

Continuing Education

The lab policy on continuing education is to follow the State of California continuing

education requirements found in Title 17 public health section 1038.1. for Clinical Lab

Scientists, section 1030.1.2 for Certified Phlebotomy Technician I and 1030.1.3 for Certified

Phlebotomy Technician II. These persons will submit to the State of California their

continuing education documentation for license and certificate renewal. Their certificate or

license will suffice as proof that the State requirement was met. No continuing education is

required for non-licensed personnel. "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."


Manual Name: Human Resources Date: 10/17/17 VP Human Resources: Dianne Cox

Policy Title

#


Reviewed, Deleted)

Comments

District Commitment & Staff Member Relations

HR.02 Revised Added language to combine with HR.90, Staff Member Relations.

Equal Employment Opportunity

HR.12 Revised Added language for legal compliance on protected classes.

Reasonable Accommodation & Medical Fitness for Work

HR.16 Revised Added language to combine with HR.108, Medical Fitness

Grievance

HR.215 Revised Renewed and updated.

Transfers

HR.31 Revised Modified to cannot transfer for one year.

Progressive Discipline HR.216 Revised Reviewed and updated.

Separation from Employment

HR.220 Revised Reviewed and updated.

Employee reduction in force or reassignment resulting in

demotion

HR.221 Revised Reviewed and updated; changed to allow employees to receive severance while looking for transfers.

Introductory Period

HR.37 Revised Modified by legal to include “at will” language.

Staff Member Relations HR.90 Deleted Merged policy with HR.02, District Commitment

Medical Fitness for Current Employees

HR.108 Deleted Merged policy with HR.16, Reasonable Accommodation

Involuntary Termination HR.217 Deleted Merged policy with HR.220, Separation of Employment.

Human Resources, Human Resources

Policy Number: HR.02 Date Created: 06/01/2007 Document Owner: Dianne Cox (VP Human Resources)


Approvers: Board of Directors (Administration), Dianne Cox (VP Human Resources)

District Commitment & Staff Member Relations Printed copies are for reference only. Please refer to the electronic copy for the latest version. POLICY: The District's believes culture that the best and most rewarding employment atmosphere results from a direct relationship between management and staff members. The District prefers to deal with staff members directly. It is the responsibility of management to encourage staff members to bring their problems and suggestions to their department management team or another member of management,; listen to staff member's concerns with respect,; make every effort to help solve staff member's problems,; and, accept constructive criticism with an open mind and without any retribution. The District will implement fair and effective Human Resources policies and procedures to:

• equal opportunity (Refer to policy HR.12 Equal Employment

Opportunity).employ individuals on the basis of their qualifications and with assurance of equal opportunity (Refer to policy HR.12).and treatment regardless of race, religion, color, sex, sexual preference, age, national origin, veteran status, (GINA) Genetic Information Non-discrimination Act, disability, marital status, medical condition, pregnancy, citizenship, physical condition, mental disability;

• provide salaries and benefits which bear a fair and reasonable

relationship to the work performed;

• establish reasonable hours of work; and,

• maintain a work environment that is safe, healthy, and free from harassment.

• Kaweah Delta Health Care District promotes staff awareness of

appropriate rest and fitness to provide patient care services.

• Kaweah Delta Health Care District recognizes that staff may be requested to work additional hours beyond their regularly-scheduled work hours in the event of a staffing short, patient emergency and/or activation of the District’s disaster plan.

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District Commitment 2

The District expects all personnel to:

• work productively to the best of their abilities and skills;

• arrive at their assigned work area and begin work on time;

• demonstrate a considerate, friendly, and constructive attitude to other

personnel, patients, and visitors; and,

• comply with Behavioral Standards and Code of Conduct.

• adopt and display the District Values in all interactions with others including:

Vision - We plan for and act to produce an ever-

improving future. Integrity - We are completely honest, candid, and

transparent in our dealings. Care - The patient must be at the center of all we do. Accountability - We are completely responsible for our

results – no excuses. Respect - We collaborate effectively with others and

are socially and interpersonally skilled. Excellence - We accept nothing less than our very best

efforts and expect the same of others. The District retains the right to:

• assign, supervise, discipline, and terminate employees at any time;

• determine and change working conditions, hours and schedules; and,

• establish, change, and delete its policies and procedures.






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District Commitment 3 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."




Approvers: Board of Directors (Administration), Dianne CoxDebbie Wood (VP Human Resources)

Equal Employment Opportunity Printed copies are for reference only. Please refer to the electronic copy for the latest version. POLICY: The District maintains a policy of nondiscrimination with all

employees and applicants for employment. All aspects of employment with the District will be governed on the basis of merit, competence, and qualifications. All decisions made with respect to recruiting, hiring, and/or promotion for all job classifications will be made solely on the basis of individual qualifications related to the requirements of the position. Likewise, the administration of all other human resource matters such as compensation, benefits, transfers, reduction-in-force, recall, training, education, and social or recreational programs will be free from illegal discriminatory practices.

Under no circumstance will aspects of employment with the

District be governed or influenced by race, color, creed, religion, sex, age, national origin, ancestry, marital status, perceived or actual disability, veteran status,(GINA) Genetic Information Non-discrimination Act, perceived or actual sexual orientation, perceived or actual pregnancy, medical condition, physical condition, citizenship, mental disability, or upon any other basis made unlawful by federal, state, or local ordinance or regulation. This policy also extends to medical condition, as defined by the California Fair Employment and Housing Act (FEHA) and to disability, as defined by the Americans with Disability Act (ADA). The District will provide reasonable accommodation for qualifying medical conditions and/or disabilities.

In accordance with California AB 1443 the District will not

tolerate discrimination against any person in the selection, termination, training, or other terms or treatment of that person in an unpaid internship, or another limited duration program to provide unpaid work experience for that person, or the harassment of an unpaid intern or volunteer because of any of the protected categories Kaweah Delta Health Care District maintains a policy of nondiscrimination with employees and applicants for employment, student interns and volunteers.

Equal Employment Opportunity 2

District policy prohibits unlawful discrimination or retaliation based on:

Race, color, religion, religious creed (including religious

dress and grooming), sex, (including breastfeeding and related medical conditions), those who identify as transgender, transgender transitioning, gender expression, gender roles, gender identity, sexual harassment, victim of domestic violence, sexual assault or stalking, national origin, disability, mental health conditions such as depression and post-traumatic stress disorder, genetic information (GINA Act of 2008), equal pay/compensation, pregnancy, age, or any other characteristic protected by law;

Retaliation against an individual for filing a charge of discrimination, participating in an investigation, opposing discriminatory practices, and/or coverage under the State’s Whistleblower Statute (prohibiting employers from retaliating against employees who report a violation to their employer, rather than the government, protecting employees from “anticipatory retaliation,” expanding the protections of the law to include individuals who disclose the information/make the complaint as part of their job duties, covering employees who report violations of local laws, and covering employees who provide information to public bodies).

Retaliation against an employee who is a family member of a person who has or is perceived to have engaged in protected activities such as managing complaints about working conditions, pay, or whistleblowing;

Retaliation against employees who request a religious or disability accommodation regardless of whether the accommodation is granted;

Employment decisions based on stereotypes or assumptions about the abilities, traits, or performance of individuals of a certain sex, race, age, religion, or ethnic group, or individuals with disabilities;

Denying employment opportunities to a person because of marriage to, or association with, an individual of a particular race, religion, national origin, or an individual with a disability. Discrimination is also prohibited because of participation in schools or places of worship associated with a particular racial, ethnic, or religious group;

Same-sex marriages;

Any other consideration made unlawful by Federal, State or local laws.

All aspects of pre-employment and employment within the District will be governed on the basis of merit, competence, and qualifications. Decisions made with respect to recruitment, hiring and job placement for all positions will be made solely on the basis of the individual qualifications related to the requirements of the position. Likewise, the administration of all other personnel matters such as compensation, assignment, or classification of employees; transfer, promotion, termination, layoff, or recall; job advertisements; testing; use

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of company facilities; training and apprenticeship programs; fringe benefits; pay, retirement plans, and disability leave; discharge; or other terms and conditions of employment will be free from illegal discriminatory practices. In accordance with California AB 1443 the District will not tolerate discrimination against any person in the selection, termination, training, or other terms or treatment of that person in an unpaid internship, or another limited duration program to provide unpaid work experience for that person, or the harassment of an unpaid intern or volunteer because of any of the protected categories.

To comply with applicable laws ensuring equal employment opportunities to qualified individuals with a disability, the District will make reasonable accommodations for known physical or mental limitations of a1515n otherwise qualified individual with a disability who is an applicant or an employee, unless undue hardship would result. A leave of absence may be considered as a type of reasonable accommodation. Any applicant or employee who requires an accommodation in order to perform the essential functions of the job should contact their supervisor, department head, or Human Resources and make a request to participate in a timely interactive process to explore reasonable accommodations. The individual with the disability is invited to identify what accommodation he or she needs to perform the job. The District will take steps to identify the barriers that make it difficult for the applicant or employee to perform his or her job, and will identify possible accommodations, if any, that will enable the individual to perform the essential functions of his or her job. If the accommodation is reasonable and will not impose an undue hardship, the District will meet the request.

The District is committed to complying with all applicable laws providing equal employment opportunities. This commitment applies to all persons involved in the operations of the District and prohibits unlawful discrimination by any employee of the District, including management personnel, supervisors, co-workers and third parties.

If an employee believes that they have been subjected to any form of unlawful harassment or discrimination, they are to report their concerns to any District department head, manager, supervisor, Vice President, the CEO or the Vice President of Human Resources of the District as soon as possible after the incident. The concerns should include details of the incident or incidents, names of the individuals involved and names of any witnesses. It is helpful that any such reports of harassment be in writing so that there is no misunderstanding as to the nature of the conduct in question. Department heads, managers or supervisors will refer all harassment complaints to the Vice CEO of Human Resources or the CEO. The District will immediately undertake an effective, thorough and objective investigation of the harassment or discrimination allegations.

If the District determines that a violation of this policy has occurred, effective remedial action will be taken in accordance with the circumstances involved. Any employee determined by the District to have violated this policy will be subject to appropriate Disciplinary Action, up to and including termination of


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employment. The District will not retaliate against an employee for filing a complaint and will not tolerate or permit known retaliation by management, employees or co-workers.

The District encourages all employees to report any incidents of harassment or discrimination forbidden by this policy immediately so that complaints and concerns can be quickly and fairly resolved.

ADDITIONAL INFORMATION: 1. Human Resources will be responsible for formulating, implementing,

coordinating and monitoring all efforts in the area of EEO. Human Resource duties relating to EEO compliance will include, but is not necessarily limited to:

a. assisting management in collecting and analyzing employment data;

b. collecting necessary information and completing an Employer

Information Report (EEO-4) for annual submission to the government; c. developing policy statements and recruitment procedures designed to

comply with the District's equal employment philosophy; and

d. complying with various reporting requirements and posting notices required to ensure full compliance with all employment-related laws and regulations.

2. Human Resources will also provide all applicants for employment a California

Employment Applicant Data Form and maintain those forms in a place separate from applications and/or Personnel files.

3. Any communication from an applicant for employment, an employee, a

government agency or an attorney concerning any Equal Employment Opportunity (EEO) matter will be referred to the Vice PresidentCEO of Human Resources.

Any questions regarding the interpretation of this manual should be referred to the Vice President of Human Resources. No changes will be made in any policy and procedure or any deviations authorized without the express written permission of the CEO.

Kaweah Delta complies with all requirements of the Americans

With Disabilities Act (ADA). If an employee requires an accommodation under the ADA the employee should contact his or her immediate supervisor/manager or contact the Human Resources Department. Supervisors/managers who receive a request for an accommodation should immediately notify the Human Resources (HR) Department. A HR Representative will contact the employee to begin an interactive process which could include but is not limited to the mailing of forms that the


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employee must complete to assess the request for accommodation. Please see policy entitled Reasonable Accommodation, (HR 16) for more information on accommodation.

Retaliation for reporting suspected violations of this policy or for

filing a complaint, testifying or assisting in any proceeding involving allegations of unlawful discrimination is also prohibited.

PROCEDURE: I. Responsibility of Human Resources Vice President or

Designee The Vice President of Human Resources or designee

has the responsibility to receive, investigate, and resolve complaints involving violations of this policy and to recommend the imposition of appropriate discipline.

The Vice President of Human Resources or designee will

conduct a thorough, objective, and complete investigation of the alleged discrimination; will make a determination, based on the investigation, whether unlawful discrimination occurred; and will communicate his/her findings to the concerned parties.

In cases involving member(s) of the Medical Staff, the

Vice President of Human Resources or designee will report the matter to the Chief Medical Officer. The Chief Medical Officer will report the allegation to the Chief of Staff.

II. Responsibility of Management Management is responsible for assisting and supporting

the Human Resources Department with its investigation, including maintaining the confidentiality of information and ensuring no retaliatory action is taken.

In cases where the complaint of unlawful discrimination is

founded, District management is responsible for taking prompt and immediate action to remedy the situation and to ensure that it does not reoccur.

Any and all disciplinary action taken will be commensurate with

the severity of the offense. Please see policy entitled GRIEVANCE PROCEDURE, (HR. 215) for the process of reporting concerns.


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Equal Employment Opportunity 7 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."




Approvers: Board of Directors (Administration), Debbie Wood (VP Human Resources)

Reasonable Accommodation & Medical Fitness for Work Printed copies are for reference only. Please refer to the electronic copy for the latest version. POLICY: It is the policy of Kaweah Delta Health Care District (“KDHCD) to comply with

the Americans with Disabilities Act (ADA), the Fair Employment and Housing Act (FEHA), and the comprehensive civil rights laws that prohibit discrimination against a qualified applicant or employee because of his/her disability. Under the ADA and FEHA, qualified individuals with disabilities must have equal access to all aspects of employment that are available to employees without disabilities. The District also complies with the Labor Commissioner’s office with regard to the rights of victims of domestic violence, sexual assault and stalking.

Pursuant to the ADA and FEHA, KDHCD will provide reasonable accommodation to a qualified applicant and/or employee with a disability to allow him/her to perform the essential functions of his/her job, unless the accommodation would create an undue hardship for the employer.

KDHCD willKDHCD will not discriminate against any qualified employee or job applicant with respect to any terms, privileges, or conditions of employment because of a person's physical or mental disability. KDHCD will take steps to ensure that all staff members are medically able, with or without reasonable accommodation, to perform the duties and responsibilities expected of and assigned to him/her. At any time during the employment relationship, if management has reason to believe that the District personnel is not free of communicable disease, or is not able to perform the duties and responsibilities to which s/he is assigned, s/he may be asked to report to Employee Health Services and/or to a licensed medical practitioner of the District’s choice for a medical examination. The District will be responsible for the cost of this examination.

DEFINITIONS: Reasonable Accommodation: Reasonable accommodation can be considered as the logical adjustment to a job or work environment that enables a disabled person or an individual who is a victim of domestic violence, sexual assault or stalking to perform the essential functions of his/her job. KDHCD is required to provide reasonable accommodation for qualified individuals with physical or mental limitations including mental health conditions such as depression and post-traumatic stress disorder. Reasonable accommodation includes, but is not limited to:

• Modifications or adjustments to an application, examination, or interview process that will enable a qualified applicant with a disability to be considered for the desired position; or

Reasonable Accommodation 2

• Modifications or adjustments to the work environment, or to the method under which the position held or desired is routinely performed, that enables a qualified individual with a disability to perform the essential functions of that position; or

• Modifications or adjustments that will enable an employee with a disability to enjoy the same benefits and privileges of employment as those enjoyed by similarly situated employees without disabilities.

KDHCD may choose to provide an alternative accommodation other than the one requested by the employee, as long as it is effective in assisting the employee in performing his/her essential job functions. Each reasonable accommodation situation is evaluated on a case-by-case basis; so that the accommodation provided meets the needs of the individual with the disability, and will allow him/her to perform the essential functions of his/her job. Examples of Reasonable accommodation may include any or all of the following:

• Purchase of an assistive device

• Worksite modifications

• Job restructuring

• Reassignment to another position

• Removal of an architectural barrier

• Purchase of assistive services

• Modified work schedule

• Removal of communication barrier

• Special testing/Interview arrangements

• Leave of absence

Essential Functions: Essential functions are the tasks that are fundamental to the job. A job function may be considered essential for any of the following reasons:

• The position exists to perform the function. • The function is highly specialized and the employee in the

position was hired for his/her expertise in performing the function.

• There are a limited number of employees to whom the performance of the function can be assigned.

Individual With a Disability: An individual is considered to be disabled if he/she:

• Has a permanent physical or mental impairment that limits the performance of one or more major life activities; or

• Has a record of such an impairment; or • Is regarded as having such impairment.

Physical or Mental Impairment: Physical or mental impairment includes, but is not limited to any physiological disorder or condition, cosmetic disfigurement, anatomical loss affecting one or more of the body systems, or any mental or psychological disorder. Examples of conditions that would constitute disabilities because they limit a major life activity include paralysis, hearing or vision loss, epilepsy, and cancer.

Reasonable Accommodation 3 Major Life Activities: Major life activities include self care, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working. The list of major life activities is not exhaustive.

Functional limitations: Determining whether a functional limitation in performing essential functions exists due to a physical or mental impairment is the first step in establishing whether an individual is entitled to a reasonable accommodation. Many impairments do not impact a person's life to the extent of limiting a major life activity. An impairment rises to the level of limiting a major life activity when it makes the performance of a major life activity difficult. When evaluating a reasonable accommodation request, KDHCD considers several factors in assessing the functional limitation(s) a physical or mental impairment causes in performing essential functions: • The specific physical or mental limitation or medical condition which requires an accommodation; • The duration or expected duration of the impairment; and • The permanent or long-term impact, or the expected permanent or long-term impact of, or resulting from, the impairment.

REQUESTING REASONABLE ACCOMMODATION1:

I. Notice: KDHCD has established procedures for requesting a reasonable accommodation to ensure there is an interactive process with the individual requesting such an accommodation. Employees are encouraged to utilize the “Reasonable Accommodation Request Form (see attachment A) to ensure all of the necessary information is included. However, written requests for accommodation are not required.

An applicant or employee who believes that s/he is in need of an accommodation must notify his/her department manager or director and/or a Human Resources Director. A department manager or director who receives a request for accommodation from an employee shall then notify a Human Resources and/or Employee Health. Director within 24 hours. The Director of Human Resources will notify the Employee Health Manager of the request within 24 hours.

All requests for reasonable accommodation, whether written or verbal, must provide the following information:

A. The type of accommodation requested;

B. An explanation of the limitation for which the accommodation is needed; and

C. A description of how the accommodation will allow the individual to perform the essential functions of his/her job.

If an employee notifies their manager or director of their disability without an explanation or request for a reasonable accommodation the manager/director must notify a Human Resources Director and/or the Employee Health Manager to insure notice of the disability is appropriately documented and the employee is assessed to determine if an accommodation is appropriate or feasible. There may be times where the District may be unable to provide an accommodation, including situations which impose an undue hardship on the District or present an undue risk to the health and safety of the individual, other employees or patients.

If a manager or director encounters an employee situation where he/she suspects the employee has a problem that may require reasonable accommodation but, where there has not been a request for reasonable accommodation, the manager/director must notify a Human Resources Director and/or the Employee Health Manager to

1 This procedure is neither exhaustive nor exclusive. The District is committed to taking all other actions necessary to ensure equal employment opportunity for persons with disabilities in accordance with the ADA, FEHA and all other applicable federal, state, and local laws.

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assess the employee to appropriately document any disability and to determine if an accommodation is appropriate or feasible.

II. Medical Documentation

A. The applicant or employee seeking reasonable accommodation may be required to provide Human Resources with medical documentation from his/her treating health care provider regarding the medical condition for which the employee is requesting accommodation in order to evaluate his/her eligibility for an accommodation. The documentation must include the following information regarding the employee’s medical condition:

(1) major life activities hindered and the manner in which each activity is hindered; (2) whether the medical condition is permanent or temporary; (3) the estimated length of the medical condition (if the medical condition is temporary); (4) the functional limitations as they relate to the employee’s job duties and the impact on the individual’s ability to perform the essential job functions; and (5) the type(s) of reasonable accommodation requested for the employee and how it will help the employee to perform his/her essential job duties. The documentation should not include the underlying medical condition at issue unless specifically requested by a physician working on behalf of the District.

B. Any medical information requested from the applicant’s or

employee’s health care provider(s) will be kept in a confidential reasonable accommodation file and will only be used to determine whether the employee requesting the reasonable accommodation meets the definition of a disabled individual as defined under relevant federal and/or state law, and what accommodation, if any, may be medically appropriate and feasible.

D. The medical documentation must be written/typed on the official

letterhead stationary of the health professional or health professional’s organization. The documentation must identify the health professional’s credentials (e.g., M.D., D.O, N.P., P.A.) and practice specialty (e.g., Physician, Nurse Practitioner, Physical Therapist) and be signed and dated by the health professional.

III. The Director of Human Resources and the Manager of Employee Health will provide

guidance to managers, directors, and persons requesting reasonable accommodation at all stages of the process. The Director of Human Resources will evaluate each reasonable accommodation request on a case-by-case basis. The decision to grant or deny a request for accommodation will be made only after considering all essential information, including but not limited to input from the employee, his/her supervisor, and his/her health professional. The individual requesting an accommodation is not automatically entitled to the accommodation he/she requests; however, an individual may refuse an accommodation offered by KDHCD.

Current employees are expected to continue to perform all essential job functions while a request for reasonable accommodation is being considered. If that is not possible, the employee may request a leave of absence. A request for a leave of absence which is granted is considered an accommodation. IV. Interactive Process: Within five (5) work days of receivingAs soon as reasonably possible

upon receiving a request for reasonable accommodation by a disabled employee or applicant, KDHCD and its representatives must engage in a timely, good faith, interactive process to determine effective reasonable accommodations. To ensure that all effective

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accommodations have been considered, the Director of Human Resources and the employee’s manager must discuss the request with the employee. This is particularly important when the specific limitation, problem, or barrier is unclear; where effective accommodation is not obvious; where modifications to the request may be appropriate; where the parties are choosing between different possible reasonable accommodations; or in other situations where the interactive process can further promote resolution of the request for accommodation. The interactive process should take place in person, unless it is impractical to do so. The interactive process with the employee or applicant shall include, but is not limited to:

A. Discussing the purpose and the essential functions of the specific position; B. A review of the medical documentation and other documentation related to the

request; C. Reviewing how the functional limitations of the disability can be overcome with

reasonable accommodation; D. Identifying potential accommodation options; E. Evaluating the effectiveness of each potential accommodation option; F. Documenting all options discussed and reasons for selecting particular option(s); G. Implementing the most appropriate option(s), after consulting with the

“Reasonable Accommodation Team” which shall include the Vice President of Human Resources or his/her designee, the employee, the employee’s manager and may include any of the following Employee Health Manager, , a Physical Therapist, Occupational Therapist, a representative of EAP); and

H.G. Keeping the applicant or employee informed until accommodation is provided or denied.

I.H. Whether the reasonable accommodation would impose an undue hardship on the District or present an undue risk to the health and safety of the individual, other employees or patients.

1. The applicant/employee is expected to cooperate in the interactive process, in good faith, by submitting medical information as necessary and participating in discussions regarding possible accommodations. Failure to comply with this policy will result in denial of an accommodation request and/or a determination that the employee is unable to perform the essential functions of his or her job.

V. THE ONGOING INTERACTIVE PROCESS KDHCD is required to make reasonable accommodations for qualified persons with disabilities. The duty to accommodate is a continuing duty that is not exhausted by one effort. If KDHCD becomes aware that an accommodation is not working, it must consider alternative accommodations. The Vice President of Human Resources or his/her designee and the manager must further engage in the interactive process with the employee to identify appropriate accommodations, as discussed above. Prior to any substantive modification or adjustment of a previously granted accommodation, the Vice President of Human Resources must be consulted. Furthermore, prior to the denial of any newly requested accommodation, the Vice-President of Human Resources must also be consulted.

VI. GRIEVANCE PROCESS

Any persons who believe that he or she has been subjected to discrimination on the basis of disability and/or has been treated in a manner that is contrary to the policy stated above, may file a complaint with the Human Resources department. Complaints should be in writing and set forth the problem or action alleged to be discriminatory as well as the remedy or relief sought by the complainant. Human Resources will conduct an investigation of the complaint and take any and all necessary action arising out of the complaint. The District will not retaliate against anyone who files a complaint or cooperates in the investigation of a complaint.


Reasonable Accommodation 7 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."





Grievance Procedure Printed copies are for reference only. Please refer to the electronic copy for the latest version. POLICY: Problems Concerns, issues or questions occasionally arise

during the course of employment. When this occurs, employees are encouraged to discuss these matters with management. If the situation remains unresolved, employees will be provided with an opportunity to appeal management decisions through a formal grievance procedure. Employees using the Grievance Procedure will not be penalized retaliated against for doing so.

DEFINITION A grievance is defined as an employee’s expressed feeling of

dissatisfaction with an action taken on behalf of the District. , or that the District has violated any of its written policies or procedures, Examples of actions that may by grieved under this policy include:

• Incorrect or inconsistent application or interpretation of the District’s policies (not the policies themselves);

• Disagreement with a written level warning. 1. Those reviewing the employee’s grievance and the

circumstances of the grievance will only discuss the matter with those individuals involved, the assigned Human Resources representative and the appropriate management staff.

2. Time spent by aggrieved employees in grievance

discussions with management during their normal working hours will be considered hours worked for payroll purposes. In addition, the grievant may be paid for up to one (1) hour of scheduled and approved counseling with Human Resources Department staff.

3. The grievance may not be changed or altered by the

employee or the manager while being heard from step to

Grievance Procedure 2

step. Certain portions of a complex grievance may be dropped by the employee if satisfied with the outcome.

4. All steps of the grievance are coordinated by a Human

Resources representative. Therefore, all responses should be routed through the Human Resources representative assigned to the grievance.

5. Decisions on grievances will be neither precedent setting

nor binding on future grievances unless they are officially stated as District policy.

6. If there is a finding in the employee's favor, the Grievance

Procedure will be used to provide relief for the employee. The Human Resources Department will specify what relief is appropriate, if any. Awards will not exceed lost wages.

7. The Human Resources Department will maintain a

continuous grievance file with copies of all grievances processed.

8. The employee and the manager involved will ensure that the facts presented in the grievance are truthful and to the best of their knowledge.

9. Employees are responsible for ensuring that their grievance is processed

until they are satisfied with the decision or until their right of appeal is exhausted. Human Resources will facilitate the process.

8. In cases where the grievance is in relation to a division

reporting to the Vice President of Human Resources, a Senior Vice President will serve in place of the Vice President of Human Resources.

PROCEDURE: A. The employee must initiate the Grievance

Procedure to seek formal consideration. To do so, the employee must contact the Human Resources Department to initiate the first step in the procedure. Upon initial contact, the employee will be provided a copy of this Grievance Policy and will receive instruction as to the appropriate format in which the written grievance must be submitted.

B. The grievance must be filed within 10 days of

when the employee became aware, or reasonably should have been aware of the facts and circumstances arising to the grievance.

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Grievance Procedure 3

C. Management will receive the grievance from Human Resources and will investigate the matter to attempt resolution. Management will prepare and forward their response, in the approved format, to the Human Resources representative within seven (7) working days or as soon as reasonably possible.

D. The Human Resources representative will forward

management’s response to the employee.

E. If the aggrieved employee is not satisfied with management's decision, the employee will be permitted to appeal to the Vice President of Human Resources within seven (7) working days.

F. The Human Resources representative will forward

the Vice President of Human Resources response within seven (7) working days to the employee or as soon as reasonably possible.

G. This decision will be final and binding on both the

aggrieved employee and the District for the specified grievance only and to the extent allowable by law.

H. Time limits for both the employee and

management may be extended at any step by Human Resources, upon a showing of good cause.

NOT APPLICABLE TO THE GRIEVANCE PROCESS:

Concerns of illegal action should be forwarded to Human Resources for immediate action. The Grievance Procedure is not the appropriate action in these cases. Examples of concerns regarding illegal actions include:

• Alleged discrimination because of race, color, sex,

age, disability, religion, national origin, marital status, or any other factor(s) unrelated to qualification or job performance;

• Alleged refusal to engage in an interactive process

and/or accommodate a disability; and,

• Improper or unfair administration of staff member benefit plans.

Grievance Procedure 4 The Grievance Procedure described herein is not applicable to

an employee whose proposed discipline is demotion, suspension for more than five (5) days or termination or whose employment with the District has terminated regardless of the reason for the termination. However, employees whose proposed discipline is suspension for more than five (5) days, demotion or involuntary termination may be entitled to a Pre-determination hearing, may have certain appeal rights and should refer to HR.218 NOTIFICATION REQUIREMENTS AND APPEAL PROCESS FOR INVOLUNTARY TERMINATION AND DEMOTION.

Grievance Procedure 5 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."




Approvers: Board of Directors (Administration), Dianne Cox (VP Human Resources)

Transfers Printed copies are for reference only. Please refer to the electronic copy for the latest version. POLICY: Employees of the District may be transferred from one department or location to another, either at their own request or as a result of a decision by management. Reasons for transfer may include, but will not necessarily be limited to, fluctuations in department workloads, more efficient utilization of personnel, career opportunities, health or personal situations. An employee's eligibility for transfer is generally determined by the requirements of the new job, the employee’s disciplinary record and upon successful completion of their six-month introductory period. The six-month introductory period requirement may be waived with approval of both the current manager/director of the employee and the manager/director of the employee of the new department. Before accepting an employee for a transfer, the manager is required to review the employee’s file in Human Resources and discuss performance issues with the employee’s current manager. Employees interested in a transfer are required to discuss their transfer request with their current manager/director. PROCEDURE: I. Definition

A transfer is defined as a move from one department or work area to another within the same job classification (i.e. R.N. in Emergency to R.N. in Childbirth Center); or a move from one job classification to a different job classification; or a combination of both.

II. Eligibility

Employees desiring a transfer to another department or job are eligible for consideration for any posted position. To be considered, the employee must complete an online application.


Transfers 2

Internal candidates will be subject to the same screening as external candidates.

In cases where their qualifications and experience and results of interview(s) are substantially equal, current employees will be offered new employment opportunities over offers to outside applicants.

III. Performance Appraisal Review Dates

Refer to PERFORMANCE MANAGEMENT PROGRAM AND COMPETENCY ASSESSMENT PROGRAM (HR.213). A. Change in Department, No Change in Classification

In cases where the staff member changed department but did not change job classification, i.e., R.N. in Emergency to R.N. in Childbirth Center, the annual performance review date will remain unchanged and become due on the same date as it was due prior to the transfer. When the staff member's performance review is due, it will be completed by the current supervisor in concert with the former supervisor. The staff member will be eligible for merit increase and/or merit lump-sum provided they otherwise meet the eligibility criteria for increase.

POLICY: Employees of Kaweah Delta Health Care District who have successfully completed one year of employment in their current position may request a transfer to a posted position. Employees must complete an online Employment Application. The one-year employment requirement may be waived with approval of both department leadership and Human Resources.

Employees may initiate a transfer request when in Disciplinary Action, as long as the potential department leader is made aware of all performance issues.

Each request for transfer will be reviewed, comparing the employee’s qualifications with the requirements of the job. If two or more applicants are equally qualified for the position, preference will be given to in-house employees. When two or more equally qualified in-house employees are being considered for the position, past performance and length of service will contribute to the final decision. PROCEDURE:

1. Employees who have successfully completed one year of employment may apply for any posted position by completing an Employment Application. The one year period may be waived with the approval of the involved department leadership and/or vice presidents.

2. All employee transfers will be processed in the following manner:

a. Each request will be sent to the hiring department leader, who will compare the employee’s qualifications with the requirements of the job. The review includes a Human Resources file check for past performance and current or previous disciplinary action.





Transfers 3

b. The most qualified candidates will be interviewed. c. It is the employee’s responsibility to notify his/her supervisor that he/she is a

final candidate when confirmed a pending job offer. This discussion must occur prior to finalization of the transfer request.

3. A minimum of two to four weeks written notice will be given by the employee to the

present supervisor. The actual length of time between written notice and the transfer will be determined jointly by the employee’s prior and new department leaders.

4. The rate of pay will be determined in accordance with the current Compensation

Program.

a. If employee transfers with same rate of pay, there is no change in the annual performance evaluation date.

b. If employee receives a higher rate of pay with transfer, the annual performance evaluation date changes to one year from date of transfer.

5. Human Resources is responsible for initiating a status change form to transfer the employee, completing the appropriate sections of the form.


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Approvers: Board of Directors (Administration), HR Advisory Committee Dianne Cox (VP of Human Resources)

Progressive Discipline Printed copies are for reference only. Please refer to the electronic copy for the latest version. POLICY: It is the policy of tThe District to uses positive measures and a process of progressive discipline to address resolve employee performance and/or behavioral problems. However, tThe District recognizes that the circumstances of each situation must be evaluated individually to determine whether to discipline progressively or to impose more advanced discipline immediately. This policy applies to all District employees. The primary purpose of Disciplinary Action is to assure compliance with policies, procedures and/or Behavioral Standards of Performance of the District. Orderly and efficient operation of our District requires that employees maintain appropriate proper standards of conduct and service excellence. Maintaining proper standards of conduct is necessary to protect the health and safety of all patients, employees, and visitors, to maintain uninterrupted operations, and to protect the District’s goodwill and property. Because the purpose of disciplinary action is to addressaffect performance issues, it should be administered as soon after the incident(s)offense as possible. Therefore, an employee who violates District policies, procedures and/or instructions of management will, depending on the seriousness of the offense and all pertinent facts and circumstances, disciplinary action will be administered promptly. be subject promptly to disciplinary action, including verbal and/or written warnings, suspension, and/or termination of employment. Certain violations are considered “major” and require more immediate and severe action such as suspension and/or termination. “Lesser” violations will generallynormally be subject to Progressive Discipline. This policy applies to all District employees. Employees may initiate a transfer request when in Disciplinary Action, as long as the potential department leader is made aware of all performance issues.

Any employee who is in Progressive Discipline is not eligible for transfer or promotion within the District without review and approval by the hiring manager and Human Resources.


Progressive Discipline 2 Progressive Discipline shall be the application of corrective measures by increasing degrees, designed to assist the employee to understand and comply with the required expectations of performance. All performance of an employee will be considered when applying Progressive Discipline. In its sole discretion, tThe District reserves the right to deviate from Progressive Discipline or act without Progressive Discipline whenever it determines that the circumstances warrant. PROCEDURE:

I. The process of Progressive Discipline may include the following, depending on the seriousness of the offense and all pertinent facts and circumstances: a. Warnings

i. Verbal Warning:

A Verbal Warning explains why the employee’s conduct/performance is unacceptable and what is necessary to correct the conduct/performance. This written record of the verbal warning typically remains in the department manager’s/supervisor’s confidential files unless more serious discipline follows.

ii. Written Warning: A Written Warning provides the nature of the issue and outlines the expectations of performance/conduct or what is necessary to correct the situation. This Warning becomes part of the employee’s personnel file, along with any pertinent back-up documentation available, and will inform the employee that failure to meet the job standards/requirements of the Warning will necessitate further disciplinary action, up to and including termination. The department management, in concert with Human Resources, determines the level of corrective disciplinary action that will take place based upon the seriousness of the offense, the existence of any prior disciplinary actions and the entirety of the employee’s work record.

1. Level I Any employee who receives a Level I is subject to further Written Warnings as stated in this policy.

2. Level II

Progressive Discipline 3

Any employee who receives a Level II is subject to further Written Warnings as stated in this policy.

3. Level III A Level III is considered Final Written Warning to the employee involved, and includes a written explanation of what is necessary to meet the expectation of performance. A Level III Warning may be accompanied by a suspension. A suspension may be without pay and is generally up to five days or forty hours.

b. Administrative Leave In the discretion of the District, aAn employee may be placed on Administrative Leave with or without pay at any time to give the District time to conduct an investigation or for other circumstances considered appropriate by the District. Management may impose an Administrative Leave at any time for an employee(s) if they believe there is a risk to employee or patient safety. Management will notify Human Resources immediately if an Administrative Leave is enforcedapplied. When an employee is placed on Administrative Leave, t The District will make every effort attempt to complete thean investigation of the matter within five business days. If the District is unable to complete an investigation of the matter within five days the Administrative Leave may be extended. After the investigation has been completed, the employee may be returned to work and, in the discretion of the District and depending on the circumstances, may be reimbursed for all or part of the period of the leave. If the employee is reinstated following the investigation, and found without fault, there will be full reimbursement of pay for the period of the leave. If it is determined that the employee should be terminated, compensation may, in the discretion of the District, will be paid until the Post Determination Review process has been completed. (See policy HR.218 Notification Requirements, Pre-Determination Process And Appeal Process for Involuntary Termination, Suspension Without Pay For More Than Five Days And Demotion).

c. Dismissal Without Prior Disciplinary History As noted, the District may determine, in its sole discretion, that the employee’s conduct or performance Instances of extreme misconduct may warrant dismissal without prior Progressive Discipline. Examples of conduct that may warrant immediate dismissal, suspension or demotion include actsActs that endanger others, job abandonment, and misappropriation of District resources. This is not an exclusive list and other types of misconduct/poor performance, may also result in


immediate dismissal, suspension or demotion. See Employee Conduct below. are examples of conduct sufficient to lead directly to a decision to terminate, suspend or demote.

d. Employee ConductCauses for Dismissal Without Prior Disciplinary History (“Major Violations”) This list of prohibited conduct is illustrative only; other types of conduct injurious to security, personal safety, employee welfare or the District’s operations may also be prohibited. This includes behavior or behaviors that undermine a culture of safety. Employee conduct that will be subject to Progressive Discipline up to and including immediate involuntary termination of employment includes but is not limited to:To provide employees with some guidelines concerning unacceptable behavior, the following are examples of “major violations.” Employees who engage in misconduct or whose performance is unsatisfactory will be subject to disciplinary action, up to and including termination. It should be noted, however, that it is impossible to provide an exhaustive list of types of conduct that are impermissible. The list below is, therefore, intended simply to provide some examples.

i. Falsifying or altering of any record (e.g., employment application, medical history form, work records, time cards, business or patient records and/or charts).

ii. Giving false or misleading information during a Human Resources investigation;

iii. Theft of property or inappropriate removal from premises or

unauthorized possession of property that belongs to the District, employees, patients, or their families or visitors;

iv. Damaging or defacing materials or property of the District,

employees, patients, or their families or visitors;

v. Possession, distribution, sale, diversion, or use of alcohol or any unlawful drug while on duty or while on District premises, or reporting to work or operating a company vehicle under the influence of alcohol or any unlawful drug;

vi. Fighting, initiating a fight, threats, abusive or vulgar language,

intimidation or coercion or attempting bodily injury to another person on District property or while on duty. Reference policy HR.202 Workforceplace Violence Prevention;

vii. Workplace bullying which can adversely affect an employee’s

work or work environment, Reference policy HR.13 Anti-Harassment and Abusive Conduct.214 Abusive Conduct;


viii. Bringing or possessing firearms, weapons, or any other hazardous or dangerous devices on District property without proper authorization;

ix. Endangering the life, safety, or health of others;

x. Intentional violation of patients’ rights (e.g., as stated in Title

XXII);

xi. Insubordination and/or refusal to carry out a reasonable directive issued by an employee’s manager (inappropriate communication as to content, tone, and/or language);

xii. Communicating confidential District or Medical Staff information,

except as required to fulfill job duties;

xiii. Sleeping or giving the appearance of sleeping while on the jobduty;

xiv. An act of sexual harassment as defined in the policy entitled

Anti-Sexual or Unlawful Harassment and Abusive Conduct HR.13;

xv. Improper or unauthorized use of District property or facilities;

xvi. Improper access to or use of the computer system or breach of

password security;

xvii. Improper access, communication, disclosure, or other use of patient information. Accessing medical records with no business need is a violation of state and federal law and as such is considered a terminable offense by KDHCD. Each case where employees are determined to have inappropriately accessed a medical record will be reviewed by the District Compliance and Privacy Officer or designee and Human Resources to determine appropriate disciplinary action the minimum of which will be a Level III with suspension or termination.

e. “Lesser Violations”

To provide employees with some guidelines concerning unacceptable behavior, the following are examples of “lesser” violations. “Lesser” violations are generally not alone the basis for dismissal, but several instances of lesser violations or a lesser violation after an incident of serious misconduct may result in termination. It should be noted, however, that it is impossible to provide an exhaustive list of types of conduct that are impermissible. The list below is, therefore, intended simply to provide some examples.



i.xviii. Unreliable attendance (See Attendance and Punctuality HR.184);

ii.xix. Violations of the District Behavioral Standards of Performance.;

xx. Unintentional breaches and/or disclosures of patient information may be a violation of patient privacy laws. Unintentional breaches and/or disclosures include misdirecting patient information to the wrong intended party via fax transmission, mailing or by face-to-face interactions.; The District Compliance and Privacy Officer or designee and Human Resources will determine the appropriate disciplinary action level for each case where employees are determined to have misdirected patient information.

xxi. Access to personal or family PHI is prohibited.;

xxii. Refusing to care for patients in the event mandated staffing

ratios are exceeded due to a healthcare emergency;.

xxiii. Working off the clock at any time. For the convenience of the employees, the District allows staff to clock in before their start time. However, employees are not permitted to work until their scheduled start time.;

xxiv. Failure to work overtime;.

xxv. Use of personal cell phones while on duty and unrelated to job

duties anywhere in the District. Cell phones are to be stored in a secure location while on duty.;

xxvi. Excessive or inappropriate use of the telephone, cell phones,

computer systems, email, internet or intranet.;

xxvii. Any criminal conduct off the job that reflects adversely on the District;.

xxviii. Making entries on another employee’s time record or allowing

someone else to misuse the District’s timekeeping system.;

xxix. Bringing children to work, or leaving children unattended on District premises during the work time of the employee;.

xxx. Immoral or inappropriate conduct on District property;.

xxxi. Unprofessional, rude, intimidating, condescending, or abrupt

verbal communication or body language.;

xxxii. Unsatisfactory job performance.;

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xxxiii. Horseplay or any other action that disrupts work,;

xxxiv. Smoking within the District and/or in violation of the policy.;

xxxv. Failure to report an accident involving a patient, visitor or employee.;

xxxvi. Absence from work without proper notification or adequate

explanation, leaving the assigned work area without permission from the supervisor, or absence of three or more days without notice or authorization;.

xxxvii. Unauthorized gambling on District premises.;

xxxviii. Failure to detect or report to the District conduct by an

employee that a reasonable person should know is improper or criminal.;

xxxix. Providing materially false information to the District, or a

government agency, patient, insurer or the like.;

xl. Spreading gossip or rumors which cause a hostile work environment for the target of the rumor.;

xli. Impersonating a licensed provider;.

xlii. Obtaining employment based on false or misleading

information, falsifying information or making material omissions on an documents or records.;

xliii. Violation of Professional Appearance Guidelines;

xliv. Being in areas not open to the general public during non-

working hours without the permission of the supervisor or interfering with the work of employees.;

iii.

Further information regarding this policy is available through your department manager or the Human Resources Department.


















Separation from Employment Printed copies are for reference only. Please refer to the electronic copy for the latest version. POLICY: Employment status will conclude upon the individual's

resignation, discharge, retirement, death, or because of a permanent reduction in the workforce. Discharge may be for any reason not prohibited by federal or state law, including employee misconduct or unsatisfactory job performance. In the absence of a specific written agreement, employees are free to resign at any time, and the District reserves the right to end employment at any time and for any reason, in its sole discretion. Nothing in this policy should be interpreted as changing the “at-will” nature of employment at the District.

PROCEDURE: I. Unless there are good reasons for shorter notice, Aall

employees are expected to provide at least two (2) weeks written notice of their intent to resign. Management is expected to provide four (4) weeks notice; all employees are expected to provide at least two (2) weeks notice. Lack of timely designated written notice could result in the employee not being considered as ineligible for rehire.

II. For policies and procedures governing involuntary

discharge for cause see policy entitled PROGRESSIVE DISCIPLINE INVOLUNTARY TERMINATION (HR. 2176) and policy entitled NOTIFICATION REQUIREMENTS, PRE-DETERMINATIN PROCESS AND APPEAL PROCESS FOR INVOLUNTARY TERMINATION, SUSPEIONS WHTOUT PAY FOR MORE THAN FIVE DAYS AND DEMOTION (HR.218).

III. For policies and procedures governing termination as a

result of retirement see policy entitled RETIREMENT AND TAX DEFERRED SAVINGS PLANS (HR. 130).

IV. For policies and procedures governing termination as a

result of reduction in the work force see policy entitled

Separation from Employment 2

STAFF REDUCTION IN FORCE AND REASSIGNMENT (HR. 221).

V. In accordance with the policy entitled PROGRESSIVE

DISCIPLINE (HR. 216), any employee who is absent from work without first having notified management of the absence, or the reason for the absence, will be considered as having resigned after the first third day of absence.

VI. Management will immediately forward notices of

resignation or termination to the Human Resources Department for review and processing.

VII. Upone termination of employment for any reason, eEmployees must return all District property including identification card or badge, keys and parking permit, and complete termination paperwork to the Human Resources Department prior to their last hour worked.

VIII. Employees who resign providing at least seventy-two

(72) hours notice will receive their final pay upon their last hour of work. Employees who provide less than seventy-two hours notice may pick-up their final pay in the Human Resources Department within forty-eight (48) hours of their last hour worked.

Employees who are terminated as a result of disciplinary

action will receive their final pay within (72) hours upon notice of termination.

For further discussion on distribution of final pay, see

policy entitled PAYMENT OF WAGES (HR. 65)

IX. Employees who are terminated may be eligible for State of California Unemployment Insurance benefits. Affected employees may obtain information and apply for such benefits through the local office of the Employment Development Department. When an employee or former staff member applies for Unemployment Insurance Benefits, the Human Resources Department will respond to the Employment Development Department’s requests for information.

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Separation from Employment 3

Separation from Employment 4 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."




Approvers: Board of Directors (Administration), Dianne Cox Debbie Wood (VP Human Resources)

Employee Reduction in Force - or- Reassignment Resulting in Demotion Printed copies are for reference only. Please refer to the electronic copy for the latest version. POLICY: The District is committed to continued growth and increased

productivity and will make all reasonable attempts to avoid cutbacks and reductions in force (RIF) or demotions whenever feasible. However, when the District experiences circumstances it cannot for which it would prove fiscally or managerially irresponsible to maintain the existing staffing levels in one or more departments, it may decide in its discretion to implement a reduction in force or realignment, changes will be made in accordance with the following procedure guidelines. The District reserves the right to deviate from the guidelines contained in this policy when it determines, in its sole discretion that such deviations(s) is/are appropriate.

GUIDELINESPROCEDURE:

I. Appropriate Staffing

District Management will determine the appropriate number of employees needed to effectively staff their departments. Staffing patterns will include the number of employees needed by department number, job number and full or part time status. Because of their separate but equal importance within the workforce, Ffull-time employees, and part-time employees and per diems are considered separate classifications.

II. Attrition and or Hiring Freeze

The preferred method to deal with a need to reduce staffing levels the number of employees is through attrition. Attrition occurs when employees who voluntarily terminate and are not replaced. Also, staff currently on Personal Leave of Absence can be informed that their job has been eliminated.Also staff currently on Personal Leave of Absence can be informed that their job has been eliminated. Also a A hiring freeze may be implemented on a District-wide, division-wide, department-wide, or job classification-specific basis or any combination of such basis. Because there are areas where specific training and/or licensure are necessary, if in-service training and/or internal transfer cannot meet the staffing needs, it may be necessary to recruit from outside the current District workforce. If a

Employee Reduction in Force - or- Reassignment Resulting in Demotion 2 hiring freeze is implemented, and qualified employees are not available through internal transfer, jobs may be posted by going through the position control process.

III. Reduction in Force (RIF)

When a department director and VP determine that there are more employees employed within a job classification or department or any unit or units of employment than is necessary to support the District’sthe District’s department’s needs, staffing pattern, a RIF maywill be proposed. All requests for RIF’s must be approved by the District’s Chief Executive Officer. Once approved, Human Resources department will determine which employees will be reduced by following this policy. For the purposes of this policy each department is considered separately. Each job number in the department is considered separately. Managerial and lead positions will be considered separate job classifications from the positions held by employees that they manage/lead. Also part-time, and full-time and per diem employee categories will be considered separately.

A. Generally, eEmployee reductions will be based on the following factors in the order listed below. However, the District may decide in its discretion to deviate from these guidelines, particularly where patient care or other important functions of the District may be affected::

1. Employees on Personal Leave of Absence will be reduced

first and are not eligible for Reduction in Force benefits. 2. Employees who have not successfully completed

introductory period at the a year of District employment. 3. Employees with documented job performance issues based

on progressive discipline noted. within 18 (eighteen) months of the RIF

4. Employees with the lowest documented job performance evaluations:

i. Below an 8 ii. Between 9-12 iii. Between 13-16

5. In all other cases, where all considerations above are equal, employees with the longest service based on date of hire with the District will be the deciding factor.

5.6. Where special skills, licensure, qualifications, experience or other key attributes are important to assist in carrying out the functions of the District, the District may deviate from the above criteria.

B. Reduced employees will have some choices to make and

deadlines in which to make them. The deadlines must be met.

1. The right to appeal the reduction (see section X);

Employee Reduction in Force - or- Reassignment Resulting in Demotion 3

2. The choice to take a three3 month RIF Personal Leave of Absence to look for a transfer (see section IV) while receiving salary continuance as reflected on the severance schedule below;

- or – 3. The choice to take a severance lump sum and terminate

employment (see section V).

IV. Three month RIF Personal Leave of Absence

It is expected that employees will apply for a transfer to a new District job during their RIF Leave of Absence. Employees who have not been accepted into a new job with the District by the end of the 3 three month RIF Personal Leave of Absence will be considered to have voluntarily terminated from their employment and they will become eligible for a severance lump sum. In addition, RIF employees who select the 3 three month RIF Personal Leave of Absence, may choose select at anytimeany time within the three 3 months to instead terminate their employment and takeselect a Sseverance lump sum. Employees who find a new District job within 3 three months will retain their original date of hire and but will not be eligible for the severance salary continuance will end. severance pay.

V. Severance Pay and Termination

Severance pay will be paid according to the schedule below. The pay will be based on straight time excluding any differentials or standby pay. Part-time employees will receive one-half the amount on the schedule below. Per diems are not eligible.

Severance pay will be paid out upon termination of employment or if on a RIF Ppersonal lLeave (see section IV). Employees with unpaid PTO accrued in their banks will be paid for those hours. EIB bank will not be paid out.

In consideration of the severance pay, there is no further financial obligation to the employee on the part of the District aside from earned retirement benefits.

Full-time Employees Years of Service Weeks to be Paid 0 - 1 1.00 2 - 4 2.00 5 - 9 3.00 10 - 14 4.00 15 - 20 5.00 More than 20 8.00 The average number of hours which the employee worked per pay period during the six month period prior to the Reduction in Force will be reviewed and considered to determine the appropriate status (i.e. Full-time vs. Part-time).

Employee Reduction in Force - or- Reassignment Resulting in Demotion 4

VI. Reassignment Resulting in Demotion

Based on staffing patterns it is sometimes necessary to change aan employee’s job duties. When this change results in a lower salary grade or salary, it is considered a demotion. Employees who are demoted are given the choice of transfer to the new role offered to them at a lower grade and salary, or take a three3 month RIF Personal Leave of Absence as described in this policy or take severance terminating employment as described in this policy. An employee has the right to appeal the reassignment resulting in demotion (see section IX). An employee who changes job duties, shift, department or supervisor, but has no change in salary grade and or in pay, is not considered a demotion.

VII. Benefits

An employee with Group Health, Dental and Vision Insurance benefits who separates from employment as a result of RIF or demotion is entitled to continue his/her their insurance benefits. For the initial three 3 months following separation from employment, the employee may continue group health, dental, and vision insurance at the active employee rates. An employee choosing to continue coverage beyond that period of time, may do so at full COBRA rates. For details, see policy entitled CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA) (HR.129), and/or the RxFlex Summary Plan Description available through Human Resources. An employee who separates from employment as a result of an RIF or demotion, who otherwise meets the eligibility requirements for District retirement, may access the benefits available through that program. For detailed information regarding retirement benefits, see policy entitled RETIREMENT AND TAX DEFERRED SAVINGS PLANS 02(HR. 130), or the Retirement Plan Document. The benefits offered through this policy are only exclusivelyavailable to employees who separate from employment with the District as a result of a RIF exclusively. They are not available to employees who separate from employment with the District for other reasons such as a result of a resignation or involuntary termination. to employees who are terminated as a result of corrective disciplinary action.

VIII. Re-Employment

Employees who separate from employment with the District as a result of a RIF and receive a severance payment are free to reapply for employment with the District. However, if after separation has occurred a former employee is selected to fill a vacancy, their employment will be considered as any other newly hired employee.

IX. Appeal Rights for Reassignment Resulting in Demotion

Employees may not grieve or appeal termination of employment as a result of a reduction in force through the policy entitled GRIEVANCE PROCEDURE (HR.215). However, employees who have served greater than one hundred eighty (180) days

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Employee Reduction in Force - or- Reassignment Resulting in Demotion 5 employment with the District immediately prior to the termination and who have passed introductory period may access their rights under policy entitled NOTIFICATION REQUIREMENTS, PRE-DETERMINATION PROCESS AND APPEAL PROCESS FOR INVOLUNTARY TERMINATION, SUSPESION WITHOUT PAY FOR MORE THAN FIVE DAYS AND DEMOTION (HR.218).

X. Appeal Rights for Employee Reduction in Force

You are entitled to appeal this separation orally, or in writing, by contacting your Vice President no later than the time indicated on your Layoff Notice (typically one business day).

XI. Under special circumstances, alternative severance packages may be developed and offered to employees. Where this is the case, acceptance of an alternate severance package will cause the employee to be ineligible for the benefits offered in this policy.

Employee Reduction in Force - or- Reassignment Resulting in Demotion 6 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."





Introductory Period Printed copies are for reference only. Please refer to the electronic copy for the latest version. POLICY: All newly hired and rehired employee must serve employees are

subject to a six (6) month introductory period. This will give the District an opportunity to evaluate the employee’s performance and. The introductory period will also provide the employee with an opportunity to gain experience and to determine whether s/he wishes to continue employment with the District.

Completion of the introductory period does not guarantee continued future or permanent employment with the District and, notwithstanding the completion of the “Introductory Period” employees will continue to be “at will” and may be terminated from their employment in accordance with Health and Safety Code Section 32121(h): that is “at the pleasure of the Board of Directors.”.

PROCEDURE: I. At the time of hire, all newly hired and rehired staff members are notified of the introductory period. The introductory period shall be for six (6) months from the date of hire.

II. The introductory period is applicable to all District policies, unless specifically excluded as stated in this policies and procedures manual.

Employees of the District are “at will” which means that they serve at the pleasure of the Board of Directors. The District maintains a review an appeal process for certain disciplinary actions taken by the District and this process is available to involuntary termination or demotion for employees who have successfully completed the introductory period. Access to the review process does not change the “at will” nature of employment at the District.

Introductory Period 2

Introductory Period 3 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

MINUTES OF THE OPEN MEETING OF THE KAWEAH DELTA HEALTH CARE DISTRICT BOARD OF DIRECTORS HELD MONDAY SEPTEMBER 25, 2017 5:45PM, IN THE BLUE ROOM AT THE KAWEAH DELTA MEDICAL CENTER MINERAL KING WING, CARL ANDERSON PRESIDING PRESENT: Directors Anderson, Havard Mirviss, Hipskind, Hawkins & House; G. Herbst,

Chief Executive Officer; T. Rayner, SPV & COO; H. Lively, MD, Chief of Staff; E. Hirsch, VP & CMO/CQO; D. Cochran, VP of Development; D. Leeper, VP & CIO; D. Lynch, Legal Counsel; C. Moccio, Board Clerk

The meeting was called to order at 5:45PM by Director Anderson.

Director Anderson asked for approval of the agenda. MMSC (Havard Mirviss/Hawkins) to approve the agenda. This was supported unanimously by those present. Vote: Yes – Anderson, Havard Mirviss, Hawkins, House & Hipskind Public participation – none Director Anderson called for the approval of the closed agenda. 1. Approval of Closed Agenda as follows: Closed Meeting Agenda – Kaweah Delta Medical

Center Blue Room – 5:46PM 1.1. Credentialing - Medical Executive Committee request that the appointment,

reappointment and other credentialing activity regarding clinical privileges and staff membership recommended by the respective department chiefs, the credentials committee and the Medical Executive Committee be reviewed for approval pursuant to Health and Safety Code 1461 and 32155, medical staff privileges – Harry Lively, MD, Chief of Staff

1.2. Approval of closed meeting minutes {08/28/17} MMSC (House/Hipskind) to approve the closed agenda. This was supported unanimously by those present. Vote: Yes – Anderson, Havard Mirviss, Hawkins, House & Hipskind Adjourn - Meeting was adjourned at 5:46PM

Carl Anderson, President Kaweah Delta Health Care District and the Board of Directors Thereof ATTEST: Lynn Havard Mirviss, Secretary/Treasurer Kaweah Delta Health Care District Board of Directors

MINUTES OF THE OPEN MEETING OF THE KAWEAH DELTA HEALTH CARE DISTRICT BOARD OF DIRECTORS HELD MONDAY SEPTEMBER 25, 2017 6:00PM, IN THE BLUE ROOM AT THE KAWEAH DELTA MEDICAL CENTER MINERAL KING WING, CARL ANDERSON PRESIDING PRESENT: Directors Anderson, Havard Mirviss, Hipskind, Hawkins & House; G. Herbst, Chief

Executive Office, T. Rayner, SVP & COO; H. Lively, MD, Chief of Staff; E. Hirsch, VP & CMO/CQO; R. Sawyer, VP & CNO, D. Cox, VP of HR, D. Cochran, VP of Development; D. Leeper, VP & CIO; D. Lynch, Legal Counsel; C. Moccio, Board Clerk

The meeting was called to order at 6:00pm by Director Anderson.

Director Anderson asked for approval of the agenda.

MMSC (Hawkins/Havard Mirviss) to approve the agenda. This was supported unanimously by those present. Vote: Yes – Anderson, Havard Mirviss, Hawkins, House & Hipskind

Public/Medical Staff participation - None Closed Session Action Taken: Approval of the closed meeting minutes 08/28/17.

Recognitions

Director Herb Hawkins presentation of Resolution 1967 to Myrna Watson, Certified Nurse Assistant, Transitional Care Services, for the Service Excellence Award – September 2017.

Director Anderson recognition of Thomas Rayner for acting as the interim Chief Executive Officer during the recruitment process for a new Chief Executive Officer.

Consent Calendar – Director Anderson requested the approval of the consent calendar (copy attached to the original of these minutes and considered a part thereof). Director Havard Mirviss requested the removal of 2.2B.

MMSC (House/Hawkins) to approve the consent calendar with the removal of items 2.2B {Policies; Mental Health; Mental Health Hospital Safety Video Surveillance MH81.02}. This was supported unanimously by those present. Vote: Yes – Anderson, Havard Mirviss, Hawkins, House & Hipskind.

2.2B {Policies; Mental Health; Mental Health Hospital Safety Video Surveillance MH81.02

Director Havard Mirviss inquired how we video tape for security and safety while maintaining privacy - in areas that we don’t video tape, how do we ensure patient and staff safety. Ms. Mary Laufer, Director of Mental Health noted that surveillance is not in bathrooms or other private patient areas and in areas we don’t tape we have panic buttons.

MMSC (Havard Mirviss/Hawkins) to approve consent calendar item 2.2B {Policies; Mental Health; Mental Health Hospital Safety Video Surveillance MH81.02}. This was supported unanimously by those present. Vote: Yes – Anderson, Havard Mirviss, Hawkins, House & Hipskind.

Board of Directors Meeting - Open 09.25.17 Page 2 of 4

Quality Report – Cardiac Services – Society of Thoracic Surgeons as presented to ProStaff and Quality Council – Leheb Araim, MD and Edward Hirsch, MD, Vice President, Chief Medical and Quality Officer (copy attached to the original of these minutes and considered a part thereof)

Graduate Medical Education – Annual institution review – Lori Winston, MD, Designated Institutional Official and Edward Hirsch, MD, Vice President, Chief Medical and Quality Officer (copy attached to the original of these minutes and considered a part thereof)

Credentialing – Harry Lively, MD – Chief of Staff - Medical Executive Committee request that the appointment, reappointment and other credentialing activity regarding clinical privileges and staff membership recommended by the respective department chiefs, the credentials committee and the Medical Executive Committee be reviewed for approval.

Director Anderson requested a motion for the approval of the credentials report excluding the Emergency Medicine providers a highlighted on Exhibit A {copy attached to the original of these minutes and considered a part thereof}.

MMSC (Hipskind/Hawkins) Whereas a thorough review of all required information and supporting documentation necessary for the consideration of initial applications, reappointments, request for additional privileges, advance from provisional status and release from proctoring and resignations (pursuant to the Medical Staff bylaws) has been completed by the Directors of the clinical services, the Credentials Committee, and the Executive Committee of the Medical Staff, for all of the medical staff scheduled for reappointment, Whereas the basis for the recommendations now before the Board of Trustees regarding initial applications, reappointments, request for additional privileges, advance from provision al status and release from proctoring and resignations has been predicated upon the required reviews, including all supporting documentation, Be it therefore resolved that the following medical staff, excluding Emergency Medicine Providers as highlighted on Exhibit A (copy attached to the original of these minutes and considered a part thereof), be approved or reappointed (as applicable), to the organized medical staff of Kaweah Delta Health Care District for a two year period unless otherwise specified, with physician-specific privileges granted as recommended by the Chief of Service, the Credentials Committee, and the Executive Committee of the Medical Staff and as will be documented on each medical staff member’s letter of initial application approval and reappointment from the Board of Trustees and within their individual credentials files. Vote: Director Anderson, Havard Mirviss, House, Hawkins & Hipskind – Yes.

Director John Hipskind, MD left the room for the vote on the credentials, for the Emergency Medicine providers as highlighted on Exhibit A {copy attached to the original of these minutes and considered a part thereof}.

MMSC (Havard Mirviss/House) Whereas a thorough review of all required information and supporting documentation necessary for the consideration of initial applications, reappointments, request for additional privileges, advance from provisional status and release from proctoring and resignations (pursuant to the Medical Staff bylaws) has been completed by the Directors of the clinical services, the Credentials Committee, and the Executive Committee of the Medical Staff, for all of the Emergency Medicine providers scheduled for reappointment. Whereas the basis for the recommendations now before the Board of Trustees regarding initial


applications, reappointments, request for additional privileges, advance from provision al status and release from proctoring and resignations has been predicated upon the required reviews, including all supporting documentation, Be it therefore resolved that the following medical staff Emergency Medicine providers be approved or reappointed (as applicable), to the organized medical staff of Kaweah Delta Health Care District for a two year period unless otherwise specified, with physician-specific privileges granted as recommended by the Chief of Service, the Credentials Committee, and the Executive Committee of the Medical Staff and as will be documented on each medical staff member’s letter of initial application approval and reappointment from the Board of Trustees and within their individual credentials files. Vote: Director Anderson, Havard Mirviss, House & Hawkins – Yes. Director Hipskind – Absent CHIEF OF STAFF REPORT – Report from Harry Lively, MD, Chief of Staff: Dr. Lively noted that the Medical Staff Rules and Regulations and Bylaws are being reviewed

by the medical staff’s new legal counsel to bring them into alignment. CHIEF EXECUTIVE OFFICER REPORT – Report from Gary Herbst, SVP/Chief Financial Officer:

o The recent Medical Staff education boot camp provided by the Medical Staff legal counsel was well attended by Medical Staff and member of the Board.

o Quail Park groundbreaking took place – construction will begin in the fall. o KDHUB IT Leadership is working with clinical leadership and the revenue cycle group to

determine how close we are to being prepared for launch. The new date should be determined as either late winter 2017 or early spring 2018.

o Community Advisory Committee Management has concluded the selection process of the three community advisory

committees working together with the Executive Team and Marketing team. The selection committee selected 60 members of the community who applied to

participate in the three community advisory committees. The next step will be to structure the format of the meetings and prepare for an orientation of the three committees.

o CARF Survey Commendation to Lisa Harrold for a job well done in leading the recent CARF survey.

The surveyors were impressed with the quality of care and the compassion of our staff. They were very complimentary of our Board and impressed with the dedication.

o Neurosurgery – The contract has been executed and we are working towards a November 1st start date.

o Chief Financial Officer search The recruiting staff from our Human Resources Department are coordinating the

recruitment effort. Interim CFO - Melinda Tupper who is currently our Revenue Cycle Director who was

recruited from Texas where she was the CFO and Chief Revenue Officer of a 513 bed hospital with 650 practicing physicians. Mr. Herbst noted that he will be placing Ms. Tupper in the interim role of Chief Financial Officer.


o Employee engagement survey Our employee engagement survey concluded last week, over 90% of staff completed

the survey – the highest results the company we are using have seen. Our goal was 75% positive rating - we came in at 84% positive rating, which is the highest our organization has ever experienced, last two were 74% and 74.1%.

BOARD PRESIDENT REPORT – Report from Mr. Carl Anderson, Board President Director Anderson had no report. Adjourn - Meeting was adjourned at 7:23PM Carl Anderson, Board President Kaweah Delta Health Care District and the Board of Directors Thereof ATTEST: Lynn Havard Mirviss, Secretary/Treasurer Kaweah Delta Health Care District Board of Directors

Policy Manuals – AP38

Appendix D


Manual Name: Medical Staff Date: 10/11/17 Support Staff Name: April McKee Routed to: Approved By: (Name/Committee – Date)

Department Director Medical Director (if applicable) Medical Staff Department (if applicable) Patient Care Policy (if applicable) Pharmacy & Therapeutics (if applicable) Interdisciplinary Practice Council (if applicable) Credentials Committee (if applicable) Executive Team (if applicable) Medical Executive Committee (if applicable) Board of Directors


#


Reviewed, Deleted)

Name and Phone # of person who wrote

the new policy or revised an existing policy

Informed Consent for Surgical, Diagnostic, or Therapeutic Procedure

MS.43 Revised Kassie Waters x5241

Chain of Command MS 31 Deleted

Medical Staff Services

Policy Number: MS.43 Date Created: No Date Set Document Owner: April McKee (Medical Staff Coordinator)


Approvers: Board of Directors (Administration), Medical Executive Committee, Cindy Moccio (Board Clerk/Exec Assist-CEO), Teresa Boyce (Director of Medical Staff Svcs)

Informed Consent for Surgical, Diagnostic, or Therapeutic Procedure Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: Kaweah Delta Health Care District (KDHCD) adheres to the principles of Informed Consent. The purpose of this policy is to define the responsibilities of KDHCD and its affiliated members of the medical staff and credentialed advance practice providers for obtaining and documenting the process of informed consent, based on statutory and legal requirements in the state of California, the Centers for Medicare & Medicaid Services and the Joint Commission. This policy is intended to provide guidance to assure patients receive sufficient information so that they have the opportunity to make knowledgeable and informed decisions about the course of their treatment related to surgical, diagnostic and other procedures that require informed consent.

Policy:

1. KDHCD recognizes the fundamental right of each person (or authorized representative) to be reasonably informed in decisions involving the person's healthcare. This patient’s rights also include the patient’s participation in the care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand provision of treatment or services deemed medically unnecessary or inappropriate.

2. The consent process consists of two important components: information

disclosure and documentation. Except in limited circumstances, disclosure of certain information pertinent to the procedure, care or treatment rendered is always required. The responsibility for disclosure rests with the healthcare provider performing the procedure or rendering the care/treatment and/or an equally credentialed member of the medical staff.

3. It is the provider’s responsibility to obtain informed consent and to document

this consent in the patient’s hospital medical record before the provider is permitted to perform any procedure that requires consent.

4. The hospital's role in the consent process is to verify the patient's informed

consent was obtained by the provider before the provider is permitted to perform the procedure.

Informed Consent for Surgical, Diagnostic, or Therapeutic Procedure 2

5. The provider, not the hospital, has the duty to disclose all information relevant to the patient's decision and to obtain the patient's informed consent for surgery and for special diagnostic or therapeutic procedures including blood transfusion.

6. Discussion between a patient and health care providers regarding his/her

value system and healthcare treatment preferences are encouraged and may include family members/surrogates in discussions as appropriate to the wishes of the patient. Whenever the word "person" or "patient" is used in this policy/procedure, one may substitute "or authorized representative."

Definitions: 1. Advance Directive: An expression by a person with capacity, which is

recorded into a document and retained, communicating his/her health care treatment preferences to become effective upon the person's loss of capacity. A living will is one type of advance directive providing that no death prolonging procedures be instituted or continued, becoming effective only when the person has a terminal illness and loss of capacity. A health care treatment directive, another type of advance directive, usually offers more specific information than a living will regarding the person's treatment preferences. A Durable Power of Attorney for Healthcare (DPOA-HC) is a specific power of attorney designating another person (proxy) to make healthcare decisions on behalf of the party executing the DPOA-HC. A DPOA-HC or Living Will executed in another state is durable (operative) in California as long as it was properly executed and operative in the state of execution.

2. Informed Consent: Agreement to the performance of a procedure or treatment based on a prior explanation of the nature and the purpose of the procedure; to include risk, benefits, alternatives and expected outcome. Informed Consent is a process, not a form. It is the communication process between a patient and a provider of healthcare services in which both parties ask questions and exchange information, culminating in the patient’s agreeing to a specific medical or surgical intervention. During this discussion, the patient may also elect to refuse a proposed treatment.

3. Capacity: a person’s ability to understand the nature and consequences of a decision and to make and communicate a decision, and includes in the case of proposed health care, the ability to understand its significant benefits, risks and alternatives.

4. Decision-making Capacity: a clinical determination made by a provider that

a patient has requisite capacities to make a medical decision.

5. Incompetence: A judicial determination of a person's lack of capacity, with an appointment of a guardian to make certain decisions for the person (ward). The court issuing the order of incompetence retains oversight over the guardian.


6. Surgery: Any procedure that is listed as a surgical procedure in any of the

various billing coding system used by CMS or the hospital, regardless of whether Medicare pays for that surgical procedure.

7. Provider: Whenever the word "provider" is used in this policy/procedure, one may substitute "provider" or “advance practice provider” credentialed to perform a certain procedure(s) by the Medical Staff.

8. Who can Give Consent? Adult- a person who has reached the age of 18, or a minor who has entered into a valid marriage, who is on active duty with the armed forces of the United States of America, or who has been declared emancipated. See attached Appendices for further guideline on who can give consent on special circumstances. (Appendix 1 – Reference Guide for Informed Consent for Special Circumstances; Appendix 2 – Legal Consent Requirements for Medical Treatment of Minors).

Procedure: 1. The provider performing the procedure is responsible to conduct the informed

consent discussion with the patient. Typically, this information exchange would include potential short- and long-term risks and benefits to the patient of the proposed intervention, including the likelihood of each, based on the available clinical evidence, and alternatives. In order to obtain informed consent, the provider must first

determine whether the patient has decision-making capacity. In a situation where a patient has been medicated (for example:

chest pain, fractures and continuous narcotic infusions) the provider must assess the patient’s capacity to give consent and may proceed with the consent process if the provider determines and documents the patient has capacity to consent.

2. The provider is responsible to document that this discussion occurred by signing the “Informed Consent for Surgical, Diagnostics or Therapeutic Procedure” (Informed Consent form) form prior to the procedure.

3. The hospital’s role is to verify that the informed consent discussion occurred.

4. On behalf of the hospital, it is the nurse who conducts the verification

process, as a witness to the patient’s signature, and as a patient advocate. First, the nurse will ask the patient and/or patient’s legal representative if

they had a discussion with the provider about the proposed procedure to make an informed decision. If the patient expresses to the nurse that he/she still have questions, the nurse must advocate for the patient and communicate with the provider prior to the initiation of the treatment or procedure.


Second, with the patient’s acknowledgement that an informed consent discussion occurred, the nurse may serve as the witness to the patient’s signature on the consent form.

5. Considerations when completing Informed Consent Form:

a. Prior to the initiation of the procedure, the provider performing the procedure will ensure that documentation is completed using the approved Informed Consent Form and is placed in the patient’s medical record.

b. A properly executed informed consent form has the following required elements and must be in the patient’s medical record prior to the surgery: 1. Patient’s full name 2. Full name of the provider/Licensed Independent Provider who will be

performing the procedure (not a practice or group name, i.e., Trauma Services is not acceptable)

3. Name of the procedure(s) (no abbreviations). 4. Patient’s signature or DPOA for Healthcare. If patient does not have

decision making capacity and has no DPOA, surrogate decision-maker.

5. Signature, date and time of the person who witnesses the patient sign the document.

c. Procedures Requiring Written Consent

1. Surgical, medical or invasive diagnostic procedures requiring informed consent.

2. Procedures utilizing moderate sedation or general anesthesia. 3. Specified non-invasive diagnostic procedures during which the patient

may be exposed to increased risk of harm, such as oxytocin challenge test.

4. Administration of blood or blood products. Consent to blood transfusion is included in the informed consent form.

5. Experimental procedures, administration of special drugs/therapies, and HIV testing. (*Consent to HIV antibody testing in the event that a Health Care worker is exposed to patient’s blood or body fluids is included in the surgical consent form),

6. Others may include Autopsy, organ and tissue donation, transfer of patients, and examination of alleged victims of sexual abuse (SART). .

7. For other state related list, see Appendix 1 – Reference Guide for Informed Consent for Special Circumstances and Appendix 2 – Legal Consent Requirements for Medical Treatment of Minors.

8. For a list of other invasive, diagnostic and treatment procedures requiring informed consent, see KDHCD’s Medical Staff Bylaws or Rules and Regulations.

d. How to complete the Informed Consent Form Procedures

Every blank space must be completed prior to the initiation of the procedure. The completed consent is placed in the patient's chart and becomes a permanent part of the Medical Record. The consent signed


during an admission remains in effect until procedure is performed or until discharged, or revoked by the patient. During an emergency surgical procedure, ideally, this form is still under the Provider Attestation section as part of the Timeout process.

Section I: a. This section is to be filled out by the provider in clear, legible

writing. Abbreviations are not acceptable.

b. The nurse may assist in completing this section based on the documented provider order.

c. Full name of the patient undergoing the procedure will be written on the consent form.

d. Full name of the provider or Advance Practice Provider performing the procedure(s). No abbreviation.

e. The name of the proposed procedure to be performed, including site specific information, such as laterality, if applicable.

ABBREVIATIONS ARE NOT PERMITED.

ALERT: If the provider’s order or the consent form for the proposed procedure was abbreviated or incomplete, a call will be placed to the provider for clarification immediately. Section II This section will either be read by the patient/legal representative and/or read to the patient if requested.

# 1– 3 Documentation of disclosure related to the proposed treatment plan, including discussion of the risks, complications, alternative treatments, expectations related to hospitalization, recovery and outcome; potential changes in the treatment plan related to unforeseen circumstances; and consent for the participation of other assistants in the OR.

#4 Photographing, Video & Audio Recordings – consent. If the patient refused to give consent, staff may cross out this section, initialed and dated by the patient and communicated to the provider. If the patient is a minor, the written consent of a parent or guardian must be obtained. #5 Observers and Paraprofessionals - patients are to be notified of any additional observers to include the purpose or role of their presence during the procedure.

# 6 Confidentiality – will be carried out as defined by KDHCD policy related to uses and disclosures of Protected Health Information. #7 Tissue Disposals. Consent for tissue disposal which will be carried out


according to customary process. If the patient requests to retain any tissue and/or body part, staff needs to contact the director of laboratory and surgery prior to the procedure. # 8 Health Care Worker Exposure – Discussion with the patient regarding the need to perform HIV testing in the event of an unanticipated exposure to bodily fluids. Follow the hospital’s policy on employee exposure to bodily fluids as required by California law. # 9 – 11 Blood Transfusions - The Paul Gann Blood Act must be followed in obtaining consent for blood transfusion. For non-surgical cases that require blood consent, use the separate consent form for blood. When considering blood transfusion:

A. The patient has the right to rescind this consent and must be documented.

B. An individual may raise religious or philosophical objections to blood products and/or blood transfusion and has the right to refuse blood transfusion. In such circumstances, the health care provider ordering the transfusion will discuss with the patient the consequences of such refusal and any reasonably available treatment alternatives. The licensed nurse will screen and document in the admission database, the patient’s wishes not to accept blood transfusion and place a “No Blood” armband on the patient’s wrist. The patients will be asked if they have a Health Care Directive related to no blood products. If so, a copy will be made and placed/scanned in the patient chart. In such circumstances when blood transfusion maybe medically indicated, the health care provider will discuss with the patient the consequences of such refusal and any reasonably available treatment alternatives. This discussion will be documented in the patient’s medical record.

Alert: Do not assume that all Jehovah’s Witness patient will categorically refuse blood transfusion. A discussion with the patient and a representative from the patient’s religious organization (with the patient’s consent) is recommended.

C. Transfusion of a competent individual over the individuals informed objection may raise allegations of battery.

D. Rare circumstances may dictate judicial intervention when blood product administration is refused, especially in potential life-threatening situations. The Director of Risk Management should be notified if refusal occurs such as the following circumstances:

i. parent refusing transfusion for a minor child; ii. refusal by a pregnant woman; or iii. existence of family dispute regarding transfusion

administration to an incompetent patient lacking an executed advanced directive


E. Consider Bioethics consult to help resolve these issues.

Section III A. Patient’s Signature

The signature signifies that the patient’s acknowledgment of the discussion with his/her provider; that the information has been shared or read to him/her and consents to the procedure, and has no further questions. If the person signing is other than the patient, the individual has to be identified next to the signature, i.e., POA-HC, etc. The medical record should reflect the reason why other than the patient is signing the consent form.

B. Witnessing the Signing of the Consent Form and Verification of Consent. Confirm that the patient has been given sufficient information by the provider regarding the procedure. The staff will ask the patient to read the consent form and/or read the consent form to the patient if requested. If the patient does not understand English, call Interpreter Services for assistance. The use of the interpreter must be documented and completed in the Interpreter’s section of the informed consent form.

SECTION IV Provider/Advance Practice Provider Attestation Section:

The provider performing the procedure or rendering the care/treatment and/or equally credentialed member of the medical staff must check the appropriate box, attesting that a discussion regarding risks, benefits; reasonable alternatives, code status, etc., has been discussed with the patient or patient’s legal representative.

EMERGENCY - If the discussion was not discussed due to an emergency condition, the appropriate box needs to be checked. The signature needs to be dated and timed. During an emergency situation, consent can be bypassed and documented.

Medical Emergency - Exemption to the Requirement for Consent is in case of an emergency. This exception applies to adults, otherwise with or without capacity, and minor patients.

a. In medical emergencies the patient’s consent is implied by law. The provider may provide necessary medical care in emergency situations without the patient’s or surrogate’s express consent when all of the following conditions are met:

• Immediate services are required for the alleviation of severe pain; or

• Immediate medical care is necessary to preserve life or avert serious impairment of the health of the patient or others; and


• The patient is unable to consent; and • The patient has no surrogate, or the practitioner determines that

waiting to obtain consent from the patient’s surrogate would increase the hazard to the life or health of the patient or others.

b. In a medical emergency, reasonable attempts to contact the patient’s POA-HC or surrogate must be made as promptly as possible, before or after treatment is begun, to explain the nature of the treatment or procedure, the indications, and the expected outcome. The patient’s previously stated wishes (e.g., verbal, advance directive) must be followed to the extent that they are known and are applicable to the current situation.

c. When the patient’s consent is not obtained due to the emergency exception: The health care provider performing the emergency intervention will document the following information in the medical record: The nature and extent of the emergency; The reasons for and possible consequences if the

procedure/intervention does not occur; Any attempts made to notify the next of kin or seek appropriate

consent from an alternative source.

Alert: The term “medical necessity” does not convey the appropriate urgency of the intervention and should not be used in place of informed consent.

6. Special Circumstances to consider when obtaining documentation of

the informed consent process requiring 2 witnesses. For further guideline, see General Consent Policy for details.

Telephone consent will be obtained after the provider has obtained consent from the legal representative, if the consenting party is unavailable to sign the form prior to starting the procedure.

Documentation shall reflect the relationship of the consenting party and the exact date and time the telephone consent was obtained.

If the patient is physically unable to write his or her name, an “X” may be used in lieu of a signature.

7. Consent from the Physician’s Office Operative permits completed on the approved KDHCD form in a physician's office are acceptable provided they are accurate and complete. If the consent comes from the office with the patient, then the nurse puts the name of the condition and procedure as written on the operative permit onto a physician's order sheet and puts "received from physician's office consent form not in an approved form.” KDHCD form will be completed and the process described in this policy will be followed, i.e., verifying that the patient received the consent information from the practioner and h/she no longer has any questions.


8. For any questions or concerns regarding special circumstances on who should be providing consent or how consent is obtained you may contact the Risk Management Department.

Related Documents: KDHCD Informed Consent Form See related policies under General Consent Policy. References:

1. Joint Commission for Hospital Accreditation. RC 02.01.01.04; RI.01.03.01 – EP01 – 09, EP 11, EP 13

2. CMS Patients’ Rights Condition of Participation (“CoP”) at 42 CFR 482.13(b) (2); Medical Records CoP at 482.24(c) (2) (v); and Surgical Services CoP at 482.51(b) (2).

3. CMS Interpretive Guidelines for Tags A-0049 (Patients’ rights), A-0238 (Medical Records), and A-0392 (Surgical Services).

4. State of California – Title 22. 5. California Hospital Association: Consent Manual 2016


Appendix 1 Kaweah Delta District Hospital Reference Guide for Informed Consent

Status of Patient Consent For Medical Consent Non-Emergency Emergency


Adult Competent

Self Self

Special Circumstances Involving Competent Adult Patients

Married Patients: In some circumstances a spouse may consent on the basis of another legal relationship or on the basis that the patient is incompetent and the spouse is the closest living relative.

In Custody of Law Enforcement: Must consent to non-emergent situations. Although law enforcement officers may request limited medical examinations and tests.

Potential HIV Exposure: Unless the law expressly permits otherwise, no person may be tested for HIV without his or her written consent. The form “Consent for the HIV Test” should be used only when the test is performed for purposes other than testing donated blood.

Patient or Spouse or

No Consent Required

“In the case of a medical emergency, treatment may proceed without the patient’s consent so long as no evidence exists to indicate that the patient would refuse the treatment-such as a particular religious belief, for example, or a relative’s statement regarding the patient’s wishes. The law implies consent in these circumstances on the theory that if the patient were able, or if a qualified legal representative were present, the consent would be given”.

To further clarify, “A medical emergency exists when: Immediate services are required for the alleviation of severe pain,

or

Immediate diagnosis and treatment of unforeseeable medical conditions are required, if such conditions would lead to serious disability or death if not immediately diagnosed and treated.

Adult determined to be Incompetent or Incapacitated

Legal Representative Attorney-in-Fact: Conservator Closest Available Relative (Should not rely upon consent from “Closest

Available Relative” if questionable motive, substantial doubt if patient would consent treatment, any other close relative objects). Identifying the Patient’s Closet Available Relative - Once it is determined that it is appropriate to rely upon the consent of the closest available relative, it is necessary to determine that the person authorizing the treatment is, in fact, the patient’s closest relative. The relative should, of course, be asked to identify his or her relationship to the patient. In addition, he or she should be asked if there are any other relatives and, if so, whether they are more closely related to the patient. This inquiry is especially important if the relative is not a member of the patient’s immediate family. If, after such inquiry, there is no reason to suspect that the relative is not the closest available relative, it is probably safe to rely upon his or her assertions. These assertions should be documented on the consent form which the relative signs by requiring a statement specifying the relationship to the patient. If there is reason to suspect that the person accompanying the patient is, in fact, not the patient’s closest available relative, his or her assertions should not be relied upon (CHA Consent Manual, 2016).

No Consent Required Same as for Special Circumstances involving

Competent Adults

Developmentally Disabled Adults

Should not presumed to be incompetent If the patient’s provider makes the

determination that he or she is incapable of consenting to treatment, the consent can be provided by the DDA’s

attorney-in-fact conservator legally authorized to

consent to such treatment closest available relative court order

Legal Representative

No Consent Required Same as for Special Circumstances involving

Competent Adults

Appendix 2 Legal Consent Requirements For Medical Treatment Of Minors


If Patient is:

Is parental

consent required?

Are parents responsible for costs? †

Is minor’s consent

sufficient?

May MD inform

parents of treatment without minor’s

consent? Unmarried, no special circumstances Yes Yes No Yes Unmarried, emergency care and parents not available [Business and Professions Code § 2397]

No Yes Yes, if capable Yes

Married or previously married [Family Code § 7002]

No No Yes No

Emancipated (declaration by court, identification card from DMV) [Family Code §§ 7002, 7050, 7140]

No 1 Yes No

Self-sufficient (15 or over, not living at home, manages own financial affairs) [Family Code § 6922]

No No Yes 1

Not married, care related to prevention or treatment of pregnancy, except sterilization [Family Code § 6925]

No No Yes No

Not married, seeking abortion No No Yes No Not married, pregnant, care not related to prevention or treatment of pregnancy and no other special circumstances

Yes Yes No Yes

On active duty with Armed forces [Family Code § 7002]

No No Yes No

12 or older, care for communicable reportable disease or condition [Family Code § 6926]

No No Yes Probably not

12 or older, care for rape [Family Code § 6927] No No Yes Yes, usually Care for sexual assault1 [Family Code § 6928] No No Yes Yes, usually 12 or older, care for alcohol or drug abuse1 [Family Code § 6929]

No2

Only if parents are

participating in counseling

Yes Yes, usually

12 or older, care for mental health treatment, outpatient only [Family Code § 6924]

No Only if parents are

participating in counseling

Yes Yes, usually

17 or older, blood donation only [Health and Safety Code § 1607.5]

No No Yes Yes, usually

1 Special requirements apply. See Chapter 2 of the Consent Manual & Health Care Law.

2 Parental consent is required for a minor’s participation in replacement narcotic abuse treatment (such as methadone, LAAM or buprenorphine products) in a program licensed pursuant to Health and Safety Code § 11875 et. seq. [Family Code § 6929(e)] † Reference: Welfare and Institutions Code § 14010 Minors are defined as all persons under 18 years of age. California Hospital Association 4/16

Manual Name: Pharmacy Date: 9/25/17 Support Staff Name: Crystal Root Routed To: Approved By:

Department Director 9/22/17 Medical Director (if applicable) Medical Staff Department (if applicable) Patient Care Policy (if applicable) Pharmacy & Therapeutics (if applicable) Interdisciplinary Practice (if applicable) Executive Team (if applicable) Medical Executive Committee (if applicable) Board of Directors


#


Revision, Deleted)

Name and Phone # of person who wrote the new

policy or revised an existing policy

Infection Control RX 4.30.0

Revised Rheta Sandoval x5301

Pharmacy

Policy Number: RX 4.30.0 Date Created: No Date Set Document Owner: Crystal Root (Administrative Assistant)


Approvers: Board of Directors (Administration), Medical Executive Committee, Pharmacy and Therapeutics, James McNulty (Director of Pharmacy)

Infection Control Printed copies are for reference only. Please refer to the electronic copy for the latest version. Purpose: To have a department specific infection control policy to prevent

contamination of drug products prepared in or dispensed by the pharmacy department.

Policy: Pharmacy department personnel shall follow established procedures to

reduce the risk of introducing microbial contaminants into the distribution system.

Procedure: I. General

A. To provide pharmacy products prepared and handled under the most

rigid infection control standards required for the risk level classification utilized.

B. To maintain a clean environment in the pharmacy.

II. Health requirements A. Individuals experiencing rashes, sunburn, weeping sores,

conjunctivitis, and active respiratory infections or other communicable disease, or those wearing cosmetics, nail polish, or artificial nails shall be excluded from the ISO Class 5 (Primary Engineering Control) and ISO Class 7 (Buffer area) compounding areas until their conditions are remedied.

B. The Employee Health Nurse may be consulted for recommendations.

III. Training of Compounding Staff A. Refer to Pharmacy Manual Policy 12.15.1 “Quality Assurance

Program: Compounded Medications” for procedures related to the training of pharmacy compounding personnel or support personnel assigned to duties in the clean room.

Infection Control 2

IV. Handwashing and personal hygiene A. Handwashing and personal hygiene are the most important factors in

infection control in any area of the hospital. Hands must be routinely washed at the following times using the hospital approved hand hygiene product: 1. Before handling medications and equipment used in the

preparation of products.

2. District-approved alcohol hand rub may be used if hands are not visibly soiled.

B. Personnel assigned to compounding sterile products follow the hand hygiene and garbing practices outlined in pharmacy manual policy 9.35.0 entitled “Intravenous Admixture Service”. 1. Personnel shall wear a fresh uniform or clothing daily. A clean

lab coat may be worn over clothing while in the pharmacy. Personnel assigned to compounding sterile products will adhere to the procedures outlined in pharmacy manual policy 9.35.0 “IV Admixture Service”.

C. Fingernails should be kept clean and trimmed to maintain fingernail length no longer than ¼” beyond fingertip.

V. Traffic control A. Unnecessary personnel traffic in the pharmacy clean room shall be

minimized to prevent excessive air turbulence from affecting the efficiency of the Laminar Flow Hood Workbench environment.

B. Particle-generating activities, such as removal of intravenous solutions, drugs, and supplies from external packaging (e.g. wholesaler delivery tote/box) should not be performed in the clean room.

VI. Department cleaning A. All pharmacy clean room compounding areas are routinely cleaned

and disinfected to maintain facility and environmental controls.

B. Activities associated with cleaning are properly documented.

C. A germicidal detergent and sterile water is used for cleaning the pharmacy area dedicated to sterile compounding. The frequency “daily” in reference to cleaning and disinfecting procedures means occurring every day the pharmacy is operating. Records of cleaning

Infection Control 3

are retained in the pharmacy for at least three years from the date the record was created. 1. Type and methods of application are in accord with procedures

outlined by the Directors (or designee) of Environmental Services and Department of Pharmacy. a) Clean Room area

(1) Floors are dusted then cleaned using a germicidal

detergent at least daily by environmental services personnel when no aseptic operations are in progress. (a) All cleaning tools, such as wipers, sponges,

and mops are nonshedding and dedicated to the clean room area of use to prevent cross-contamination. These tools shall not be removed from these areas except for disposal.

(2) Counters and easily cleanable work surfaces are cleaned using a germicidal detergent (and if concentrate is used, only sterile water can be used to dilute the cleaning agent) and then disinfected using a suitable sterile agent daily by environmental services personnel.

(3) Environmental services personnel picks up disposed of packaging materials, used sharps, and pharmaceutical waste collected in the clean room as often as necessary to enhance sanitation and avoid accumulation in the controlled area.

(4) Storage shelving is emptied of all supplies and then cleaned using a germicidal detergent (andif concentrate is used, only sterile water can be used to dilute the cleaning agent) by environmental services personnel weekly. (a) Exception: storage areas and containers

housing cytotoxic agents are cleaned and disinfected by pharmacy personnel at least monthly.

(5) Walls, ceilings, tables, and stools are cleaned using a germicidal detergent (and if concentrate is used, only sterile water can be used to dilute the cleaning agent) by environmental services

Formatted: Font: Italic



Infection Control 4

personnel monthly.

(6) All ISO Class 5 surfaces, work table surfaces, carts, counters are cleaned using a germicidal detergent and sterile water by pharmacy personnel daily. After each cleaning, disinfection using sterile isopropyl alcohol occurs.

b) Areas of the pharmacy outside of the clean room (1) Open shelves in areas of the pharmacy outside of

the clean room are cleaned at least every six months by environmental services personnel.

VII. Department Cleaning – Equipment A. Department equipment such as glassware or utensils used in the

preparation of oral products, the unit dose packaging device, or the laminar flow hood workbench (LAFW) work surfaces are cleaned and disinfected by pharmacy personnel as outlined in the pharmacy manual (pharmacy manual policy 7.20, 11.05, and 9.40 respectively).

B. The cleaning of the LAFW work surface is addressed in section IX B Aseptic technique.

VIII. Sterility assurance of packaging program A. General cleanliness, neatness, and organization of the packaging area

will be maintained.

B. Strict adherence to cleanliness while packaging unit doses of medications will be assured as defined in Pharmacy Manual Policy 11.05.0 entitled “Unit Dose Packaging and Syringe Preparation”.

C. Good personal hygiene and clean work habits shall be followed.

IX. Sterility assurance of IV admixture preparation will be ensured by the following indicators which will be re-evaluated as specified: A. Laminar flow hood

1. Maintenance personnel are responsible for visually inspecting

pre-filters monthly and cleaning them when necessary. Documentation of the filter change shall be maintained by maintenance.

2. An outside vendor will be contracted semi-annually to certify the efficiency of the HEPA (absolute) filter.

Infection Control 5

3. A daily cleaning log of the Laminar flow hood will be maintained by pharmacy.

B. Compounding Aseptic Containment Isolator (CACI)

1. Pharmacy personnel are responsible for visually inspecting pre-

filters weekly and replacement when necessary.

2. An outside vendor will be contracted semi-annually to certify the efficiency of the HEPA (absolute) filter.

3. A daily cleaning log of the CACI will be maintained by pharmacy.

C. Aseptic technique 1. Strict aseptic technique will be maintained when preparing

sterile products.

2. Supportive personnel are supervised by a Registered Pharmacist for strict adherence to aseptic techniques. In addition, pharmacy personnel preparing sterile products shall complete didactic training, pass written competence assessments, undergo skill assessment using observational audit tools, and media-fill testing. This training shall be completed and documented before any compounding personnel begin to prepare compounded sterile products and at least annually thereafter.

3. The work surface of the LAFW is cleaned and disinfected following procedures described in Pharmacy Manual Policy 9.40.0 “Use and Maintenance of the Laminar Flow Hood Workbench”.

4. Procedural details are listed in Appendix A, “Aseptic Procedure for Preparation of IV Admixtures in Laminar Air Flow Environment” of the Intravenous Admixture Service Policy (pharmacy manual policy 9.35.0).

5. End-product testing for sterility is performed periodically but no less frequently than annually. a) As Kaweah Delta Medical Center Pharmacy prepares

only low and medium-risk compounded sterile products (CSPs) and does not assign beyond use dates or expiration dates that exceed the limits outlined by United States Pharmacopeia Chapter <797>, CSP sterility testing is limited to products that are batch-produced

Infection Control 6

sterile to sterile transfers.

D. Environmental monitoring 1. Environmental monitoring of the clean room and ante-room is

done periodically to identify potential sources of contamination thus allowing for implementation of corrective actions to minimize the possibility of CSP contamination.

2. Engineering Control Performance Verification of Laminar Airflow Hoods and Containment Isolators

a) An outside vendor is contracted no less than semi-

annually to classify air cleanliness within the Laminar flow hood and in the buffer and ante-room areas of the clean room. (1) The Laminar Airflow Workbenches or Containment

Isolators must be ISO Class 5 (100 particles per cubic foot) or better.

(2) Buffer areas must maintain at least ISO Class 7 (10,000 particles per cubic foot) conditions and ante-areas must maintain at least ISO Class 8 (100,000 particles per cubic foot) conditions.

(3) The principle of displacement airflow is employed for buffer areas that are not physically separated from the ante-areas. (a) The air velocity across the line of

demarcation from the buffer area to the ante-area must be at minimum 40 feet per minute.

b) An outside vendor is contracted no less than semi-annually for evaluation of airborne microorganisms using volumetric collection methods in the clean room. (1) Any colony-forming unit (cfu) count that exceeds

its respective action level should prompt a re-evaluation of the adequacy of personnel work practices, cleaning procedures, operational procedures, and air filtration efficiency within the aseptic compounding location. (a) Recommended action levels for microbial

contamination (cfu per cubic meter [1000

Infection Control 7

liters] of air per plate) are as follows: (i) ISO Class 5 environment - > 1

(ii) ISO Class 7 environment - > 10

(iii) ISO Class 8 or worse - >100

(2) Counts of cfu are to be used as an approximate

measure of the environmental bioburden, Action levels are determined on the basis of cfu data gathered at each sampling location and trended over time. The above cfu action levels should be used only as a guideline.

c) Unsatisfactory result(s) on the certification test report are brought to the attention of the Director of Pharmacy (or designee) to determine appropriate corrective actions.

d) A pressure gauge or velocity meter is used to monitor the air pressure differential or airflow between the buffer area and the ante-area (when the buffer area is functionally separate from the ante-area) and/or between the ante-area and the general environment outside of the compounding area. (1) A reading is made and documented on a log each

day. The pressure and/or airflow requirements are defined on the log where the readings are recorded.

3. Surface Sampling a) Surface sampling is an important component of the

maintenance of a suitable microbially controlled environment for compounding CSPs. Transfer of microbial contamination from improperly disinfected work surfaces via inadvertent touch contact by compounding personnel can be a potential source of contamination into CSPs.

b) Surface sampling is performed in all ISO classified areas on a periodic basis and is accomplished using contact plates or swabs at the conclusion of compounding activities. Immediately after sampling a surface with the contact plate, the sampled area shall be thoroughly wiped with a non-shedding wipe soaked in sterile 70% isopropyl alcohol.

Infection Control 8

c) The greatest value of viable microbial monitoring are realized when normal baseline cfu counts are determined over a period of time. Surface sample environmental monitoring data shall be collected and trended as a means of evaluating the overall control of the compounding environment. The number of discrete colonies of microorganisms are counted and reported as cfu and documented on an environmental monitoring form. (1) Action levels shall be determined based on

baseline data gathered. (a) An increasing trend in cfu counts may

prompt a re-evaluation of the adequacy of cleaning procedures, operational procedures, personnel work practices, and air filtration efficiency within the aseptic compounding location.

(b) When action levels are exceeded, an investigation into the source of the contamination occurs.

E. Physical inspection of finished compounded sterile products includes

visual inspection for clarity, color change, integrity of container and coring of the stopper.

F. Storage of admixtures 1. Once prepared and prior to use, IV admixtures are to be stored

appropriately in a secured area.

2. Expiration dating will be assigned as outlined in pharmacy manual policy 4.40.0 “Labeling Standards”.

X. Infection control surveillance of unit dose dispensing A. Cleanup

1. Patient medication bins should be kept clean.

2. Spilled liquids or other spilled materials outside of the laminar

flow hood will necessitate cleaning with germicidal detergent, thorough rinsing, and drying.

3. Spilled liquids or other spilled materials within the horizontal

laminar flow hood will necessitate cleaning with a germicidal detergent and sterile water followed by disinfection with sterile

Infection Control 9

70% Isopropyl Alcohol. The surface shall be allowed to air dry prior to use.

4. Spilled liquids or other spilled materials within the CACI will

necessitate cleaning as detailed in the pharmacy manual policy 7.80.0 entitled “Handling Hazardous Agents”.

B. Any unused multiple dose dosage forms (vials, ointments, creams, liquids, etc.) will be returned to pharmacy for proper disposal when the patient is discharged from the hospital, or upon order discontinuation.

C. Pharmacy will be responsible for checking all areas where drugs are stored for expired product.

XI. Manufacturing and floor stock services A. Manufacturing containers

1. It is pharmacy policy not to reuse any glass or plastic containers

that were dispensed to the patient.

2. Fresh containers are used whenever medicines are dispensed.

B. Manufacturing – diluent 1. Sterile water is used whenever water is used in a manufacturing

recipe, unless the manufacturer recommends otherwise.

C. Cleaning 1. Glassware and other utensils are thoroughly cleaned with HADS

after use.

2. The items are rinsed thoroughly with hot water and left to air dry on a clean towel.

3. After drying, they are to be stored in closed cupboards to prevent dust accumulation.

D. Floor stock 1. Pharmacy will be responsible for all the general cleanliness and

orderliness of all floor stock drugs on the nursing units and specialty departments.

2. This will also be coordinated with the nursing personnel in these areas.

XII. Reference

Infection Control 10

A. 2007 USP NF General Chapter <797> Pharmaceutical Compounding – Sterile Preparations

B. CCR 1751.4, 1735.5 "These guidelines, procedures, or policies herein do not represent the only medically or legally acceptable approach, but rather are presented with the recognition that acceptable approaches exist. Deviations under appropriate circumstances do not represent a breach of a medical standard of care. New knowledge, new techniques, clinical or research data, clinical experience, or clinical or bio-ethical circumstances may provide sound reasons for alternative approaches, even though they are not described in the document."

Unique Plan Description: ANES PACU Opioid Pain Control Medications - Normal Renal Function Plan Selection Display: ANES PACU Opioid Pain Control Medications - Normal Renal Function PlanType: Medical Version: 1 Begin Effective Date: 6/16/2017 16:13 End Effective Date: Current Available at all facilities ANES PACU Opioid Pain Control Medications - Normal Renal Function Medications

Normal Renal Function (CrCl GREATER than 50mL/min)(NOTE)* Pain (Mild level 1-3) Sublimaze

25 mcg, IV Push, Injection, every 5 min, PRN pain, mild (scale 1-3) Comments: (CrCl GREATER than 50 mL/min). Hold if 02 saturation LESS than 92% or Respiratory Rate LESS than 10. MAX total dose = 225 mcg

Dilaudid 0.25 mg, IV Push, Injection, every 5 min, PRN pain, mild (scale 1-3)

Comments: (CrCl GREATER than 50 mL/min). Hold if 02 saturation LESS than 92% or Respiratory Rate LESS than 10. MAX total dose = 3 mg

morphine 2 mg, IV Push, Injection, every 5 min, PRN pain, mild (scale 1-3)


Pain (Moderate level 4-6) Sublimaze

50 mcg, IV Push, Injection, every 5 min, PRN pain, moderate (scale 4-6) Comments: (CrCl GREATER than 50 mL/min). Hold if 02 saturation LESS than 92% or Respiratory Rate LESS than 10. MAX total dose = 225 mcg

Dilaudid 0.5 mg, IV Push, Injection, every 5 min, PRN pain, moderate (scale 4-6)


morphine 4 mg, IV Push, Injection, every 5 min, PRN pain, moderate (scale 4-6)


Pain (Severe level 7-10) Sublimaze

75 mcg, IV Push, Injection, every 5 min, PRN pain, severe (scale 7-10) Comments: (CrCl GREATER than 50 mL/min). Hold if 02 saturation LESS than 92% or Respiratory Rate LESS than 10. MAX total dose = 225 mcg

Dilaudid 1 mg, IV Push, Injection, every 5 min, PRN pain, severe (scale 7-10)


morphine 7 mg, IV Push, Injection, every 5 min, PRN pain, severe (scale 7-10)


Intractable/Unrelieved-Opiate Tolerant methadone

5 mg, IV Push, Injection, every 5 min for 2 doses, PRN other (see comment) Comments: For Intractable, Unrelieved pain in opiate tolerant patients. Hold if 02 saturation LESS than 92% or Respiratory Rate LESS than 10. MAX total dose = 10 mg

*Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

Unique Plan Description: ANES PACU Opioid Pain Control Medications - Renal Patients Plan Selection Display: ANES PACU Opioid Pain Control Medications - Renal Patients PlanType: Medical Version: 1 Begin Effective Date: 6/16/2017 16:21 End Effective Date: Current Available at all facilities ANES PACU Opioid Pain Control Medications - Renal Patients Medications

Renal Patients (CrCl LESS than 50mL/min)(NOTE)* Pain (Mild level 1-3) Sublimaze

25 mcg, IV Push, Injection, every 5 min, PRN pain, mild (scale 1-3) Comments: (CrCl LESS than 50 mL/min). Hold if 02 saturation LESS than 92% or Respiratory Rate LESS than 10. MAX total dose = 225 mcg

Dilaudid 0.25 mg, IV Push, Injection, every 5 min, PRN pain, mild (scale 1-3)

Comments: CrCl LESS than 50 mL/min. Hold if 02 saturation LESS than 92% or Respiratory Rate LESS than 10. MAX total dose = 3 mg

morphine 2 mg, IV Push, Injection, every 5 min, PRN pain, mild (scale 1-3)

Comments: (CrCl LESS than 50 mL/min). Hold if 02 saturation LESS than 92% or Respiratory Rate LESS than 10. MAX total dose = 20 mg

Pain (Moderate level 4-6) Sublimaze

50 mcg, IV Push, Injection, every 5 min, PRN pain, moderate (scale 4-6) Comments: (CrCl LESS than 50 mL/min). Hold if 02 saturation LESS than 92% or Respiratory Rate LESS than 10. MAX total dose = 225 mcg

Dilaudid 0.5 mg, IV Push, Injection, every 5 min, PRN pain, moderate (scale 4-6)

Comments: CrCl LESS than 50 mL/min. Hold if 02 saturation LESS than 92% or Respiratory Rate LESS than 10. MAX total dose = 3 mg

morphine 4 mg, IV Push, Injection, every 5 min, PRN pain, moderate (scale 4-6)


Pain (Severe level 7-10) Sublimaze

75 mcg, IV Push, Injection, every 5 min, PRN pain, severe (scale 7-10) Comments: (CrCl LESS than 50 mL/min). Hold if 02 saturation LESS than 92% or Respiratory Rate LESS than 10. MAX total dose = 225 mcg

Dilaudid 1 mg, IV Push, Injection, every 5 min, PRN pain, severe (scale 7-10)

Comments: CrCl LESS LESS 50 mL/min. Hold if 02 saturation LESS than 92% or Respiratory Rate LESS than 10. MAX total dose = 3 mg

morphine 7 mg, IV Push, Injection, every 5 min, PRN pain, severe (scale 7-10)


Intractable/Unrelieved-Opiate Tolerant methadone

5 mg, IV Push, Injection, every 5 min for 2 doses, PRN other (see comment) Comments: For Intractable, Unrelieved pain in opiate tolerant patients. Hold if 02 saturation LESS than 92% or Respiratory Rate LESS than 10. MAX total dose = 10 mg

Unique Plan Description: Antibiotic POST-Op CABG, Other Cardiac Plan Selection Display: Antibiotic POST-Op CABG, Other Cardiac PlanType: Medical Version: 1 Begin Effective Date: 8/22/2016 16:40 End Effective Date: Current Available at all facilities Plan Comment: removed pathogen notes 6/21/17 per build request dsm; Vanco updated to 2 doses, Ancef to 3 doses, 7/24/17 dsm; reviewed in POD 7/27/17 with changes dsm; doses updated 8/23/17 dsm; Antibiotic POST-Op CABG, Other Cardiac Medications

Recommended Regimen(NOTE)* Ancef

2 g, IV Piggyback, Soln-IV, every 8 hours. for 2 doses, Indication: Prophylaxis, Surgical If MRSA Risk factors add Vancomycin to ceFAZolin (Ancef)(NOTE)* <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY margin:0; P margin:0 </STYLE><META name=GENERATOR content="MSHTML 11.00.9600.18763"></HEAD><BODY>MRSA Risk FactorsKnown colonization with MRSAChronic wound care of hemodialysisNursing home or extended care facility setting within the last yearAcute inpatient hospitalization within the last yearTransfer from another inpatient facility after a minimum 3 day stayContinuous inpatient stay GREATER than 24 hour prior to the principal surgial procedure</BODY></HTML>(NOTE)*

vancomycin 15 mg/kg, IV Piggyback, Soln-IV, every 12 hours. for 1 doses, Indication: Prophylaxis, Surgical

Alternative if documented severe B-lactam allergy(NOTE)* gentamicin

80 mg, IV Piggyback, Soln-IV, every 8 hours. for 2 doses, Indication: Prophylaxis, Surgical [Less Than 81 kg] (DEF)*

120 mg, IV Piggyback, Soln-IV, every 8 hours. for 2 doses, Indication: Prophylaxis, Surgical [Greater Than or Equal To 81 kg]



Unique Plan Description: Antibiotic POST-Op Colon/Abdomen (NON-Gynecological) Plan Selection Display: Antibiotic POST-Op Colon/Abdomen (NON-Gynecological) PlanType: Medical Version: 1 Begin Effective Date: 8/23/2016 14:21 End Effective Date: Current Available at all facilities Plan Comment: removed pathogen notes 6/21/17 per build request dsm; reviewed in POD 7/27/17 dsm;; updated 8/23/17 dsm; Antibiotic POST-Op Colon/Abdomen (NON-Gynecological) Medications

Current guidelines DO NOT require post-op antibiotic dosing in this setting(NOTE)* Recommended Regimen(NOTE)*

Cefotan 2 g, IV Piggyback, Soln-IV, Once, Indication: Prophylaxis, Surgical


80 mg, IV Piggyback, Soln-IV, every 8 hours. for 2 doses, Indication: Prophylaxis, Surgical [Less Than 81 kg] (DEF)*

120 mg, IV Piggyback, Soln-IV, every 8 hours. for 2 doses, Indication: Prophylaxis, Surgical [Greater Than or Equal To 81 kg]

Flagyl 500 mg, IV Piggyback, Soln-IV, every 8 hours. for 2 doses, Indication: Prophylaxis, Surgical


Unique Plan Description: Antibiotic POST-Op Head/Neck Plan Selection Display: Antibiotic POST-Op Head/Neck PlanType: Medical Version: 1 Begin Effective Date: 8/22/2016 16:45 End Effective Date: Current Available at all facilities Plan Comment: removed pathogen notes 6/21/17 per build request dsm; updated 8/23/17 dsm; Antibiotic POST-Op Head/Neck Medications

ONLY for use with clean-contaminated procedures(NOTE)* Recommended Regimen(NOTE)*

Ancef 2 g, IV Piggyback, Soln-IV, Every 8 hours. for 2 doses, Indication: Prophylaxis, Surgical

Flagyl 500 mg, IV Piggyback, Soln-IV, every 8 hours. for 2 doses, Indication: Prophylaxis, Surgical

Alternative if documented severe B-lactam allergy(NOTE)* Cleocin Phosphate Inj

900 mg, IV Piggyback, Soln-IV, every 8 hours. for 2 doses, Indication: Prophylaxis, Surgical *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

Unique Plan Description: Antibiotic POST-Op Neuro/Ortho/Vasc/Podiatry Plan Selection Display: Antibiotic POST-Op Neuro/Ortho/Vasc/Podiatry PlanType: Medical Version: 1 Begin Effective Date: 8/9/2016 16:42 End Effective Date: Current Available at all facilities Plan Comment: removed pathogen notes 6/21/17 per build request dsm; updated 8/23/17 dsm; Antibiotic POST-Op Neuro/Ortho/Vasc/Podiatry Medications


2 g, IV Piggyback, Soln-IV, every 8 hours. for 2 doses, Indication: Prophylaxis, Surgical [Greater Than or Equal To 80 kg]

If MRSA Risk factors may use Vancomycin alone or in combination with ceFAZolin (Ancef)(NOTE)* <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY margin:0; P margin:0 </STYLE><META name=GENERATOR content="MSHTML 11.00.9600.18763"></HEAD><BODY>MRSA Risk FactorsKnown colonization with MRSAChronic wound care of hemodialysisNursing home or extended care facility setting within the last yearAcute inpatient hospitalization within the last yearTransfer from another inpatient facility after a minimum 3 day stayContinuous inpatient stay GREATER than 24 hour prior to the principal surgial procedure</BODY></HTML>(NOTE)*



900 mg, IV Piggyback, Soln-IV, every 8 hours. for 2 doses, Indication: Prophylaxis, Surgical *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

Unique Plan Description: Antibiotic POST-Op Ortho (Open Fracture) Plan Selection Display: Antibiotic POST-Op Ortho (Open Fracture) PlanType: Medical Version: 1 Begin Effective Date: 12/21/2016 16:29 End Effective Date: Current Available at all facilities Plan Comment: removed pathogen notes 6/21/17 per build request dsm; updated 8/23/17 dsm; Antibiotic POST-Op Ortho (Open Fracture) Medications Type I / Type II


2 g, IV Piggyback, Soln-IV, every 8 hours. for 2 doses, Indication: Prophylaxis, Surgical Alternative if documented severe B-lactam allergy(NOTE)*

Cleocin Phosphate Inj 900 mg, IV Piggyback, Soln-IV, every 8 hours. for 2 doses, Indication: Prophylaxis, Surgical

Type III Recommended Regimen(NOTE)*

Ancef 2 g, IV Piggyback, Soln-IV, every 8 hours. for 8 doses, Indication: Prophylaxis, Surgical

Consult to Pharmacy - Gentamicin Dose Per Pharmacy Reason for Consult: Other, please specify, Surgical Prophylaxis - Recommend 5 mg/kg every 24 hr x

2 doses Alternative if documented severe B-lactam allergy(NOTE)*

Cleocin Phosphate Inj 900 mg, IV Piggyback, Soln-IV, every 8 hours. for 8 doses, Indication: Prophylaxis, Surgical

Consult to Pharmacy - Gentamicin Dose Per Pharmacy Reason for Consult: Other, please specify, Surgical Prophylaxis - Recommend 5 mg/kg every 24 hr x

2 doses *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

Unique Plan Description: Antibiotic PRE-Op CABG/Other Cardiac Plan Selection Display: Antibiotic PRE-Op CABG/Other Cardiac PlanType: Medical Version: 1 Begin Effective Date: 8/16/2017 06:36 End Effective Date: Current Available at all facilities Plan Comment: added based on input from Ben and to match the POST anx power plan buil 8/16/17 dsm) Antibiotic PRE-Op CABG/Other Cardiac Medications


2 g, IV Piggyback, Soln-IV, PREOP for 1 doses, Indication: Prophylaxis, Surgical, Administer over: 30 minutes

If MRSA Risk factors add Vancomycin to ceFAZolin (Ancef)(NOTE)* vancomycin

15 mg/kg, IV Piggyback, Soln-IV, PREOP for 1 doses, Indication: Prophylaxis, Surgical Comments: MAX DOSE = 2 g.


80 mg, IV Piggyback, Soln-IV, PREOP for 1 doses, Indication: Prophylaxis, Surgical [Less Than 81 kg] (DEF)*

120 mg, IV Piggyback, Soln-IV, PREOP for 1 doses, Indication: Prophylaxis, Surgical [Greater Than or Equal To 81 kg]

vancomycin 15 mg/kg, IV Piggyback, Soln-IV, PREOP for 1 doses, Indication: Prophylaxis, Surgical

Comments: MAX DOSE = 2 g. *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

Unique Plan Description: Antibiotic PRE-Op Colon/Abdomen (NON-Gynecological) Plan Selection Display: Antibiotic PRE-Op Colon/Abdomen (NON-Gynecological) PlanType: Medical Version: 1 Begin Effective Date: 12/15/2016 09:56 End Effective Date: Current Available at all facilities Plan Comment: removed pathogen notes 6/21/17 per build request dsm; Antibiotic PRE-Op Colon/Abdomen (NON-Gynecological) Medications

Recommended Regimen(NOTE)* Cefotan


Alternative if documented severe B-lactam allergy(NOTE)* Flagyl

500 mg, IV Piggyback, Soln-IV, PREOP for 1 doses, Indication: Prophylaxis, Surgical, Administer over: 1 hr

gentamicin 80 mg, IV Piggyback, Soln-IV, PREOP for 1 doses, Indication: Prophylaxis, Surgical [Less Than 81

kg] (DEF)* 120 mg, IV Piggyback, Soln-IV, PREOP for 1 doses, Indication: Prophylaxis, Surgical [Greater Than

or Equal To 81 kg] *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

Unique Plan Description: Antibiotic PRE-Op Head/Neck Plan Selection Display: Antibiotic PRE-Op Head/Neck PlanType: Medical Version: 1 Begin Effective Date: 12/15/2016 11:08 End Effective Date: Current Available at all facilities Plan Comment: removed pathogen notes 6/21/17 per build request dsm; updated 081617 dsm Antibiotic PRE-Op Head/Neck Medications

ONLY for use with clean-contaminated procedures(NOTE)* Recommended Regimen(NOTE)*

Ancef 2 g, IV Piggyback, Soln-IV, PREOP for 1 doses, Indication: Prophylaxis, Surgical, Administer over:

30 minutes Flagyl

500 mg, IV Piggyback, Soln-IV, PREOP for 1 doses, Indication: Prophylaxis, Surgical, Administer over: 1 hr


900 mg, IV Piggyback, Soln-IV, PREOP for 1 doses, Indication: Prophylaxis, Surgical, Administer over: 30 minutes


Unique Plan Description: Antibiotic PRE-Op Neuro/Ortho/Vasc/Podiatry Plan Selection Display: Antibiotic PRE-Op Neuro/Ortho/Vasc/Podiatry PlanType: Medical Version: 1 Begin Effective Date: 12/15/2016 10:46 End Effective Date: Current Available at all facilities Plan Comment: removed pathogen notes 6/21/17 per build request dsm; updated 8/16/17 dsm; updated clinda 8/23/17 dsm; Antibiotic PRE-Op Neuro/Ortho/Vasc/Podiatry Medications



If MRSA Risk factors may use Vancomycin alone or in combination with ceFAZolin (Ancef)(NOTE)* vancomycin

15 mg/kg, IV Piggyback, Soln-IV, PREOP for 1 doses, Indication: Prophylaxis, Surgical, Administer over: 1 hr [Less Than 80 kg]

Comments: MAX DOSE = 2 g. Alternative if documented severe B-lactam allergy(NOTE)*

Cleocin Phosphate Inj 900 mg, IV Piggyback, Soln-IV, PREOP for 1 doses, Indication: Prophylaxis, Surgical, Administer

over: 30 minutes *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

Unique Plan Description: Antibiotic PRE-Op Urology (NON-Penile Prosthesis) Plan Selection Display: Antibiotic PRE-Op Urology (NON-Penile Prosthesis) PlanType: Medical Version: 1 Begin Effective Date: 12/15/2016 11:18 End Effective Date: Current Available at all facilities Plan Comment: removed pathogen notes 6/21/17 per build request dsm; updated 8/16/17 dsm; Antibiotic PRE-Op Urology (NON-Penile Prosthesis) Medications



Alternative if documented severe B-lactam allergy(NOTE)* Levaquin

500 mg, IV Piggyback, Soln-IV, PREOP for 1 doses, Indication: Other (Please specify in comments), Administer over: 1 hr

Comments: Prophylaxis - Surgical. *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

Unique Plan Description: Antibiotic PRE-Op Urology (Penile Prosthesis) Plan Selection Display: Antibiotic PRE-Op Urology (Penile Prosthesis) PlanType: Medical Version: 1 Begin Effective Date: 12/15/2016 11:28 End Effective Date: Current Available at all facilities Plan Comment: removed pathogen notes 6/21/17 per build request dsm; updated 8/16/17 dsm; Antibiotic PRE-Op Urology (Penile Prosthesis) Medications



gentamicin 80 mg, IV Piggyback, Soln-IV, PREOP for 1 doses, Indication: Prophylaxis, Surgical [Less Than 81

kg] (DEF)* 120 mg, IV Piggyback, Soln-IV, PREOP for 1 doses, Indication: Prophylaxis, Surgical [Greater Than

or Equal To 81 kg] Alternative if documented severe B-lactam allergy(NOTE)*

Cleocin Phosphate Inj 900 mg, IV Piggyback, Soln-IV, PREOP for 1 doses, Indication: Prophylaxis, Surgical, Administer

over: 30 minutes gentamicin

80 mg, IV Piggyback, Soln-IV, PREOP for 1 doses, Indication: Prophylaxis, Surgical [Less Than 81 kg] (DEF)*

120 mg, IV Piggyback, Soln-IV, PREOP for 1 doses, Indication: Prophylaxis, Surgical [Greater Than or Equal To 81 kg]


Unique Plan Description: CC Electrolyte Protocol Plan Selection Display: CC Electrolyte Protocol PlanType: Medical Version: 1 Begin Effective Date: 7/3/2017 13:33 End Effective Date: Current Available at: KD Med Cntr Plan Comment: built from Nursing Communication Order for Electrolyte Replacement ProtocoL 7/25/17 dsm; CC Electrolyte Protocol Patient Care

Refer to Electrolyte Replacement Protocol for administration and lab draw direction.(NOTE)* Medications Potassium Replacement

Oral(NOTE)* potassium chloride

20 mEq, Oral, Liquid, Once (DEF)* Comments: Dilute in water or juice

20 mEq, NG Tube, Liquid, Once Comments: Dilute in water or juice

40 mEq, Oral, Liquid, Once Comments: Dilute in water or juice

40 mEq, NG Tube, Liquid, Once Comments: Dilute in water or juice

40 mEq, Oral, Liquid, every 2 hours. for 2 doses Comments: Dilute in water or juice

40 mEq, NG Tube, Liquid, every 2 hours. for 2 doses Comments: Dilute in water or juice

For IV PERIPHERAL Line(NOTE)* potassium chloride for peripheral IV

10 mEq, IV Piggyback, Soln-IV, every 1 hr for 2 doses, Administer over: 1 hr (DEF)* Comments: Total Dose = 20 mEq

10 mEq, IV Piggyback, Soln-IV, every 1 hr for 4 doses, Administer over: 1 hr Comments: Total Dose = 40 mEq


For IV CENTRAL Line(NOTE)* potassium chloride for central IV

20 mEq, IV Piggyback, Soln-IV, Once, Administer over: 1 hr (DEF)* Comments: Total Dose = 20 mEq



Lab(NOTE)* Renal Panel 2 (BMP+Mg,Phos,Uric)

Blood, Routine, T;N, Nurse collect Comments: Draw per Elecrolyte Replacement Protocol. Nurse to coordinate with lab as needed.

Magnesium Replacement magnesium sulfate

1 g, IV Piggyback, Soln-IV, Once, Administer over: 1 hr (DEF)* 2 g, IV Piggyback, Soln-IV, Once, Administer over: 1 hr 2 g, IV Piggyback, Soln-IV, every 1 hr for 2 doses, Administer over: 1 hr

Comments: Total Dose = 4 Gram Lab(NOTE)*

Renal Panel 2 (BMP+Mg,Phos,Uric)


Calcium Replacement calcium gluconate

1 g, IV Piggyback, Soln-IV, Once, Administer over: 1 hr (DEF)* Comments: 4.6 mEq = 1 Gram

2 g, IV Piggyback, Soln-IV, Once, Administer over: 1 hr Comments: 9.2 mEq = 2 Grams

Lab(NOTE)* Calcium, Ionized (Serum)


Phosphorus Replacement sodium phosphate

30 mmol, IV Piggyback, Soln-IV, Once, Administer over: 4 hr Lab(NOTE)*

Renal Panel 2 (BMP+Mg,Phos,Uric) Blood, Routine, T;N, Nurse collect

Comments: Draw per Elecrolyte Replacement Protocol. Nurse to coordinate with lab as needed.


Unique Plan Description: CC General ICU Admission Plan Selection Display: CC General ICU Admission PlanType: Medical Version: 4 Begin Effective Date: 4/25/2017 09:38 End Effective Date: Current Available at: KD Med Cntr Plan Comment: reviewed 4/25/17 in POD; Plasma-Lyte bolus added 6/6/17 BB; updates made 6/21/17 dsm; CC General ICU Admission Admit/Transfer/Discharge/Status Admit to Inpatient

Level of Care: ICU (DEF)* Level of Care: CVICU

Patient Care Vital Signs

T;N, every 1 hr, Per Standard of Care (DEF)* every 2 hr, Per standard of care every 4 hr, Per standard of care

Intake and Output T;N, every 1 hr, Per Standard of Care (DEF)* every 2 hr, Per Standard of Care every 4 hr, Per Standard of Care every 6 hr, Per Standard of Care every 8 hr, Per Standard of Care

Weight in Kilograms Daily

Neurological Checks every 1 hr (DEF)* every 2 hr every 4 hr every 6 hr every 12 hr

No Blood Pressure (BP) or Veno-Arterial Punctures Left Upper extremity restriction (DEF)* Right Upper extremity restriction Bilateral Upper extremity restriction Left Lower extremity restriction Right Lower extremity restriction Bilateral Lower extremity restriction

VTE Prophylaxis Guidelines Lines/Tubes/Drains Peripheral IV

unless already in place Peripheral IV

second, unless already in place Arterial Line Arterial Line Care Central Line Care Insert Indwelling Urinary Catheter

Reason: Q1HR output monitoring in Critical Care (DEF)* Reason: Neurogenic Bladder Reason: Urinary tract obstruction

Chest Tube Care -20 cm water suction, Place to Water Seal with activity

Nasogastric (NG) Tube Insertion Nasogastric (NG) Tube Care

Tube to Low Intermittent Suction (DEF)* Tube to Low Constant Suction Tube to Clamped, Check residuals every 4 hr

Orogastric (OG) Tube Insertion Orogastric (OG) Tube Care

Tube to Low Intermittent Suction (DEF)* Tube to Low Constant Suction Tube to Clamped, Check residuals every 4 hr

Activity Head of Bed

30 degrees or greater (DEF)* 45 degrees or greater flat trendelenburg reverse trendelenburg

Up with Assistance Up to Chair

BID (DEF)* TID As tolerated

Bedrest with Bathroom Privileges Bedrest (strict)

Reason: Hemodynamic Instability (DEF)* Reason: Femoral Vascular Catheter Reason: Intra-Aortic Balloon Pump Reason: Intracranial Pressure Monitoring Reason: Open Abdomen Reason: Unstable C-Spine

Ambulate BID (DEF)* TID QID

Diet/Nutrition NPO

Except for Medications (DEF)* No Exceptions Except for Ice Chips Except for Sips of Water

Regular Diet Cardiac Diet

Low Cholesterol/Low Fat (DEF)* Renal Medium (1,700-2,000 cal) 75g CHO, Low Cholesterol/Low Fat Renal, Medium (1,700-2,000 cal) 75g CHO, Low Cholesterol/Low Fat

Diabetic Diet Diabetic

Renal Diet Renal

Continuous Infusions Bolus Sodium Chloride 0.9% Bolus

30 mL/kg, IV Bolus, Soln-IV, Once (DEF)*

500 mL, IV Bolus, Soln-IV, Once 1,000 mL, IV Bolus, Soln-IV, Once

Lactated Ringers Bolus 30 mL/kg, IV Bolus, Soln-IV, Once (DEF)* 500 mL, IV Bolus, Soln-IV, Once 1,000 mL, IV Bolus, Soln-IV, Once

Plasma-Lyte A PH-7.4 BOLUS 30 mL/kg, IV Bolus, Soln-IV, Once (DEF)* 500 mL, IV Bolus, Soln-IV, Once 1,000 mL, IV Bolus, Soln-IV, Once

IV Continuous Drips Lactated Ringers Drip

1,000 mL, IV, 100 mL/hr Sodium Chloride 0.9%

1,000 mL, IV, 100 mL/hr Dextrose 5% with 0.45% NaCl and KCl 20 mEq/L

1,000 mL, IV, 100 mL/hr Dextrose 10% in Water

1,000 mL, IV, 100 mL/hr Common IV Fluids(SUB)* Cardiovascular Drips

<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY margin:0; P margin:0 </STYLE><META name=GENERATOR content="MSHTML 11.00.9600.18739"></HEAD><BODY>NorEPINEPHrine (levophed) starting rate 0.01 mcg/kg/min</BODY></HTML>(NOTE)*

Levophed 4 mg/Dextrose 5% Water 250 mL IV (IVS)* Dextrose 5% Water*

250 mL, IV, Titration instructions: 0.02 mcg/kg/min every 1-2min, Max Dose: 3 mcg/kg/min, Goal: MAP more than 65

norepinephrine IV additive 4 mg, EB, 0.01 mcg/kg/min

<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY margin:0; P margin:0 </STYLE><META name=GENERATOR content="MSHTML 11.00.9600.18739"></HEAD><BODY>Vasopressin rate 0.03 units/min</BODY></HTML>(NOTE)*

vasopressin (Pitressin) 100 units/Sodium Chloride 0.9% 100 mL* (IVS)* Sodium Chloride 0.9%*

100 mL, IV, Goal: n/a vasopressin IV additive

100 units, EB, 0.03 unit/min CC Vasoactive Drips(SUB)* Medications VTE Prophylaxis

To address VTE prophylaxis, order chemical and/or mechanical VTE prophylaxis via the subphase(s) below. Or to document a risk score and/or contraindication to prophylaxis, select the VTE Advisor order below(NOTE)*

VTE Critical Care Patients(SUB)* VTE Prophylaxis Guidelines Sedation CC Analgesia and Sedation Management(SUB)*

Glycemic Control GM IV Insulin Infusion(SUB)* GM Subcut Eating (basal/bolus + correction)(SUB)* GM Subcut NPO/Continuous Enteral Feeding (basal + correction)(SUB)* Gastrointestinal Agents Pepcid

20 mg, IV Push, Injection, every 12 hours. (DEF)* 20 mg, Oral, Tab, every 12 hours. 20 mg, NG Tube, Tab, every 12 hours.

Protonix 40 mg, Oral, Tab-DR, Daily

Comments: Do not crush or chew. Respiratory Medications Proventil 2.5 mg/3 mL (0.083%) inhalation solution

2.5 mg, NEB, Device: Aerosol, Soln-Inhalation, Resp every 4 hours (DEF)* 2.5 mg, NEB, Device: Aerosol, Soln-Inhalation, Resp every 6 hours

Proventil 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg, NEB, Device: Aerosol, Soln-Inhalation, Resp every 4 hours, PRN shortness of breath or

wheezing (DEF)* 2.5 mg, NEB, Device: Aerosol, Soln-Inhalation, Resp every 2 hours, PRN shortness of breath or

wheezing 2.5 mg, NEB, Device: Aerosol, Soln-Inhalation, Resp every 6 hours, PRN shortness of breath or

wheezing Proventil HFA 90 mcg/inh inhalation aerosol

6 inh, Inhale, Aerosol, Resp every 4 hours (DEF)* 2 inh, Inhale, Aerosol, Resp every 4 hours

Atrovent 0.02% 500 mcg/2.5 mL solution for nebulization 0.5 mg, NEB, Device: Aerosol, Soln-Inhalation, Resp every 4 hours (DEF)* 0.5 mg, NEB, Device: Aerosol, Soln-Inhalation, Resp every 6 hours

Atrovent 0.02% 500 mcg/2.5 mL solution for nebulization 0.5 mg, NEB, Device: Aerosol, Soln-Inhalation, Resp every 4 hours, PRN shortness of breath or

wheezing (DEF)* 0.5 mg, NEB, Device: Aerosol, Soln-Inhalation, Resp every 2 hours, PRN shortness of breath or

wheezing 0.5 mg, NEB, Soln-Inhalation, Resp every 6 hours, PRN shortness of breath or wheezing

Brovana 15 mcg/2 mL inhalation solution 15 mcg, NEB, Device: Aerosol, Soln-Inhalation, Resp BID

Pulmicort Respules 0.5 mg/2 mL inhalation suspension 0.5 mg, NEB, Susp, Resp BID

Diuretics Lasix

40 mg, IV Push, Injection, BID Antibiotics ID Empiric Severe Sepsis (Unknown Source) Antibiotics(SUB)* ID Empiric Pneumonia HCAP/HAP/VAP Antibiotics(SUB)* ID Empiric Pneumonia CAP Antibiotics(SUB)* ID Empiric Skin and Soft Tissue Infection (SSTI/Cellulitis) Antibiotics(SUB)* ID Empiric Urinary Tract Infection (UTI) Antibiotics(SUB)* ID Clostridium Difficile (C.Diff) Antibiotics(SUB)* ID Empiric Febrile Neutropenia Antibiotics(SUB)* ID Empiric Intra-Abdominal Infection Antibiotics(SUB)* ID Empiric Meningitis Antibiotics(SUB)* Smoking Cessation Medications

Smoking and Tobacco Cessation(SUB)* Laboratory CBC w/ Diff

Blood, Stat, T;N PTT

Blood, Stat, T;N PT/INR

Blood, Stat, T;N Basic Metabolic Panel

Blood, Stat, T;N CMP

Blood, Stat, T;N Magnesium Level

Blood, Stat, T;N Phosphorus Level

Blood, Stat, T;N Ammonia Level

Blood, Stat, T;N Lipase Level

Blood, Stat, T;N Troponin-I (cardiac marker)

Blood, Stat, T;N Creatine Kinase

Blood, Stat, T;N B-Type Natriuretic Peptide (BNP)

Blood, Stat, T;N Hemoglobin A1c (Glycosylated)

Blood, Stat, T;N Lactic Acid, Plasma (Venous)

Blood, Stat, T;N Procalcitonin

Blood, Stat, T;N Liver Panel

Blood, Stat, T;N Urinalysis with Microscopic

Urine, Stat Collect, T;N, Nurse collect Sputum Culture

Stat collect, ST - Stat, T;N Drugs of Abuse Screen, Urine toxicology

Urine, Stat Collect, T;N, Nurse collect Blood Culture X 2 Lab to Draw(SUB)* POC Arterial Blood Gas (ABG) POC Venous Blood Gas (VBG) Type and Screen Only CC Add On Labs(SUB)* Morning Labs CBC w/ Diff

Blood, AM Draw (Inpatient Only), T+1;0330 PTT

Blood, AM Draw (Inpatient Only), T+1;0330 PT/INR

Blood, AM Draw (Inpatient Only), T+1;0330

Basic Metabolic Panel Blood, AM Draw (Inpatient Only), T+1;0330

CMP Blood, AM Draw (Inpatient Only), T+1;0330

Troponin-I (cardiac marker) Blood, AM Draw (Inpatient Only), T+1;0330

Lactic Acid, Plasma (Venous) Blood, AM Draw (Inpatient Only), T+1;0330

Liver Panel Blood, AM Draw (Inpatient Only), T+1;0330

Microbiology Communication Order

Blood culture times 2 for temperature greater than 38.5C degrees, unless previous blood cultures have been obtained in the past 48 hours

Diagnostic Tests XR Chest 1 View Portable

ASAP, Reason: Shortness of breath (DEF)* Stat, Reason: Shortness of breath Routine, Reason: Shortness of breath

XR Chest 1 View Portable In AM, Reason: Shortness of breath

XR Abdomen KUB 1 View ASAP, Reason: Abdominal pain (DEF)* Stat, Reason: Abdominal pain Routine, Reason: Abdominal pain ASAP, Reason: Feeding tube placement Routine, Reason: Feeding tube placement

CT Brain/Head w/o Contrast ASAP, Reason: Altered level of consciousness (DEF)* Stat, Reason: Altered level of consciousness Routine, Reason: Altered level of consciousness

CT Abdomen and Pelvis w/o Contrast ASAP, Reason: Abdominal pain (DEF)* ASAP, Reason: Ascites ASAP, Reason: Bowel obstruction ASAP, Reason: Sepsis ASAP, Reason: Pancreatitis, known

CT Abdomen and Pelvis w/ Contrast ASAP, Reason: Abdominal pain (DEF)* Stat, Reason: Abdominal pain Routine, Reason: Abdominal pain

CT Chest W/ Contrast ASAP

CT Chest WO Contrast ASAP

CT Angio Chest ASAP

Card/Vasc/Neuro Electrocardiogram 12 lead

ASAP, Reason: Arrhythmia(s), symptomatic (DEF)* ASAP, Reason: Chest Pain ASAP, Reason: Drug Toxicity ASAP, Reason: Dyspnea ASAP, Reason: Effects of Pharmacotherapy

ASAP, Reason: Electroylte Abnormality ASAP, Reason: Pulmonary Disorder(s), Acute/Chronic ASAP, Reason: Syncope or Pre-syncope ASAP, Reason: TIA and/or CVA

Respiratory Oxygen Therapy

SpO2 goal 92% or GREATER, Use least amount of O2 to maintain oxygen level within parameters. (DEF)*

SpO2 goal 90 - 94 % SpO2 goal 90% or GREATER SpO2 goal 94% or GREATER SpO2 goal 89 - 94 %

Patient may use CPAP/BiPAP machine from home

CC Ventilator Management Adult(SUB)* Consults/Referrals OT Evaluation and Treatment Acute PT Evaluation and Treatment Acute SLP Evaluation and Treatment Acute Consult to Wound Care Specialist Consult to Practitioner Communication Orders Notify Treating Practitioner Vital Signs

Systolic BP GREATER than 200 mmHg, Systolic BP LESS than 90 mmHg, Mean AP LESS than 65 mmHg, HR GREATER than 130 beats/min, HR LESS than 60 beats/min, RR GREATER than 35 breaths/min, RR LESS than 10 breaths/min, SpO2 LESS than 90 %, Urine Output LESS t...


Unique Plan Description: ED Pneumonia Suspected Plan Selection Display: ED Pneumonia Suspected PlanType: Medical Version: 1 Begin Effective Date: 10/26/2016 13:32 End Effective Date: Current Available at: KD Med Cntr Plan Comment: MD Order Only-Pneumonia (Order Medications via Grouped Orders 2/9/17 dsm; NS removed per Dr. Hipskind for all ED (non-sp) plans 2/20/17 dsm; updated 8/14/17 ekg rbb ED Pneumonia Suspected Patient Care

This plan contains orders related to all types of pneumonia. If Sepsis is suspected, refer to ED Sepsis I and ED Sepsis II(NOTE)*

Vital Signs T;N, Per unit protocol

Cardiac Monitoring ED T;N

Pulse Oximetry Continuous T;N, Constant Indicator

Weight in Kilograms T;N

Peripheral IV T;N, If not already placed

Continuous Infusions Bolus Lactated Ringers Bolus

500 mL, IV Bolus, Soln-IV, Once Maintenance Infusions Lactated Ringers Injection

1,000 mL, IV, 30 mL/hr Laboratory CBC w/ Diff

Blood, Stat, T;N, Nurse collect BMP Basic Metabolic Panel

Blood, Stat, T;N, Nurse collect VBG ED Alert Panel

Blood, Stat, T;N, Nurse collect ABG ED Alert Panel

Blood, Stat, T;N, Once, Nurse collect Sputum Culture

Sputum, Stat collect, ST - Stat, T;N Blood Culture X 2 Lab to Draw(SUB)* Blood Culture X 2 RN to Draw(SUB)* Diagnostic Tests Radiology XR Chest 2 Views

T;N, Stat XR Chest 1 View Portable

T;N, Stat Card/Vasc/Neuro EKG (ED)

T;N, Stat Respiratory

Oxygen Therapy Stat, Flow Rate (L/min): 2, SpO2 goal 94% or GREATER, Nasal Cannula, Contact practitioner if the

pt. has an increase in O2 requirements or inability to maintain SpO2 as specified Respiratory Therapy to Evaluate

T;N, Stat, Oxygen Therapy *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

Unique Plan Description: ED Seizure Plan Selection Display: ED Seizure PlanType: Medical Version: 1 Begin Effective Date: 2/9/2017 10:00 End Effective Date: Current Available at: KD Med Cntr ED Seizure Patient Care Vital Signs

T;N, every 2 hr, Per unit protocol Cardiac Monitoring ED

T;N Neurological Assessment

T;N, Include Glascow Coma Scale Pulse Oximetry Continuous

T;N Seizure Precautions

Weight in Kilograms

T;N, Once Peripheral IV

T;N, If not already present Medications Keppra

1 g, IV Piggyback, Injection, Once Laboratory Blood Glucose Monitoring POC

T;N, Once VBG ED Alert Panel

Blood, Stat, T;N, Nurse collect Drug Screen, ER Urine

Urine, Stat Collect, T;N, Nurse collect BMP Basic Metabolic Panel

Blood, Stat, T;N, Nurse collect Dilantin Level

Blood, Stat, T;N, Nurse collect Depakote Level

Blood, Stat, T;N, Nurse collect Phenytoin Level

Blood, Stat, T;N, Nurse collect Phenobarbital Level

Blood, Stat, T;N, Nurse collect Carbamazepine Level

Blood, Stat, T;N, Nurse collect Diagnostic Tests CT Brain/Head w/o Contrast

T;N, Stat MRI Brain w/o Contrast

T;N, Stat, 0 Respiratory Oxygen Therapy

Stat, Flow Rate (L/min): 15, SpO2 goal 94% or GREATER, Non-Rebreather Mask, Contact practitioner if the pt. has an increase in O2 requirements or inability to maintain SpO2 as specified (DEF)*

Stat, Flow Rate (L/min): 2, SpO2 goal 94% or GREATER, Nasal Cannula, Contact practitioner if the pt. has an increase in O2 requirements or inability to maintain SpO2 as specified

Respiratory Therapy to Evaluate T;N, Stat, Oxygen Therapy


Unique Plan Description: ED Trauma Major Alert Plan Selection Display: ED Trauma Major Alert PlanType: Medical Version: 2 Begin Effective Date: 3/7/2017 08:22 End Effective Date: Current Available at: KD Med Cntr Plan Comment: DCW build dsm 2/6/17; meds updated 2/13/17 dsm; revi ewed/updated 3/7/17 dsm; ED Trauma Major Alert Patient Care Trauma Alert

T;N, Call Major Trauma Alert Communication Order

T;N, Initiate Trauma Protocol, Trauma Packet and Trauma Flowsheet Weight in Kilograms

T;N Blood Pressure

T,N, Manual Blood Pressure x1 - If SBP LESS than 100 mmHg continue manual every 5 minutes Blood Pressure

T;N, Monitor BP every 5 minutes x 1 hour and/or cleared by practitioner AND every 15 minutes thereafter

Cardiac Monitoring ED T;N

Neurological Checks T;N, Include Glasgow Coma Scale (GCS) every 30 minutes

Consumption with CAGE Screening T;N

Oximetry - Continuous T,N

Warming Measures T;N, Assure patient warmth to keep body temperature greater than 36C (96.8F)

Communication Order T;N, Clothing to be removed, as well as jewelry, contact lenses, dentures, piercings, etc

Communication Order T;N, Pediatric Crash cart in room for patient 14 years and younger

Lines/Tubes/Drains Peripheral IV

T;N, Large bore IV if not already placed Peripheral IV

T;N, Large bore IV if not already placed Rapid Fluid Warmer

Level One Insert Foley

Post rectal exam completion by practitioner Activity Bedrest (strict)

T;N, Trauma Comments: Major Trauma

Each splint will require a unique Splint Application Order(NOTE)* Splint Application - Prefabricated

Cervical Collar Rigid Splint Application - Custom Thermoplastic

Splint Application - Prefabricated Diet/Nutrition NPO

T;N Continuous Infusions Bolus Sodium Chloride 0.9% Bolus

1,000 mL, IV Bolus, Soln-IV, Once IV Maintenance Sodium Chloride 0.9%

1,000 mL, IV, 100 mL/hr (DEF)* 1,000 mL, IV, 30 mL/hr

Medications Boostrix (Tdap)

0.5 mL, IM, Susp-Inj, As Directed for 1 doses Comments: If no Tetanus booster within 7 years or unable to verify Tetanus status

fentaNYL 1 mcg/kg, IV Push, Injection, Once

Ancef 2 g, IV Piggyback, Soln-IV, Once

Tranexamic Acid recommended if injury occured LESS than 3 hours.(NOTE)* tranexamic acid

1 g, IV Piggyback, Injection, Once, Administer over: 10 minutes Laboratory VBG ED Alert Panel

Blood, Stat, T;N, Nurse collect Alcohol Level

Blood, Stat, T;N, Nurse collect CBC w/ Diff


Blood, Stat, T;N, Nurse collect PTT


Urine, Stat Collect, T;N, Nurse collect Urinalysis

Stat Collect, T;N, Nurse collect PT (with INR)

Blood, Stat, T;N, Nurse collect Type and Screen Only

Stat, T;N, Once HCG Qualitative Serum

Blood, Stat, T;N, Nurse collect Lactic Acid, Plasma (Venous)

Blood, Stat, T;N, Nurse collect ABG

Blood, Stat, T;N, Once, Nurse collect Comments: Add O2 source and flow

Order Teg Platelet IF patient is over age 65 OR on antiplatelet agent(NOTE)* Teg Platelet Mapping

Blood, Stat, T;N, Nurse collect Blood Bank

PROTOCOL: Massive Transfusion (MTP) Protocol T;N

For Emergency Blood Release, select the "Blood Products: Transfuse Now" Sub Phase(NOTE)* Blood Products: Transfuse Now(SUB)* Diagnostic Tests FOCUSED US Abdomen(ED Practitioner Bedside)

T;N, Trauma FOCUSED US Chest (ED Practitioner Bedside)

T;N, Trauma FOCUSED US Cardiac (ED Practitioner Bedside)

T;N, Trauma XR Chest 1 View Portable

T;N, Stat XR Spine Cervical 1 View

T;N, Stat XR Spine Thoracic 1 View

T;N, Stat XR Spine Lumbar 1 View

T;N, Stat XR Pelvis 1 or 2 Views

T;N, Stat Respiratory Oxygen Therapy

Trauma, Flow Rate (L/min): 2, SpO2 goal 94% or GREATER, Nasal Cannula, Contact practitioner if the pt. has an increase in O2 requirements or inability to maintain SpO2 as specified (DEF)*

Trauma, Flow Rate (L/min): 15, SpO2 goal 94% or GREATER, Non-Rebreather Mask, Contact practitioner if the pt. has an increase in O2 requirements or inability to maintain SpO2 as specified

Respiratory Therapy to Evaluate T;N, Trauma, Oxygen Therapy


Unique Plan Description: ED Trauma Moderate Alert Plan Selection Display: ED Trauma Moderate Alert PlanType: Medical Version: 1 Begin Effective Date: 11/30/2016 11:29 End Effective Date: Current Available at all facilities Plan Comment: name updated, meds added, all items reviewed 3/7/17 dsm; ED Trauma Moderate Alert Patient Care Trauma Alert

T;N, Call Moderate Trauma Alert Communication Order

T;N, Initiate Trauma Protocol, Trauma Packet and Trauma Flowsheet Weight in Kilograms

T;N Blood Pressure

T,N, Manual Blood Pressure x1 Vital Signs

T,N, Every 30 minutes. Once cleared by treating practitioner, can change to every 60 minutes Cardiac Monitoring ED

T;N Neurological Checks

T;N, GCS baseline on arrival then every hour until cleared by practitioner Consumption with CAGE Screening

T;N Oximetry - Continuous

T,N Warming Measures

T,N, Assure patient warmth to keep body temperature greater then 36C (96.8F) Communication Order

T;N, Clothing to be removed, as well as jewelry, contact lenses, dentures, piercings, etc Communication Order

T;N, Pediatric Crash cart in room for patient 14 years and younger Lines/Tubes/Drains Peripheral IV

T,N, Large Bore IV if not already placed Peripheral IV

T,N, Large Bore IV if not already placed Insert Foley

Post rectal exam completion by Practitioner Activity

Each splint will require a unique Splint Application Order(NOTE)* Splint Application - Custom Thermoplastic Splint Application - Prefabricated Continuous Infusions Sodium Chloride 0.9%

1,000 mL, IV, 30 mL/hr Medications Boostrix (Tdap)

0.5 mL, IM, Susp-Inj, As Directed for 1 doses Comments: Give only if patient has not receieved within last 7 years or cannot get information from patient.

fentaNYL 1 mcg/kg, IV Push, Injection, Once

Ancef 2 g, IV Piggyback, Soln-IV, Once

Laboratory Alcohol Level

Blood, Stat, T;N, Nurse collect CBC w/ Diff


Blood, Stat, T;N, Nurse collect PT (with INR)


Urine, Stat Collect, T;N, Nurse collect Urinalysis

Urine, Stat Collect, T;N, Nurse collect Type and Screen Only

Blood, Stat, T;N, Nurse collect HCG Qualitative Serum

Blood, Stat, T;N, Nurse collect Blood Bank PROTOCOL: Massive Transfusion (MTP) Protocol

T;N For Emergency Blood Release, select the "Blood Products: Transfuse Now" Sub Phase(NOTE)*

Blood Products: Transfuse Now(SUB)* Diagnostic Tests FOCUSED US Abdomen(ED Practitioner Bedside)

T;N, Trauma FOCUSED US Cardiac (ED Practitioner Bedside)

T;N, Trauma FOCUSED US Chest (ED Practitioner Bedside)

T;N, Trauma XR Chest 1 View Portable

T;N, Stat XR Spine Cervical 1 View

T;N, Stat XR Spine Thoracic 1 View

T;N, Stat XR Spine Lumbar 1 View

T;N, Stat XR Pelvis 1 or 2 Views

T;N, Stat Respiratory Oxygen Therapy

Trauma, Flow Rate (L/min): 2, SpO2 goal 94% or GREATER, Nasal Cannula, Contact MD if the pt. has an increase in O2 requirements or inability to maintain SpO2 as specified (DEF)*

Trauma, Flow Rate (L/min): 15, SpO2 goal 94% or GREATER, Non-Rebreather Mask, Contact MD if the pt. has an increase in O2 requirements or inability to maintain SpO2 as specified

Respiratory Therapy to Evaluate T;N, Trauma, Oxygen Therapy

*Report Legend:

Unique Plan Description: MED POST PICC Insertion Care Plan Selection Display: MED POST PICC Insertion Care PlanType: Medical Version: 1 Begin Effective Date: 7/26/2017 14:57 End Effective Date: Current Available at all facilities Plan Comment: updated meds per ORC 9/1/17; MED POST PICC Insertion Care Patient Care PICC Line PICC Line OK to Use PICC Line Care

T;N, every week, Change dressing 24 hours after insertion then weekly and prn PICC Line Care

Verify patency of PICC line prior to DISCHARGE by assessing for brisk blood return and no resistance with flushing

sodium chloride 0.9% flush 10 mL, IV Push, Soln, every 12 hours.

Comments: PICC Catheter ALL Lumens sodium chloride 0.9% flush

20 mL, IV Push, Soln, As Directed, PRN other (see comment) Comments: All ports PICC after blood draws

Midline Catheter Midline Catheter Care

Change dressing every week and prn sodium chloride 0.9% flush

10 mL, IV Push, Soln, every 12 hours. Comments: Midline single lumen

sodium chloride 0.9% flush 20 mL, IV Push, Soln, As Directed, PRN other (see comment)

Comments: Midline single lumen after blood draws Medications Cathflo Activase

2 mg, Intracatheter, Injection, As Directed for 2 doses (DEF)* Comments: Administer 2mg to each lumen of the PICC catheter and let dwell for 60-120 minutes

2 mg, Intracatheter, Injection, Once Comments: Administer 2mg to lumen of the PICC catheter and let dwell for 60-120 minutes

Diagnostic Tests XR Chest 1 View Portable

Stat, Reason: Line placement *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

Unique Plan Description: NICU Discharge Plan Selection Display: NICU Discharge PlanType: Medical Version: 1 Begin Effective Date: 8/25/2014 12:07 End Effective Date: Current Available at all facilities NICU Discharge Admit/Transfer/Discharge/Status Discharge Patient

T;N, Home (DEF)* T;N, As per CPS and Social Work T;N, Another Hospital

Patient Care PRE Discharge Orders

These orders will be carried out PRIOR to patient discharge(NOTE)* Fax newborn record and discharge summary Peripheral IV Discontinue Central Venous Catheter Discontinue Discontinue IV Fluids DISCHARGE Instructions

These orders are for POST discharge instructions and will flow to the Patient Discharge Instructions(NOTE)* Discharge Diet Instruction

Other (please specify), Breastfeed (DEF)* Other (please specify), Ad lib per cues around the clock

Activity(NOTE)* Discharge Activity Restrictions

As tolerated Discharge Patient Instructions

Call your child's primary doctor or go to the Emergency Department for temperature GREATER than 100.4 degrees F (DEF)*

Call your child's primary doctor or go to the Emergency Department for vomiting large volumes or many times

Call your child's primary doctor or go to the Emergency Department for many loose watery stools Call your child's primary doctor or go to the Emergency Department for missing more than 2

feedings Call your child's primary doctor or go to the Emergency Department if not waking up to feed Call your child's primary doctor or go to the emergency room for respiratory distress or working hard

to breathe Call your child's primary doctor or go to the emergency room for fewer than 6 wet diapers in 24

hours Non Categorized Initial Approval Date Annual Review Date *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

Unique Plan Description: NICU FentaNYL Continuous Infusion Plan Selection Display: NICU FentaNYL Continuous Infusion Plan Synonyms: NICU Sublimaze Continuous Infusion PlanType: Medical Version: 1 Begin Effective Date: 12/6/2016 13:56 End Effective Date: Current Available at all facilities NICU FentaNYL Continuous Infusion Patient Care Communication Order

Continuous respiratory rate, heart rate and oxygen saturation monitoring Blood Pressure

As Directed, Continuous blood pressure monitoring (intra-arterial pressure preferred) Communication Order

If GREATER than 5 days of sustained use of FentaNYL, monitor for signs of withdrawal upon discontinuation

Communication Order Observe for abdominal distention, loss of bowel sounds and muscle rigidity

Vital Signs every 15 min

Intake and Output every 4 hr

Select if patient does NOT have an arterial line(NOTE)* Blood Pressure

every 15 min, If an arterial line is not in place. Continuous Infusions

<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY background-color: rgb(255,255,255);margin:0; P margin:0 </STYLE><META name=GENERATOR content="MSHTML 11.00.9600.18739"></HEAD><BODY>FentaNYL (Sublimaze) starting rate: 1 mcg/kg/hr (recommended starting range 1 to 5 mcg/kg/hr) </BODY></HTML>(NOTE)*

fentaNYL PEDS (less than 20 kg) 150 mcg/Sod Chlor 0.9% 30 mL (Sublimaze)* (IVS)* Sodium Chloride 0.9%*

30 mL, IV, Goal: n/a Comments: CONC: 5 mcg/mL. Hold and notify Practitioner if heart rate LESS than 100 bpm or respiratory rate LESS than 30 br/min.

fentaNYL IV additive 150 mcg

Communication Orders Notify Treating Practitioner

If HR LESS than 100 bpm, RR LESS than 30 br/min or MAP 20% below minimum range for patient Notify Treating Practitioner

If urine output LESS than 1 ml/kg/hr Non Categorized Initial Approval Date Annual Review Date *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set

Unique Plan Description: NICU HIV Exposed Newborn Plan Selection Display: NICU HIV Exposed Newborn PlanType: Medical Version: 1 Begin Effective Date: 12/6/2016 16:42 End Effective Date: Current Available at: KD Med Cntr Plan Comment: reviewed with Leah 3/22/17 during mtg; NICU HIV Exposed Newborn Patient Care Newborn Bath

T;N, Bathe infant immediately after birth, using gloves. Do NOT perform any invasive procedures INCLUDING Vitamin K injection until the infant is bathed

Nursing Communication Order T;N, Avoid any breaks in the fetal/newborn skin mucous membranes

Suction Activity T,N, Nasopharyngeal, Suction airway gently only if absolutely necessary

Peripheral IV T,N, Place if unable to tolerate oral feeds

If Maternal HIV Status Unknown-Pumping(NOTE)* Breast Pump

T;N, Pump until cleared to Breast Feed Medications Antiretroviral Agents

Antiretroviral Orders - initiate treatment as soon as possible, within 6-12 hours of delivery(NOTE)* GA LESS Than 30 Weeks Retrovir PEDS/NICU

For GA: < 30 Weeks, 2 mg/kg, Oral, Syrup, every 12 hours., Indication: Prophylaxis, Non-Surgical [Less Than 4 weeks] (DEF)*

Comments: Begin within 6-12 hours of delivery For GA: < 30 Weeks, 3 mg/kg, Oral, Syrup, every 12 hours., Indication: Prophylaxis, Non-Surgical

[Greater Than or Equal To 4 weeks] Comments: Begin within 6-12 hours of delivery

For GA: < 30 Weeks, 1.5 mg/kg, IV Piggyback, Syringe inj, PED, every 12 hours., Indication: Prophylaxis, Non-Surgical [Less Than 4 weeks]

Comments: Begin within 6-12 hours of delivery For GA: < 30 Weeks, 2.3 mg/kg, IV Piggyback, Syringe inj, PED, every 12 hours., Indication:

Prophylaxis, Non-Surgical [Greater Than or Equal To 4 weeks] Comments: Begin within 6-12 hours of delivery

GA 30 Weeks to LESS Than 35 Weeks Retrovir PEDS/NICU

For GA: >= 30 weeks to < 35 weeks, 3 mg/kg, Oral, Syrup, every 12 hours., Indication: Prophylaxis, Non-Surgical [Greater Than or Equal To 15 days] (DEF)*

Comments: Begin within 6-12 hours of delivery For GA: >= 30 weeks to < 35 weeks, 1.5 mg/kg, IV Piggyback, Syringe inj, PED, every 12 hours.,

Indication: Prophylaxis, Non-Surgical [Less Than 15 days] Comments: Begin within 6-12 hours of delivery

For GA: >= 30 weeks to < 35 weeks, 2.3 mg/kg, IV Piggyback, Syringe inj, PED, every 12 hours., Indication: Prophylaxis, Non-Surgical [Greater Than or Equal To 15 days]

Comments: Begin within 6-12 hours of delivery For GA: >= 30 weeks to < 35 weeks, 2 mg/kg, Oral, Syrup, every 12 hours., Indication: Prophylaxis,

Non-Surgical [Less Than 15 days] Comments: Begin within 6-12 hours of delivery

GA GREATER than or EQUAL to 35 Weeks Retrovir PEDS/NICU

For GA: >= 35 weeks, 4 mg/kg, Oral, Syrup, every 12 hours., Indication: Prophylaxis, Non-Surgical (DEF)*

Comments: Begin within 6-12 hours of delivery For GA: >= 35 weeks, 3 mg/kg, IV Piggyback, Syringe inj, PED, every 12 hours., Indication:

Prophylaxis, Non-Surgical Comments: Begin within 6-12 hours of delivery

Additional Antiretroviral Agents Nevirapine (Viramune) (NVP) recommended for HIV-Exposed infants of women who received NO antepartum antiretroviral prophylaxis. To be given in addition to zidovudine (Retrovir)(NOTE)*

+144 Hours Viramune 8 mg, Oral, Susp, Once, Indication: Prophylaxis, Non-Surgical [1.5 - 2 kg] (DEF)* 12 mg, Oral, Susp, Once, Indication: Prophylaxis, Non-Surgical [Greater Than or Equal To 2 kg]

Viramune 8 mg, Oral, Susp, every 48 hr for 2 doses, Indication: Prophylaxis, Non-Surgical [1.5 - 2 kg] (DEF)* 12 mg, Oral, Susp, every 48 hr for 2 doses, Indication: Prophylaxis, Non-Surgical [Greater Than or

Equal To 2 kg] Laboratory

Do NOT delay treatment if unable to obtain labs(NOTE)* CBC with Diff

Blood, Stat, T;N, Nurse collect SGOT (AST)

Blood, Stat, T;N, Nurse collect SGPT (ALT)

Blood, Stat, T;N, Nurse collect HIV Ag/Ab Combo 1/2 Screen-Routine

Blood, Stat, T;N, Nurse collect Consults/Referrals Consult to Infectious Diseases Specialist

Consult Reason: HIV Exposed Newborn Notify Practitioner

Notify Pediatrician/Neonatologist of newborn's birth Communication Orders Communication Order

Maintain confidentiality regarding serostatus of mother and special care/testing of infant Non Categorized Initial Approval Date Annual Review Date *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

Unique Plan Description: NICU to Mother Baby Unit Plan Selection Display: NICU to Mother Baby Unit PlanType: Medical Version: 1 Begin Effective Date: 1/18/2017 12:14 End Effective Date: Current Available at: KD Med Cntr Plan Comment: meds added NICU To Mother Baby Unit Transfer Order Set 2/13/17 ES; reviewed during mtg with Leah 3/22/17; NICU to Mother Baby Unit Admit/Transfer/Discharge/Status Level of Care Transfer

Mother Baby Unit Keep As Same Admission Status Patient Care Open Crib Vital Signs

every 4 hr, temperature, respiratory rate, heart rate Weight in Kilograms

Daily Intake and Output

Every shift Pulse Oximetry - Spot Check

every 8 hr, record Sa02 Nursing Communication Order

Jaundice Screening and Management Policy Newborn Hearing Screening Cord Care

every 12 hr, Cleanse umbilical cord with water every shift Screening Newborn Cardiac Screening for CHD

T;N, per protocol Activity Place on back to sleep Car Seat Oximetry Challenge Initial

Angle tolerance testing prior to discharge per Child Passenger Safety Education. Transportation of high risk infants in car safety seats: Angle Tolerance Test Policy

Diet/Nutrition Infant Formula (non-formulary) Breastfeeding Diet Breast Milk Feeding (Advance) Medications Engerix-B Pediatric 10 mcg/0.5 mL IM vaccine

10 mcg, IM, Syringe inj, PED, As Directed for 1 doses Comments: Do NOT give if already given in NICU

Laboratory CBC with Diff

Blood, Routine, T;N+360 Bilirubin TD- For Babies Only

Blood, Routine, T;N CRP High Sensitivity

Blood, Routine, T;N Blood Glucose Monitoring POC

T;N, Blood glucose screening per Screening and Management of Neonatal Hypoglycemia Policy Drug Screen Urine

Urine, Routine Collect, T;N PKU Heel Stick

T;N, Once Communication Orders Notify Practitioner

If HR LESS than 80 bpm at rest or GREATER than 200 bpm; or RR LESS than 20 br/min or GREATER than 60 br/min for longer than 10 minutes or recurrently; or if Temperature LESS than 36.3C (97.4 F or more than 38C (100.4 F)

Notify Practitioner WBC is LESS than 6,000 or GREATER than 30,000 and/or band count is 25% or GREATER

Notify Practitioner If persistent vomiting, feeding intolerance or poor feeding; Any new abnormal findings noted on

assessment; GREATER than 3% weight loss at 24 hours after birth; GREATER than 7% weight loss at 48 hours after birth

Notify Practitioner Please notify Practitioner of infant's arrival on unit

Non Categorized Initial Approval Date Annual Review Date *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

Unique Plan Description: PED Cellulitis Admission Plan Selection Display: PED Cellulitis Admission PlanType: Medical Version: 1 Begin Effective Date: 5/11/2015 08:39 End Effective Date: Current Available at: KD Med Cntr Plan Comment: changes made per Dr. Randolph's review 7/31/17 dsm; PED Cellulitis Admission Admit/Transfer/Discharge/Status Admission Status(SUB)* Patient Care Resuscitation Status

Full Code (Full Treatment) (DEF)* Do Not Resuscitate (Allow Natural Death)

Vital Signs every 4 hr (DEF)* every 2 hr every 1 hr every 12 hr

Intake and Output every 12 hr (DEF)* every 2 hr every 4 hr every 6 hr every 8 hr Daily

Communication Order Cellulitis site check with vitals

Patient Isolation Droplet/Contact

Heat Therapy T;N, QID, Warm compresses

Activity Up ad Lib

As age appropriate Bedrest with Bathroom Privileges Diet/Nutrition NPO

No Exceptions (DEF)* Except for Sips of Water Except for Ice Chips NPO except popsicles when awake

Breastfeeding Diet Feed at least: Ad Lib-feeding

Clear Liquid Diet Full Liquid Diet Regular Diet Peds 1-3 Diet Peds 4-8 Diet Peds 9-13 years Diet Infant Formula (non-formulary) Enteral Tube Feedings(SUB)*

Continuous Infusions Peripheral IV Dextrose 5% with 0.45% NaCl and KCl 20 mEq/L

1,000 mL, IV, mL/hr Common IV Fluids(SUB)* Medications Antibiotics Cleocin PEDS/NICU

10 mg/kg, IV Piggyback, Syringe inj, PED, every 8 hours., Indication: Skin and soft-tissue infection [Less Than 60 kg] (DEF)*

Comments: Cellulitis. MAX = 600 mg 600 mg, IV Piggyback, Syringe inj, PED, every 8 hours., Indication: Skin and soft-tissue infection

[Greater Than or Equal To 60 kg] Comments: Cellulitis

Ancef PEDS/NICU 25 mg/kg, IV Piggyback, Syringe inj, PED, every 8 hours., Indication: Skin and soft-tissue infection

[Less Than 40 kg] (DEF)* Comments: Cellulitis. MAX = 1,000 mg

1,000 mg, IV Piggyback, Syringe inj, PED, every 8 hours., Indication: Skin and soft-tissue infection [Greater Than or Equal To 40 kg]

Comments: Cellulitis Vancomycin PEDS/NICU

10 mg/kg, IV Piggyback, Syringe inj, PED, every 6 hours., Indication: Cellulitis Pain Management Tylenol

15 mg/kg, Oral, Susp, every 4 hours., PRN other (see comment) (DEF)* Comments: Mild Pain (scale 1-3) or Temperature GREATER than 38.5 degC (101.3 degF). If ibuprofen and acetaminophen ordered for temperature alternate between acetaminophen and ibuprofen (do not administer at the same time)

15 mg/kg, PR, Supp, every 4 hours., PRN other (see comment) Comments: Mild Pain (scale 1-3) or Temperature GREATER than 38.5 degC (101.3 degF). If ibuprofen and acetaminophen ordered for temperature alternate between acetaminophen and ibuprofen (do not administer at the same time)

Motrin Childrens 10 mg/kg, Oral, Susp, every 6 hours., PRN other (see comment) [Less Than 40 kg] (DEF)*

Comments: Moderate Pain (scale 4-6) or Temperature GREATER than 38.5 degC (101.3 degF). If ibuprofen and acetaminophen ordered for temperature alternate between acetaminophen and ibuprofen (do not administer at the same time)

400 mg, Oral, Susp, every 6 hours., PRN other (see comment) [Greater Than or Equal To 40 kg] Comments: Moderate Pain (scale 4-6) or Temperature GREATER than 38.5 degC (101.3 degF). If ibuprofen and acetaminophen ordered for temperature alternate between acetaminophen and ibuprofen (do not administer at the same time)

Motrin 200 mg, Oral, Tab, every 6 hours., PRN other (see comment) (DEF)*

Comments: Moderate Pain (scale 4-6) or Temperature GREATER than 38.5 degC (101.3 degF). If ibuprofen and acetaminophen ordered for temperature alternate between acetaminophen and ibuprofen (do not administer at the same time)

400 mg, Oral, Tab, every 6 hours., PRN other (see comment) Comments: Moderate Pain (scale 4-6) or Temperature GREATER than 38.5 degC (101.3 degF). If ibuprofen and acetaminophen ordered for temperature alternate between acetaminophen and ibuprofen (do not administer at the same time)

morphine 0.05 mg/kg, IV Push, Injection, every 3 hr, PRN pain, severe (scale 7-10) (DEF)* 0.1 mg/kg, IV Push, Injection, every 3 hr, PRN pain, severe (scale 7-10)

Laboratory CBC w/ Diff

Blood, Routine, T;N CRP High Sensitivity

Blood, Routine, T;N CMP

Blood, Routine, T;N Basic Metabolic Panel

Blood, Routine, T;N Microbiology Blood Culture

Blood, Routine collect, RT - Routine, T;N (DEF)* Blood, Stat collect, ST - Stat, T;N

Consults/Referrals Consult to Registered Dietitian Communication Orders

Notify Treating Provider Vital Signs are PALS guidelines for age- please adjust as per condition/situation(NOTE)*

Notify Treating Practitioner Vital Signs Systolic BP LESS than 60 mmHg, HR GREATER than 205 beats/min, HR LESS than 80 beats/min,

RR GREATER than 60 breaths/min, RR LESS than 30 breaths/min, Temp GREATER than 38 degrees Celsius [Less Than 1 months] (DEF)*

Comments: Age: 0 days - less than 1 month Systolic BP LESS than 70 mmHg, HR GREATER than 205 beats/min, HR LESS than 80 beats/min,

RR GREATER than 60 breaths/min, RR LESS than 30 breaths/min, Temp GREATER than 38 degrees Celsius [1 - 3 months]

Comments: Age: 1 month - less than 3 months Systolic BP LESS than 70 mmHg, HR GREATER than 190 beats/min, HR LESS than 75 beats/min,

RR GREATER than 60 breaths/min, RR LESS than 30 breaths/min, Temp GREATER than 38.5 degrees Celsius [3 - 12 months]

Comments: Age: 3 months - less than 1 year Systolic BP LESS than 72 mmHg, HR GREATER than 190 beats/min, HR LESS than 75 beats/min,

RR GREATER than 40 breaths/min, RR LESS than 24 breaths/min, Temp GREATER than 38.5 degrees Celsius [1 - 2 years]

Comments: Age: 1 year Systolic BP LESS than 74 mmHg, HR GREATER than 190 beats/min, HR LESS than 75 beats/min,




Comments: Age: 3 years Systolic BP LESS than 78 mmHg, HR GREATER than 140 beats/min, HR LESS than 60 beats/min,








Comments: Age: 7 years

Systolic BP LESS than 86 mmHg, HR GREATER than 140 beats/min, HR LESS than 60 beats/min, RR GREATER than 30 breaths/min, RR LESS than 18 breaths/min, Temp GREATER than 38.5 degrees Celsius [8 - 9 years]





Comments: Age: 10 years - less than 13 years Systolic BP LESS than 90 mmHg, HR GREATER than 100 beats/min, HR LESS than 60 beats/min,



RR GREATER than 20 breaths/min, RR LESS than 10 breaths/min, Temp GREATER than 38.5 degrees Celsius [Greater Than or Equal To 18 years]

Comments: Age: Greater than 18 years Notify Treating Practitioner

Urine output LESS than 1 mL/kg/hr over 6 hours [Less Than 45 kg] (DEF)* Urine output LESS than 0.5 mL/kg/hr [Greater Than or Equal To 45 kg]

Notify Treating Practitioner Persistent vomiting or poor feeding

Notify Treating Practitioner Vesicular rash

Non Categorized Initial Approval Date Annual Review Date *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

Unique Plan Description: PED Constipation and Bowel Cleanout Admission Plan Selection Display: PED Constipation and Bowel Cleanout Admission PlanType: Medical Version: 1 Begin Effective Date: 7/8/2015 20:44 End Effective Date: Current Available at: KD Med Cntr Plan Comment: reviewed 6/16/17 dsm; changes made per Dr. Randolph's review 7/31/17 dsm; PED Constipation and Bowel Cleanout Admission Admit/Transfer/Discharge/Status Admission Status(SUB)* Patient Care Resuscitation Status


Vital Signs every 4 hr (DEF)* every 2 hr every 1 hr every 12 hr

Intake and Output every 12 hr (DEF)* every 4 hr every 2 hr every 6 hr every 8 hr Daily

Peripheral IV Nasogastric (NG) Tube Insertion

T;N, Either nare for administration of polyethalene glycol (GoLYTELY) Activity Up ad Lib

As age appropriate Up with Assistance Bedrest with Bathroom Privileges Ambulate

every 12 hr Diet/Nutrition NPO

No Exceptions (DEF)* Except for Medications

Clear Liquid Diet Peds 1-3 Diet Peds 4-8 Diet Peds 9-13 years Diet Continuous Infusions Dextrose 5% Water/0.9% Sodium Chloride/KCl 20 mEq

1,000 mL, IV, mL/hr Dextrose 5% with 0.45% NaCl and KCl 20 mEq/L

1,000 mL, IV, mL/hr Common IV Fluids(SUB)* Medications Bowel Maintenance

GoLYTELY oral powder for reconstitution 4,000 mL, NG Tube, Liquid, As Directed for 1 doses

Comments: Administer until rectal effluent is clear. Start at a rate of 50-100 mL/hr. Advance 50 mL/hr every 30-60 minutes as tolerated. Goal rate is 40 mL/kg/hr with a maximum of 800 mL/hr. If vomiting, stop medication and contact practitioner to repeat rectal exam, manually remove impacted stool, wait 1 hour and restart medication. For intake and output, Go-lytely should not be counted as intake.

MiraLax oral powder for reconstitution 0.25 packets, Oral, Powder, BID (DEF)*

Comments: Mix in 4 ounces clear liquid or juice. 0.25 packets is approximately 5 mL of powder

0.5 packets, Oral, Powder, BID Comments: Mix in 4 ounces clear liquid or juice. 0.5 packets is approximately 10 mL of powder

1 packets, Oral, Powder, BID Comments: Mix in 8 ounces clear liquid or juice

0.25 packets, Oral, Powder, TID Comments: Mix in 4 ounces clear liquid or juice. 0.25 packets is approximately 5 mL of powder

0.5 packets, Oral, Powder, TID Comments: Mix in 4 ounces clear liquid or juice. 0.5 packets is approximately 10 mL of powder

1 packets, Oral, Powder, TID Comments: Mix in 8 ounces clear liquid or juice

glycerin pediatric rectal suppository 0.5 supp, PR, Supp, Daily (DEF)* 1 supp, PR, Supp, Daily [Less Than 2 years]

Fleet Enema (Adult) rectal enema 66 mL, PR, Enema, Once [5 - 12 years] (DEF)* 33 mL, PR, Enema, Once [2 - 5 years] 133 mL, PR, Enema, Once [Greater Than or Equal To 12 years]

Nausea/Vomiting Reglan PEDS/NICU

0.15 mg/kg, IV Push, Syringe inj, PED, Once, PRN nausea/vomiting Comments: Maximum single dose 10 mg.

Diagnostic Tests Communication Order

Order XR KUB when stools are running clear x 2 : indication is constipation Communication Orders Notify Treating Practitioner Vital Signs

Systolic BP LESS than 60 mmHg, HR GREATER than 205 beats/min, HR LESS than 80 beats/min, RR GREATER than 60 breaths/min, RR LESS than 30 breaths/min, Temp GREATER than 38 degrees Celsius [Less Than 1 months] (DEF)*

Comments: Age: 0 days - LESS than 1 month Systolic BP LESS than 70 mmHg, HR GREATER than 205 beats/min, HR LESS than 80 beats/min,


Comments: Age: 1 month - LESS than 3 months Systolic BP LESS than 70 mmHg, HR GREATER than 190 beats/min, HR LESS than 75 beats/min,


Comments: Age: 3 months - LESS than 1 year Systolic BP LESS than 72 mmHg, HR GREATER than 190 beats/min, HR LESS than 75 beats/min,


Comments: Age: 1 year























Urine output LESS than 1 mL/kg/hr over 6 hours [Less Than 45 kg] (DEF)* Urine output LESS than 0.5 mL/kg/hr over 6 hours [Greater Than or Equal To 45 kg]

Notify Treating Practitioner No stool output within 8 hours of polyethylene glycol (Miralax or GoLYTELY) initiation

Notify Treating Practitioner If ineffective after any two enemas, stop polyethalene glycol (GoLYTELY) and call treating

practitioner and consult general surgery Notify Treating Practitioner

For Mental status changes, increasing irritability or lethargy Notify Treating Practitioner

Increasing respiratory distress or increasing oxygen needs Notify Treating Practitioner

Increasing abdominal pain or girth Notify Treating Practitioner

Persistent vomiting Non Categorized Initial Approval Date Annual Review Date *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

Unique Plan Description: PED Discharge Plan Selection Display: PED Discharge PlanType: Medical Version: 1 Begin Effective Date: 6/8/2017 13:50 End Effective Date: Current Available at all facilities PED Discharge Admit/Transfer/Discharge/Status Discharge Patient

T;N, Home with Responsible Caregiver (DEF)* T;N, Home with Home Health T;N, Acute Care Facility

Patient Care PRE Discharge Orders

These orders will be carried out PRIOR to patient discharge(NOTE)* Peripheral IV Discontinue Fax newborn record and discharge summary DISCHARGE Instructions

These orders are for POST discharge instructions and will flow to the Patient Discharge Instructions(NOTE)* Discharge Diet Instruction

Feed every 2-3 hours on demand (DEF)* Feed every 3 hours around the clock Age appropriate diet as tolerated


Other (please specify):, As tolerated (DEF)* Other (please specify):, As appropriate to age

Discharge Patient Instructions Call your child's primary doctor or go to the Emergency Department for temperature (DEF)* Call your child's primary doctor or go to the Emergency Department for persistent vomiting Call your child's primary doctor or go to the Emergency Department for persistent diarrhea Call your child's primary doctor or go to the Emergency Department for missing more than 2

feedings if infant Call your child's primary doctor or go to the Emergency Department for respiratory distress not

relieved by treatment recommended Call your child's primary doctor or go to the Emergency Department for return of symptoms that led

to hospitalization Non Categorized Initial Approval Date Annual Review Date *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

Unique Plan Description: PED Kawasaki Disease Admission Plan Selection Display: PED Kawasaki Disease Admission PlanType: Medical Version: 1 Begin Effective Date: 2/10/2015 10:16 End Effective Date: Current Available at all facilities Plan Comment: updated VS remove Q8/Q12/QS, remove breastfeeding, precheck I/O, remove diet sentences, remove infant formula, add correct IVIG and sentence, correct ASA, remove O2 CM, RD, CBC, CRP, BMP in AM 6/16/17 dsm; changes made per Dr. Randolph's review 7/31/17 dsm; PED Kawasaki Disease Admission Admit/Transfer/Discharge/Status Admit to Inpatient Place in Observation Patient Care General Telemetry PEDIATRICS Resuscitation Status


Vital Signs every 4 hr (DEF)* every 2 hr every 6 hr

Pulse Oximetry - Spot Check every 4 hr (DEF)* every 2 hr every 12 hr

Pulse Oximetry Continuous Intake and Output

every 12 hr (DEF)* every 2 hr every 4 hr every 6 hr every 8 hr every shift

Peripheral IV Activity Up ad Lib Up with Assistance Bedrest with Bathroom Privileges Diet/Nutrition NPO

No Exceptions (DEF)* Except for Hard Candy Except for Ice Chips Except for Ice Chips and Meds Except for Ice Chips, Meds and Hard Candy Except for Medications

Clear Liquid Diet Pediatric

Regular Diet appropriate for age

Peds 1-3 Diet

Peds 4-8 Diet Peds 9-13 years Diet Medications aspirin chewable

10 mg/kg, Chewed, Tab-Chew, QID Comments: Round to the nearest half tab

Privigen 10% intravenous solution 2 g/kg, IV Piggyback, Soln-IV, Once

Comments: Start Infusion at 0.3mL/kg/hr and increase rate per manufacturer instructions to MAX of 2.4 mL/kg/hr.

Anaphylaxis EPINEPHrine 1 mg/mL injectable

0.01 mg/kg, IM, Injection, Once, PRN anaphylaxis Comments: MAX DOSE = 0.5 mg. Give in mid-outer thigh PRN anaphylactic reaction to IVIG (Privigen)

Benadryl 1 mg/kg, IV Push, Injection, Once, PRN anaphylaxis

Comments: MAX DOSE = 40 mg. Give PRN anaphylactic reaction to IVIG (Privigen) Pepcid PEDS/NICU

0.5 mg/kg, IV Piggyback, Syringe inj, PED, Once, PRN anaphylaxis Comments: MAX DOSE = 20 mg. Give PRN anaphylactic reaction to IVIG (Privigen)

Solu-Medrol (PEDS/NICU) 1 mg/kg, IV Push, Syringe inj, PED, Once, PRN anaphylaxis

Comments: MAX DOSE = 125 mg. Give PRN anaphylactic reaction to IVIG (Privigen) Laboratory CBC w/ Diff

Blood, Routine, T;N ESR

Blood, Routine, T;N CMP

Blood, Routine, T;N Urinalysis with Microscopic

Urine, Clean Catch, Routine Collect, T;N AM Labs CBC

Blood, AM Draw (Inpatient Only), T+1;0330 BMP Basic Metabolic Panel

Blood, AM Draw (Inpatient Only), T+1;0330 ESR

Blood, AM Draw (Inpatient Only), T+1;0330 Diagnostic Tests Echo Pediatric Communication Orders Notify Treating Practitioner Vital Signs





RR GREATER than 60 breaths/min, RR LESS than 30 breaths/min, Temp GREATER than 38.5

degrees Celsius [3 - 12 months] Comments: Age: 3 months - LESS than 1 year

























Urine output LESS than 1 mL/kg/hr over 6 hours [Less Than 45 kg] (DEF)* Urine output LESS than 0.5 mL/kg/hr over 6 hours [Greater Than or Equal To 45 kg]

Notify Treating Practitioner Capillary refill time GREATER than 3 seconds or flash return

Non Categorized Initial Approval Date

Annual Review Date *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

Unique Plan Description: PED Pneumonia Admission Plan Selection Display: PED Pneumonia Admission PlanType: Medical Version: 1 Begin Effective Date: 2/28/2017 10:47 End Effective Date: Current Available at: KD Med Cntr Plan Comment: meds added 4/18/17 from Pediatric Pneumonia Admission Order Set dsm; pod review 7/11/17 dsm; changes made per Dr. Randolph's review 7/31/17 dsm; PED Pneumonia Admission Admit/Transfer/Discharge/Status Admission Status(SUB)* Patient Care General Telemetry PEDIATRICS Resuscitation Status


Vital Signs every 4 hr

Intake and Output every 12 hr

Activity Up ad Lib Bedrest with Bathroom Privileges Diet/Nutrition NPO Communication Order

Small amounts of liquid then advance to regular diet for age as tolerated Breastfeeding Diet Infant Formula (non-formulary) Clear Liquid Diet Peds 1-3 Diet Peds 4-8 Diet Peds 9-13 years Diet Soft/Bland Diet Continuous Infusions Saline Lock Insert Sodium Chloride 0.9% Bolus

20 mL/kg, IV Bolus, Soln-IV, Once, Administer over: 30 minutes Dextrose 5% with 0.45% NaCl and KCl 20 mEq/L

1,000 mL, IV, mL/hr Medications Antibiotics Ampicillin IV PEDS/NICU

50 mg/kg, IV Piggyback, Syringe inj, PED, every 6 hours., Indication: Pneumonia Comments: Max single dose not to exceed 500 mg

Rocephin PEDS/NICU 50 mg/kg, IV Piggyback, Syringe inj, PED, every 24 hours., Indication: Pneumonia (DEF)*

Comments: Max single dose not to exceed 2 g 50 mg/kg, IM, Syringe inj, PED, every 24 hours., Indication: Pneumonia

Comments: Max single dose not to exceed 2 g Claforan PEDS/NICU

50 mg/kg, IV Piggyback, Syringe inj, PED, every 8 hours., Indication: Pneumonia Comments: Max single dose not to exceed 2 g

Zithromax PEDS/NICU 10 mg/kg, Oral, Susp, Once, Indication: Pneumonia

Comments: Max single dose not to exceed 500 mg +24 Hours Zithromax PEDS/NICU

5 mg/kg, Oral, Susp, Daily for 4 days, Indication: Pneumonia Comments: Max single dose not to exceed 250 mg

Cleocin PEDS/NICU 13 mg/kg, IV Piggyback, Syringe inj, PED, every 8 hours., Indication: Other (Please specify in

comments) Comments: Max single dose not to exceed 600 mg

Pain and/or Fever Tylenol

15 mg/kg, Oral, Susp, every 4 hours., fever (DEF)* Comments: Temperature GREATER than 38 degC (100.4 degF)

15 mg/kg, PR, Supp, every 4 hours., fever Comments: Temperature GREATER than 38 degC (100.4 degF)

Motrin Childrens 10 mg/kg, Oral, Susp, every 6 hours., PRN other (see comment)

Comments: If acetaminophen (Tylenol) ineffective for pain or temperature GREATER than 38 degC (100.4 degF)

Laboratory CBC with Diff

Blood, Routine, T;N Blood Culture

Blood, Routine collect, RT - Routine, T;N Renal Panel 1

Blood, Routine, T;N RSV Molecular Alere

Nasal, Routine Collect, T;N, Nurse collect Mycoplasma IgM Ab Screen

Blood, Routine, T;N Influenza A/B

Nasal, Routine Collect, T;N, Nurse collect Adenovirus, Quantitative PCR-ARUP

Blood, Routine, T;N Respiratory Viruses DFA-ARUP

Micro Specimen, Routine, T;N Diagnostic Tests XR Chest 1 View Portable XR Chest 2 Views Respiratory Oxygen Therapy

SpO2 goal 92% or GREATER, Call Practitioner for oxygen need greater than 40% Communication Orders Notify Practitioner

Increasing respiratory distress not controlled by treatment Notify Treating Practitioner Vital Signs






Comments: Age: 3 months - LESS than 1 year Systolic BP LESS than 72 mmHg, HR GREATER than 190 beats/min, HR LESS than 75 beats/min,
























Comments: Age: Greater than 18 years *Report Legend: DEF - This order sentence is the default for the selected order

Unique Plan Description: PED Post NICU Observation Plan Selection Display: PED Post NICU Observation PlanType: Medical Version: 1 Begin Effective Date: 3/27/2017 13:29 End Effective Date: Current Available at: KD Med Cntr PED Post NICU Observation Admit/Transfer/Discharge/Status Level of Care Transfer

T;N, Transfer to Pediatrics Keep As Same Admission Status Patient Care Vital Signs

T;N, Temperature, pulse and respiratory rate every 4 hours for 24 hours then every 8 hours. Weight in Kilograms

T;N, Daily Open Crib Monitoring Blood Glucose Monitoring per Neonatal Hypoglycemia Algorithm

T;N, PRN Comments: Blood glucose screening to be continued according to Screening and Management of Neonatal Hypoglycemia Policy.

Interventions Nursing Care/Treatment

Oral sucrose per Administration of Oral Sucrose to Infants policy Comments: Give age appropriate dose of a 24% oral sucrose solution. Apply sucrose to pacifier.0.5 ml for infants 27 to 31 weeks gestation1ml for infants 32 to 36 weeks gestation2ml for infants GREATER than 37 weeks gestation

Screening Newborn Cardiac Screening for CHD

T;N, Per protocol Newborn Hearing Screening

Algo hearing screen prior to discharge Newborn Screening

Genetic screening per California Newborn Screening policy Newborn Screening

Complete jaundice screen per Jaundice Screening and Management Policy Diet/Nutrition Breast Milk

T;N, Breastfeeding Allowed Breastfeeding Diet

Feed at least: Ad Lib-feeding Infant Formula (non-formulary) Medications Vaccinations Engerix-B Pediatric 10 mcg/0.5 mL IM vaccine

10 mcg, IM, Injection, As Directed for 1 doses Comments: Mother with negative Hepatitis B status. Give after initial bath.

Laboratory CBC w/ Diff

Blood, Routine, T;N, Nurse collect Comments: At 6 hours of age. Call Practitioner immediately if WBC is LESS than 6,000 or

GREATER than 30,000 and/or band count is 25% or GREATER C-Reactive Protein High Sensitivity

Blood, Routine, T;N, Nurse collect Comments: At 24 hours of life

Drug Screen Urine Urine, Routine Collect, T;N

Communication Orders Notify Practitioner

Please notify practitioner of infant arrival on unit Notify Treating Practitioner Vital Signs

T;N, HR GREATER than 160 beats/min, HR LESS than 80 beats/min, Temp GREATER than 38.5 degrees Celsius, Temperature LESS than: 36.3 degrees Celsius, at rest or heart rate GREATER than 60 or LESS than 40 for longer than 10 minutes or recurrently.

Notify Practitioner T;N, Persistent vomiting or feeding intolerance or any new abnormal findings noted on assessment

Notify Practitioner Notify Treating Practitioner Vital Signs Non Categorized Initial Approval Date Annual Review Date *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

Unique Plan Description: SURG General Surgery Outpatient Plan Selection Display: SURG General Surgery Outpatient PlanType: Medical Version: 1 Begin Effective Date: 6/12/2017 15:20 End Effective Date: Current Available at: KD Med Cntr PRE-Op Admit/Transfer/Discharge/Status Place in Outpatient Patient Care Verify Surgical Consent Sequential Compression Device Diet/Nutrition NPO Medications SOLU-Medrol

125 mg, IV Push, Injection, PREOP for 1 doses Proventil 2.5 mg/3 mL (0.083%) inhalation solution

2.5 mg, NEB, Device: Continuous Aerosol, Soln-Inhalation, PREOP for 1 doses Valium

5 mg, Oral, Tab, PREOP for 1 doses Laboratory CBC w/ Diff

Blood, Routine, T;N Renal Panel 1

Blood, Routine, T;N Complete Metabolic Panel

Blood, Routine, T;N PTT

Blood, Routine, T;N Protime (with INR)

Blood, Routine, T;N HCG Qualitative Urine

Urine, Routine Collect, T;N, Nurse collect Card/Vasc/Neuro EKG 12 lead IntraOp Patient Care Insert Indwelling Urinary Catheter PACU Phase I Patient Care Ice Pack Application

To Incision Activity Abdominal Binder PACU Phase II Patient Care Ice Pack Application

To Incision Patient Education

Instruct patient on how to care for surgical drain(s) Activity

Abdominal Binder Communication Orders Nursing Communication Order

Prior to release, please place bra on patient if patient brought one with her Supplies Miscellaneous Distribution Order

Athletic Supporter Discharge Admit/Transfer/Discharge/Status Discharge Patient Patient Care Peripheral IV Discontinue

Prior to discharge Discharge Activity Restrictions

No Restrictions (DEF)* No Heavy Lifting No Strenuous Exercise No Driving

Discharge Wound Care Instructions Discharge Drain Care Instructions Diet/Nutrition Discharge Diet Instruction

Regular home diet (DEF)* Calorie Controlled Diet Clear liquids only Low Sodium Soft foods Tube Feeding


Unique Plan Description: SURG General Surgery PERI-Op Plan Selection Display: SURG General Surgery PERI-Op PlanType: Medical Version: 1 Begin Effective Date: 6/12/2017 14:56 End Effective Date: Current Available at all facilities Pre-Op Admit/Transfer/Discharge/Status Admission Status(SUB)* Patient Care Verify Surgical Consent Sequential Compression Device Diet/Nutrition NPO NPO at Midnight Communication Order

NPO 8 hours before procedure Medications SOLU-Medrol

125 mg, IV Push, Injection, PREOP for 1 doses Proventil 2.5 mg/3 mL (0.083%) inhalation solution

2.5 mg, NEB, Device: Aerosol, Soln-Inhalation, PREOP for 1 doses Valium

5 mg, Oral, Tab, PREOP for 1 doses VTE Prophylaxis VTE General Surgery(SUB)* Laboratory CBC w/ Diff

Blood, Routine, T;N Renal Panel 1

Blood, Routine, T;N Complete Metabolic Panel

Blood, Routine, T;N PTT

Blood, Routine, T;N Protime (with INR)

Blood, Routine, T;N HCG Qualitative Urine

Urine, Routine Collect, T;N Card/Vasc/Neuro EKG 12 lead IntraOp Patient Care Insert Indwelling Urinary Catheter Nasogastric (NG) Tube Insertion Abdominal Binder Miscellaneous Distribution Order

Athletic Supporter PACU Patient Care Ice Pack Application

To Incision JP Drain

Empty and Record Output As Directed, Prior to transfer to floor *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

Unique Plan Description: VASC Discharge Plan Selection Display: VASC Discharge PlanType: Medical Version: 1 Begin Effective Date: 6/27/2017 14:11 End Effective Date: Current Available at all facilities VASC Discharge Admit/Transfer/Discharge/Status Discharge Patient Patient Care PRE Discharge Orders

These orders will be carried out PRIOR to patient discharge(NOTE)* Peripheral IV Discontinue

Prior to discharge (DEF)* Once all IV medications are finished

Urinary Catheter Discontinue Discontinue at discharge

DISCHARGE Instructions These orders are for POST discharge instructions and will flow to the Patient Discharge Instructions(NOTE)*

Discharge Patient Instructions You have received anesthetic, narcotic, and/or sedating medications. Your reflexes may be slow.

Exercise caution when driving or performing tasks that require mental alertness Discharge Patient Instructions

Call South Valley Vascular (559-625-4118) if you have any of the following problems: worsening pain, fever GREATER than 101.5 F or shaking chills, wound redness, drainage or bleeding (oozing is normal, but you should not soak the dressing)

Discharge Patient Instructions Call South Valley Vascular (559-625-4118) for any problems that you feel may be related to your

surgery Discharge Patient Instructions

If for any reason, you cannot reach your surgeon, or the surgeon who is covering for your surgeon, please go to the hospital Emergency Department

Diet(NOTE)* Discharge Diet Instruction

As your appetite returns, advance to your usual diet as tolerated. If you are on a specialized diet (for example, high blood pressure, diabetes, kidney disease), resume this diet.


No work for 2 weeks Discharge Activity Restrictions

No driving for 2 weeks Discharge Activity Restrictions

No strenuous activity (for example, lifting more than 25 pounds, repetitive bending, running or P.E.) for 2 weeks

Discharge Bathing Instructions You may shower in 3 days. If you have tapes (steri-strips) on the skin, you may get them wet and

pat them dry after you shower. They will eventually fall off on their own. Wound/Incision Care(NOTE)*

Discharge Surgical Wound Instructions Change dressing tomorrow and place a new dressing on your wound every other day

*Report Legend: DEF - This order sentence is the default for the selected order

Unique Plan Description: VTE Critical Care Patients Plan Selection Display: VTE Critical Care Patients PlanType: Medical Version: 1 Begin Effective Date: 8/29/2016 15:09 End Effective Date: Current Available at: KD Med Cntr VTE Critical Care Patients Patient Care Mechanical Prophylaxis

SCD/Anti-Embolic Stockings(NOTE)* Recommended if Chemoprophylaxis is Contraindicated | Below Knee Preferred Length(NOTE)*

Above the Knee Intermittent Pneumatic Compression Device Below the Knee Intermittent Pneumatic Compression Device TED Hose

T;N, Knee High (DEF)* T;N, Thigh High

Medications Chemoprophylaxis

HIGH Risk(NOTE)* Lovenox

40 mg, Subcut, Injection, Daily MODERATE Risk(NOTE)*

Lovenox 40 mg, Subcut, Injection, Daily

heparin 5,000 units/mL injectable 5,000 units, Subcut, Injection, BID


Unique Plan Description: VTE Elective Total Hip Patients Plan Selection Display: VTE Elective Total Hip Patients PlanType: Medical Version: 1 Begin Effective Date: 8/30/2016 13:43 End Effective Date: Current Available at all facilities VTE Elective Total Hip Patients Patient Care Mechanical Prophylaxis

SCD/Anti-Embolic Stockings(NOTE)* SCD Recommended with high risk bleeding | Below Knee Preferred Length(NOTE)*

Below the Knee Intermittent Pneumatic Compression Device Above the Knee Intermittent Pneumatic Compression Device Medications Chemoprophylaxis


30 mg, Subcut, Injection, BID Comments: 12 hours PRE-Op or POST-Op

Fondaparinux (Arixtra) CONTRAINDICATED if CrCl LESS than 30 mL/min or weight LESS than 50 kg(NOTE)*

Arixtra 2.5 mg, Subcut, Injection, Daily [Greater Than or Equal To 50 kg]

Comments: Start POST-Op Rivaroxaban (Xarelto) CONTRAINDICATED if CrCl LESS than 30 mL/min(NOTE)*

Xarelto 10 mg, Oral, Tab, every evening

Consult to Pharmacy - Warfarin Dose Per Pharmacy INR=2.5, PRE-Op or evening of surgery, VTE Prophylaxis, Target INR: Other (See Comments),

Once Order aspirin in conjunction with mechanical prophylaxis to meet VTE prophylaxis requirements(NOTE)*

Ecotrin 325 mg, Oral, Tab-DR, every evening


Unique Plan Description: VTE Elective Total Knee Patients Plan Selection Display: VTE Elective Total Knee Patients PlanType: Medical Version: 1 Begin Effective Date: 8/30/2016 14:45 End Effective Date: Current Available at all facilities VTE Elective Total Knee Patients Patient Care Mechanical Prophylaxis

Recommended if Chemoprophylaxis is Contraindicated | Below Knee Preferred Length(NOTE)* Below the Knee Intermittent Pneumatic Compression Device Above the Knee Intermittent Pneumatic Compression Device Medications Chemoprophylaxis


30 mg, Subcut, Injection, BID Fondaparinux (Arixtra) CONTRAINDICATED if CrCl LESS than 30 mL/min or weight LESS than 50 kg(NOTE)*


Rivaroxaban (Xarelto) CONTRAINDICATED if CrCl LESS than 30 mL/min(NOTE)* Xarelto

10 mg, Oral, Tab, every evening Consult to Pharmacy - Warfarin Dose Per Pharmacy

INR=2.5, VTE Prophylaxis, Target INR: Other (See Comments), Once Order aspirin in conjunction with mechanical prophylaxis to meet VTE prophylaxis requirements(NOTE)*

Ecotrin 325 mg, Oral, Tab-DR, every evening


Unique Plan Description: VTE General Surgery Plan Selection Display: VTE General Surgery PlanType: Medical Version: 1 Begin Effective Date: 8/29/2016 15:41 End Effective Date: Current Available at all facilities VTE General Surgery Patient Care Mechanical Prophylaxis

SCD/Anti-Embolic Stockings(NOTE)* Recommend to combine SCD/AES with chemoprophylaxis if patient is HIGH risk with multiple risk factors present | Below knee preferred length(NOTE)*

Above the Knee Intermittent Pneumatic Compression Device Below the Knee Intermittent Pneumatic Compression Device TED Hose


LOW Risk(NOTE)* Ambulate

Early ambulation Medications Chemoprophylaxis

If multiple risk factors present, combine Chemoprophylaxis with SCD/AES(NOTE)* HIGH Risk(NOTE)*

Lovenox 30 mg, Subcut, Injection, BID

Fondaparinux (Arixtra) CONTRAINDICATED if CrCl LESS than 30 mL/min or weight LESS than 50 kg(NOTE)*


heparin 5,000 units/mL injectable 5,000 units, Subcut, Injection, TID

MODERATE Risk(NOTE)* Lovenox

40 mg, Subcut, Injection, Daily Fondaparinux (Arixtra) CONTRAINDICATED if CrCl LESS than 30 mL/min or weight LESS than 50 kg(NOTE)*




Unique Plan Description: VTE Gynecological Extensive Surgery for Malignancy or Additional Risk Plan Selection Display: VTE Gynecological Extensive Surgery for Malignancy or Additional Risk PlanType: Medical Version: 1 Begin Effective Date: 8/30/2016 16:53 End Effective Date: Current Available at all facilities VTE Gynecological Extensive Surgery for Malignancy or Additional Risk Patient Care Mechanical Prophylaxis

HIGH Risk(NOTE)* May add SCD/AES to Enoxaparin (Lovenox) or Heparin orders(NOTE)*

Below the Knee Intermittent Pneumatic Compression Device Starting just before surgery and while patient is not ambulating

Above the Knee Intermittent Pneumatic Compression Device Starting just before surgery and while patient is not ambulating

TED Hose T;N, Knee High (DEF)* T;N, Thigh High

MODERATE Risk(NOTE)* Below the Knee Intermittent Pneumatic Compression Device

Starting just before surgery and while patient is not Above the Knee Intermittent Pneumatic Compression Device

Starting just before surgery and while patient is not TED Hose



T;N, Early ambulation and frequent Medications Chemoprophylaxis


40 mg, Subcut, Injection, Daily Comments: Start immediately POST-Op


Comments: Start immediately POST-Op Fondaparinux (Arixtra) CONTRAINDICATED if CrCl LESS than 30 mL/min or weight LESS than 50 kg(NOTE)*



40 mg, Subcut, Injection, Daily Comments: Start POST-Op


Comments: Start POST-Op *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal

Unique Plan Description: VTE Gynecological Lap With Additional Risk or Major Surgery Plan Selection Display: VTE Gynecological Lap With Additional Risk or Major Surgery PlanType: Medical Version: 1 Begin Effective Date: 8/30/2016 16:35 End Effective Date: Current Available at all facilities VTE Gynecological Lap With Additional Risk or Major Surgery Patient Care Mechanical Prophylaxis

HIGH Risk(NOTE)* Below the Knee Intermittent Pneumatic Compression Device

Starting just before surgery and while patient is not ambulating Above the Knee Intermittent Pneumatic Compression Device

Starting just before surgery and while patient is not ambulating MODERATE Risk(NOTE)*

Below the Knee Intermittent Pneumatic Compression Device Starting just before surgery and while patient is not

Above the Knee Intermittent Pneumatic Compression Device Starting just before surgery and while patient is not

TED Hose T;N, Knee High (DEF)* T;N, Thigh High


T;N, Early ambulation and frequent Medications Chemoprophylaxis


40 mg, Subcut, Injection, Daily Comments: Start immediately POST-Op


Comments: Start immediately POST-Op MODERATE Risk(NOTE)*

Lovenox 40 mg, Subcut, Injection, Daily

Comments: Start POST-Op heparin 5,000 units/mL injectable

5,000 units, Subcut, Injection, BID Comments: Start POST-Op


Unique Plan Description: VTE Hip Fracture Surgery Patients Plan Selection Display: VTE Hip Fracture Surgery Patients PlanType: Medical Version: 1 Begin Effective Date: 8/30/2016 14:28 End Effective Date: Current Available at all facilities VTE Hip Fracture Surgery Patients Patient Care Mechanical Prophylaxis



HIGH Risk(NOTE)* Fondaparinux (Arixtra) CONTRAINDICATED if CrCl LESS than 30 mL/min or weight LESS than 50 kg(NOTE)*


Lovenox 30 mg, Subcut, Injection, BID


Consult to Pharmacy - Warfarin Dose Per Pharmacy INR=2.5, PRE-Op or evening of surgery, VTE Prophylaxis, Target INR: Other (See Comments),

Once *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

Unique Plan Description: VTE Intracranial Neurosurgery Patients Plan Selection Display: VTE Intracranial Neurosurgery Patients PlanType: Medical Version: 1 Begin Effective Date: 8/30/2016 15:07 End Effective Date: Current Available at all facilities VTE Intracranial Neurosurgery Patients Patient Care Mechanical Prophylaxis

SCD/Anti-Embolic Stockings(NOTE)* Prophylaxis used routinely with optimal use of SCD(NOTE)*



40 mg, Subcut, Injection, Daily Comments: Start day AFTER surgery


Comments: Start day AFTER surgery *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

Unique Plan Description: VTE Medical Patients Plan Selection Display: VTE Medical Patients PlanType: Medical Version: 1 Begin Effective Date: 8/29/2016 14:28 End Effective Date: Current Available at all facilities VTE Medical Patients Patient Care Mechanical Prophylaxis


Below the Knee Intermittent Pneumatic Compression Device Above the Knee Intermittent Pneumatic Compression Device TED Hose



Early ambulation Medications Chemoprophylaxis










Unique Plan Description: VTE Spinal Neurosurgery Patients Plan Selection Display: VTE Spinal Neurosurgery Patients PlanType: Medical Version: 1 Begin Effective Date: 8/30/2016 15:19 End Effective Date: Current Available at all facilities VTE Spinal Neurosurgery Patients Patient Care Mechanical Prophylaxis

SCD/Anti-Embolic Stockings(NOTE)* Prophylaxis used routinely with optimal use of SCD(NOTE)*



40 mg, Subcut, Injection, Daily Comments: Start day AFTER surgery


Comments: Start day AFTER surgery *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

Unique Plan Description: VTE Trauma Patients Plan Selection Display: VTE Trauma Patients PlanType: Medical Version: 1 Begin Effective Date: 8/29/2016 15:30 End Effective Date: Current Available at: KD Med Cntr VTE Trauma Patients Patient Care Mechanical Prophylaxis


Below the Knee Intermittent Pneumatic Compression Device Above the Knee Intermittent Pneumatic Compression Device Intermittent pneumatic compression devices

Foot TED Hose


Medications Chemoprophylaxis


30 mg, Subcut, Injection, BID (DEF)* 40 mg, Subcut, Injection, Daily


40 mg, Subcut, Injection, Daily (DEF)* 30 mg, Subcut, Injection, BID


Unique Plan Description: VTE Urologic Surgery Patients Plan Selection Display: VTE Urologic Surgery Patients PlanType: Medical Version: 1 Begin Effective Date: 8/30/2016 13:33 End Effective Date: Current Available at all facilities VTE Urologic Surgery Patients Patient Care Mechanical Prophylaxis


Below the Knee Intermittent Pneumatic Compression Device Above the Knee Intermittent Pneumatic Compression Device TED Hose



Early Ambulation Medications Chemoprophylaxis

HIGH Risk(NOTE)* heparin 5,000 units/mL injectable

5,000 units, Subcut, Injection, TID Lovenox



MODERATE Risk(NOTE)* heparin 5,000 units/mL injectable

5,000 units, Subcut, Injection, BID Lovenox




Unique Plan Description: VTE Venous Thromboembolism Prophylaxis Plan Selection Display: VTE Venous Thromboembolism Prophylaxis PlanType: Medical Version: 1 Begin Effective Date: 7/5/2017 06:20 End Effective Date: Current Available at: KD Med Cntr VTE Venous Thromboembolism Prophylaxis Medications

<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY background-color: rgb(255,255,255);margin:0; P margin:0 </STYLE><META name=GENERATOR content="MSHTML 11.00.9600.18739"></HEAD><BODY>High Risk: Includes critical care, hip, pelvis, and knee surgery requiring general anesthesia GREATER than 30 minutes, spinal cord injury, cancer surgery, major trauma, patients with adverse individual risk factors, or history of VTE </BODY></HTML>(NOTE)* <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY background-color: rgb(255,255,255);margin:0; P margin:0 </STYLE><META name=GENERATOR content="MSHTML 11.00.9600.18739"></HEAD><BODY>Moderate Risk: Includes patients 40 - 60 years old who have no significant individual risk factors and who are not undergoing high risk orthopedic or cancer surgeries </BODY></HTML>(NOTE)* <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY margin:0; P margin:0 </STYLE><META name=GENERATOR content="MSHTML 11.00.9600.18739"></HEAD><BODY>Low Risk: Includes patients LESS than 40 years old with favorable individual risk factors and requiring general anesthesia lasting LESS than 30 minutes </BODY></HTML>(NOTE)* Surgical patient types are only those identified by SCIP. Other surgical patient types can alos be identified and similarly stratified by risk(NOTE)* These are treatment guidelines; deviations for a particular patient should be based on a benefit versus risk estimate, to include not only VTE rsk but also the bleeding risk associated wtih drug selection and timing of drug administration(NOTE)*

VTE Medical Patients(SUB)* VTE Critical Care Patients(SUB)* VTE Trauma Patients(SUB)* VTE General Surgery(SUB)* VTE Urologic Surgery Patients(SUB)* VTE Elective Total Hip Patients(SUB)* VTE Hip Fracture Surgery Patients(SUB)* VTE Elective Total Knee Patients(SUB)* VTE Intracranial Neurosurgery Patients(SUB)* VTE Spinal Neurosurgery Patients(SUB)* VTE Gynecological Lap With Additional Risk or Major Surgery(SUB)* VTE Gynecological Extensive Surgery for Malignancy or Additional Risk(SUB)* *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription

Unique Plan Description: ANES Adult Inpatient Plan Selection Display: ANES Adult Inpatient PlanType: Medical Version: 1 Begin Effective Date: 6/1/2015 08:27 End Effective Date: Current Available at: KD Med Cntr Plan Comment: reviewed in POD 6/14/17 dsm/es; Day of Surgery PRE-Op Patient Care Forced Air Blanket

for patient comfort (DEF)* To keep body temperature GREATER than 36 degrees Celsius (96.8 degrees Fahrenheit)

Arterial Line Set-up Central Line Insertion Setup Continuous Infusions Lactated Ringers Injection

1,000 mL, IV, 125 mL/hr, Order Duration: 1 doses (DEF)* 1,000 mL, IV, 20 mL/hr, Order Duration: 1 doses

Comments: KVO rate Use Sodium Chloride 0.9% for patients with abnormal renal function or diabetes(NOTE)*

Sodium Chloride 0.9% 1,000 mL, IV, 125 mL/hr, Order Duration: 1 doses (DEF)* 1,000 1,000 mL mL, IV IV, 20 20 mL/hr mL/hr, Order Duration: Continuous Order Duration: 1 doses

Comments: KVO rate Medications Antibiotic Prophylaxis Antibiotic PRE-Op Neuro/Ortho/Vasc/Podiatry(SUB)* Antibiotic PRE-Op Head/Neck(SUB)* Antibiotic PRE-Op Colon/Abdomen (NON-Gynecological)(SUB)* Antibiotic PRE-Op Urology (NON-Penile Prosthesis)(SUB)* Antibiotic PRE-Op Urology (Penile Prosthesis)(SUB)* Pain Management CeleBREX

200 mg, Oral, Cap, PREOP for 1 days Tylenol

650 mg, Oral, Tab, PREOP for 1 doses (DEF)* 650 mg, PR, Supp, PREOP for 1 doses

Ofirmev 1,000 mg, IV Piggyback, Soln-IV, PREOP for 1 doses

morphine 2 mg, IV Push, Injection, PREOP for 2 doses (DEF)*

Comments: Give 1 dose PREOP, then may repeat x1 in 15 minutes if pain GREATER than 4/10.

4 mg, IV Push, Injection, PREOP for 2 doses Comments: Give 1 dose PREOP, then may repeat x1 in 15 minutes if pain GREATER than 4/10.

Dilaudid 0.5 mg, IV Push, Injection, PREOP for 2 doses (DEF)*

Comments: Give 1 dose PREOP, then may repeat x1 in 15 minutes if pain GREATER than 4/10.

1 mg, IV Push, Injection, PREOP for 2 doses Comments: Give 1 dose PREOP, then may repeat x1 in 15 minutes if pain GREATER than 4/10.

OxyIR 10 mg, Oral, Tab, PREOP for 1 doses

Antiemetics Zofran

4 mg, IV Push, Injection, PREOP for 1 doses (DEF)* 8 mg, IV Push, Injection, PREOP for 1 doses

Reglan 10 mg, Oral, Tab, PREOP for 1 doses (DEF)* 10 mg, IV Push, Injection, PREOP for 1 doses

Transderm-Scop 1.5 mg transdermal film, extended release 1 patches, Transdermal, Film-ER, PREOP for 1 doses

Comments: Apply 1 patch to a hairless area behind ear. Aprepitant (Emend) approved only for use in patients with known or expected intractable postoperative nausea and/or vomiting(NOTE)*

Emend 40 mg, Oral, Cap, PREOP for 1 doses

Comments: Administer within 3 hours PRIOR to induction of anesthesia for intractable postoperative nausea and vomiting

Antihypertensives Catapres

0.2 mg, Oral, Tab, PREOP for 1 doses hydrALAZINE

5 mg, IV Push, Injection, PREOP for 1 doses hydrALAZINE

5 mg, IV Push, Injection, PRN for 1 doses, PRN hypertension Comments: If distolic blood pressure still GREATER than 100 mmHg 15 minutes after first dose

labetalol 5 mg, IV Push, Injection, PREOP for 1 doses

GI Prophylaxis Pepcid

20 mg, IV Push, Injection, PREOP for 1 doses Reglan

10 mg, IV Push, Injection, PREOP for 1 doses Sedatives Versed

2 mg, IV Push, Injection, PREOP for 1 doses Haldol

0.5 mg, IV Push, Injection, PREOP for 2 doses, PRN agitation Comments: Administer every 15 minutes x 2 as needed

Respiratory Medications Xopenex CONC 1.25 mg/0.5 mL inhalation sol

1.25 mg, NEB, Device: Aerosol, Soln-Inhalation, PREOP for 1 doses Proventil 2.5 mg/3 mL (0.083%) inhalation solution

2.5 mg, NEB, Device: Aerosol, Soln-Inhalation, PREOP for 1 doses Laboratory CBC w/ Diff

Blood, Stat, T;N, Once Hematocrit

Blood, Stat, T;N, Once PT (with INR)

Blood, Stat, T;N, Once PTT

Blood, Stat, T;N, Once

Basic Metabolic Panel Blood, Stat, T;N, Once

Complete Metabolic Panel Blood, Stat, T;N, Once

Potassium Blood, Stat, T;N, Once

Blood Glucose Monitoring POC T;N, Once

Calcium Level Blood, Stat, T;N, Once

Calcium, Ionized (Serum) Blood, Stat, T;N, Once

Type and Screen Only Blood, Stat, T;N, Once

Teg Platelet Mapping Blood, Stat, T;N, Once

POC ABG Blood, Stat collect, T;N, Once

HCG Qualitative Serum Blood, Stat, T;N, Once

HCG Qualitative Urine Urine, Stat Collect, T;N, Once

Diagnostic Tests Cardiac Echo XR Chest 1 View Portable Card/Vasc/Neuro EKG 12 lead

Stat, Pre-Op [High Risk Operation] Communication Orders Notify Practitioner

For abnormal vital signs Notify Practitioner

For Platelets LESS than 100, Sodium LESS than 130, Potassium GREATER than 5.5, Potassium LESS than 3.1, Glucose GREATER than 200, Glucose LESS than 80, INR GREATER than 1.4, aPTT GREATER than 30

Anesthesia Phase I (PACU) Recovery Continuous Infusions Lactated Ringers Injection


1,000 mL, IV, 125 mL/hr Medications Pain Management Ofirmev

1,000 mg, IV Piggyback, Soln-IV, Once Toradol

15 mg, IV Push, Injection, Once, PRN other (see comment) (DEF)* Comments: Administer at the onset of POST-op pain.

30 mg, IV Push, Injection, Once, PRN other (see comment) Comments: Administer at the onset of POST-op pain.

ANES PACU Opioid Pain Control Medications - Normal Renal Function(SUB)* ANES PACU Opioid Pain Control Medications - Renal Patients(SUB)* Agitation/Anxiety

Versed 1 mg, IV Push, Injection, every 5 min for 2 doses, PRN agitation/anxiety (DEF)* 2 mg, IV Push, Injection, every 5 min for 2 doses, PRN agitation/anxiety

Ativan 0.5 mg, IV Push, Injection, Once, PRN agitation/anxiety (DEF)* 1 mg, IV Push, Injection, Once, PRN agitation/anxiety

Nausea/Vomiting If metoclopramide (Reglan) ordered together with ondansetron (Zofran), metoclopramide (Reglan) will be administered if ondansetron (Zofran) if ineffective.(NOTE)*

Zofran 4 mg, IV Push, Injection, Once, PRN nausea/vomiting

Comments: Use first if metoclopramide (Reglan) also ordered. Reglan

10 mg, IV Push, Injection, every 10 min for 2 doses, PRN nausea/vomiting Comments: If ondansetron (Zofran) also ordered, only give metoclopramide (Reglan) if ineffective.

Compazine 10 mg, IV Push, Injection, Once, PRN nausea/vomiting

Shivering/Rigors Demerol HCl

12.5 mg, IV Push, Injection, Once, PRN shivering/rigors (DEF)* Comments: Hold if O2 Sats LESS than 92% or Respiratory Rate LESS than 10 br/min.

25 mg, IV Push, Injection, Once, PRN shivering/rigors Comments: Hold if O2 Sats LESS than 92% or Respiratory Rate LESS than 10 br/min

Other Medications atropine

0.4 mg, IV Push, Injection, every 1 min for 2 doses, PRN other (see comment) Comments: Heart Rate LESS than 50 beats per min, Max dose 0.8 mg.

Robinul 0.2 mg, IV Push, Injection, every 5 min, PRN other (see comment)

Comments: PRN Heart Rate LESS than 50 beats per minute. Max dose 0.8 mg. HYPOtension Lactated Ringers Bolus

500 mL, IV Bolus, Soln-IV, As Directed, PRN other (see comment) Comments: Infuse over 30 minutes. For Systolic Blood Pressure LESS than 80 mmHg and/or mean Blood Pressure LESS than 50

Sodium Chloride 0.9% Bolus 500 mL, IV Bolus, Soln-IV, As Directed, PRN other (see comment)

Comments: Infuse over 30 minutes. For Systolic Blood Pressure LESS than 80 mmHg and/or mean Blood Pressure LESS than 50

ePHEDrine 25 mg/5 mL-NaCl 0.9% intravenous solution 5 mg, IV Push, Injection, every 5 min for 2 doses, PRN other (see comment) (DEF)*

Comments: For Systolic Blood Pressure LESS than 80 mmHg and/or Mean Arterial Pressure LESS than 50

10 mg, IV Push, Injection, every 5 min for 2 doses, PRN other (see comment) Comments: For Systolic Blood Pressure LESS than 80 mmHg and/or Mean Arterial Pressure LESS than 50

Neo-Synephrine 100 mcg, IV Push, Syringe-inj, As Directed, PRN other (see comment)


HYPERtension labetalol

5 mg, IV Push, Injection, every 5 min for 2 doses, PRN other (see comment) (DEF)* Comments: For Systolic Blood Pressure GREATER than 180 mmHg and/or Diastolic Blood

Pressure GREATER than 90 mmHg 10 mg, IV Push, Injection, every 5 min for 2 doses, PRN other (see comment)

Comments: For Systolic Blood Pressure GREATER than 180 mmHg and/or Diastolic Blood Pressure GREATER than 90 mmHg

hydrALAZINE 5 mg, IV Push, Injection, every 15 min for 2 doses, PRN other (see comment) (DEF)*


10 mg, IV Push, Injection, every 15 min for 2 doses, PRN other (see comment) Comments: For Systolic Blood Pressure GREATER than 180 mmHg and/or Diastolic Blood Pressure GREATER than 90 mmHg

Respiratory Medications albuterol 2.5 mg/3 mL (0.083%) inhalation solution

2.5 mg, NEB, Device: Aerosol, Soln-Inhalation, Once, PRN respiratory distress Xopenex CONC 1.25 mg/0.5 mL inhalation sol

1.25 mg, NEB, Device: Aerosol, Soln-Inhalation, Once, PRN respiratory distress Asthmanefrin 2.25% inhalation solution

0.5 mL, NEB, Device: Aerosol, Soln-Inhalation, Once, PRN respiratory distress Laboratory CBC without Diff

Blood, Stat, T;N PT (with INR)


Blood, Stat, T;N BMP Basic Metabolic Panel

Blood, Stat, T;N POC Arterial Blood Gas (ABG) POC Metabolic Panel Ionized CA (Chem 8) Blood Glucose Monitoring POC Diagnostic Tests XR Chest 1 View Portable

Stat, Reason: Line placement (DEF)* Stat, Reason: Respiratory distress Stat, Reason: Chest pain

Card/Vasc/Neuro ECG 12 Lead

Stat, Reason: Arrhythmia(s), symptomatic (DEF)* Stat, Reason: Chest Pain Stat, Reason: Dyspnea


SpO2 goal 90% or GREATER (DEF)* SpO2 goal 90 - 94 % SpO2 goal 89 - 94 %

BIPAP FI02: 40, 15, 5, Protocols BiPAP Protocol

CPAP CPAP 8 cmH20

Ventilator - Volume Control A/C Ventilator - Volume Control SIMV Special PROTOCOL: Beta Blocker

Unique Plan Description: ANES Adult Outpatient Plan Selection Display: ANES Adult Outpatient PlanType: Medical Version: 1 Begin Effective Date: 8/24/2017 09:25 End Effective Date: Current Available at all facilities Day of Surgery PRE-Op Patient Care Forced Air Blanket

for patient comfort (DEF)* to keep body temperature greater than 36 degrees Celsius

Arterial Line Set-up Central Line Insertion Setup Continuous Infusions Lactated Ringers Injection

1,000 mL, IV, 125 mL/hr, Order Duration: 1 doses (DEF)* 1,000 mL, IV, 20 mL/hr, Order Duration: 1 doses

Comments: KVO rate Use Sodium Chloride 0.9% for patients with abnormal renal function or diabetes(NOTE)*

Sodium Chloride 0.9% 1,000 mL, IV, 125 mL/hr, Order Duration: 1 doses (DEF)* 1,000 1,000 mL mL, IV IV, 20 20 mL/hr mL/hr, Order Duration: Continuous Order Duration: 1 doses

Comments: KVO rate Medications Antibiotic Prophylaxis Antibiotic PRE-Op Neuro/Ortho/Vasc/Podiatry(SUB)* Antibiotic PRE-Op Head/Neck(SUB)* Antibiotic PRE-Op Colon/Abdomen (NON-Gynecological)(SUB)* Antibiotic PRE-Op Urology (NON-Penile Prosthesis)(SUB)* Antibiotic PRE-Op Urology (Penile Prosthesis)(SUB)* Pain Management CeleBREX

200 mg, Oral, Cap, PREOP for 1 days Tylenol

650 mg, Oral, Tab, PREOP for 1 doses (DEF)* 650 mg, PR, Supp, PREOP for 1 doses

Ofirmev 1,000 mg, IV Piggyback, Soln-IV, PREOP for 1 doses

morphine 2 mg, IV Push, Injection, PREOP for 2 doses (DEF)*

Comments: Give 1 dose PREOP, then may repeat x1 in 15 minutes if pain greater than 4/10. 4 mg, IV Push, Injection, PREOP for 2 doses

Comments: Give 1 dose PREOP, then may repeat x1 in 15 minutes if pain greater than 4/10. Dilaudid

0.5 mg, IV Push, Injection, PREOP for 2 doses (DEF)* Comments: Give 1 dose PREOP, then may repeat x1 in 15 minutes if pain greater than 4/10.

1 mg, IV Push, Injection, PREOP for 2 doses Comments: Give 1 dose PREOP, then may repeat x1 in 15 minutes if pain greater than 4/10.

OxyIR 10 mg, Oral, Tab, PREOP for 1 doses

Antiemetics Zofran

4 mg, IV Push, Injection, PREOP for 1 doses (DEF)* 8 mg, IV Push, Injection, PREOP for 1 doses

Reglan 10 mg, Oral, Tab, PREOP for 1 doses (DEF)* 10 mg, IV Push, Injection, PREOP for 1 doses

Transderm-Scop 1.5 mg transdermal film, extended release 1 patches, Transdermal, Film-ER, PREOP for 1 doses

Comments: Apply 1 patch to a hairless area behind ear. Aprepitant (Emend) approved only for use in patients with known or expected intractable postoperative nausea and/or vomiting(NOTE)*

Emend 40 mg, Oral, Cap, PREOP for 1 doses

Comments: Administer within 3 hours PRIOR to induction of anesthesia for intractable postoperative nausea and vomiting

Antihypertensives Catapres

0.2 mg, Oral, Tab, PREOP for 1 doses hydrALAZINE

5 mg, IV Push, Injection, PREOP for 1 doses hydrALAZINE

5 mg, IV Push, Injection, PRN for 1 doses, PRN hypertension Comments: If distolic blood pressure still GREATER than 100 mmHg 15 minutes after first dose

labetalol 5 mg, IV Push, Injection, PREOP for 1 doses

GI Prophylaxis Pepcid

20 mg, IV Push, Injection, PREOP for 1 doses Reglan

10 mg, IV Push, Injection, PREOP for 1 doses Sedatives Versed

2 mg, IV Push, Injection, PREOP for 1 doses Haldol

0.5 mg, IV Push, Injection, PREOP for 2 doses, PRN agitation Comments: Administer every 15 minutes x 2 as needed

Respiratory Medications Xopenex CONC 1.25 mg/0.5 mL inhalation sol

1.25 mg, NEB, Device: Aerosol, Soln-Inhalation, PREOP for 1 doses Proventil 2.5 mg/3 mL (0.083%) inhalation solution

2.5 mg, NEB, Device: Aerosol, Soln-Inhalation, PREOP for 1 doses Laboratory CBC w/ Diff

Blood, Stat, T;N, Once Hematocrit

Blood, Stat, T;N, Once PT (with INR)

Blood, Stat, T;N, Once PTT

Blood, Stat, T;N, Once Basic Metabolic Panel

Blood, Stat, T;N, Once Complete Metabolic Panel

Blood, Stat, T;N, Once

Potassium Blood, Stat, T;N, Once

Blood Glucose Monitoring POC T;N, Once

Calcium Level Blood, Stat, T;N, Once

Calcium, Ionized (Serum) Blood, Stat, T;N, Once

HCG Qualitative Urine Urine, Stat Collect, T;N, Once

HCG Qualitative Serum Blood, Stat, T;N, Once

Type and Screen Only Blood, Stat, T;N, Once

Teg Platelet Mapping Blood, Stat, T;N, Once

POC ABG Blood, Stat collect, T;N, Once

Diagnostic Tests Cardiac Echo XR Chest 1 View Portable Card/Vasc/Neuro EKG 12 lead

Stat, Pre-Op [High Risk Operation] Communication Orders Notify Practitioner

For abnormal vital signs Notify Practitioner

For Platelets LESS than 100, Sodium LESS than 130, Potassium GREATER than 5.5, Potassium LESS than 3.1, Glucose GREATER than 200, Glucose LESS than 80, INR GREATER than 1.4, aPTT GREATER than 30

Anesthesia Phase I (PACU) Continuous Infusions Lactated Ringers Injection


1,000 mL, IV, 125 mL/hr Medications Pain Management Ofirmev

1,000 mg, IV Piggyback, Soln-IV, Once Toradol

15 mg, IV Push, Injection, Once, PRN other (see comment) (DEF)* Comments: Administer at the onset of POST-op pain.

30 mg, IV Push, Injection, Once, PRN other (see comment) Comments: Administer at the onset of POST-op pain.

ANES PACU Opioid Pain Control Medications - Normal Renal Function(SUB)* ANES PACU Opioid Pain Control Medications - Renal Patients(SUB)* Agitation/Anxiety Versed

1 mg, IV Push, Injection, every 5 min for 2 doses, PRN agitation/anxiety (DEF)* 2 mg, IV Push, Injection, every 5 min for 2 doses, PRN agitation/anxiety

Ativan

0.5 mg, IV Push, Injection, Once, PRN agitation/anxiety (DEF)* 1 mg, IV Push, Injection, Once, PRN agitation/anxiety

Nausea/Vomiting If metoclopramide (Reglan) ordered together with ondansetron (Zofran), metoclopramide (Reglan) will be administered if ondansetron (Zofran) ineffective.(NOTE)*

Zofran 4 mg, IV Push, Injection, Once, PRN nausea/vomiting

Comments: Use first if metoclopramide (Reglan) also ordered. Reglan

10 mg, IV Push, Injection, every 10 min for 2 doses, PRN nausea/vomiting Comments: If ondansetron (Zofran) also ordered, only give metoclopramide (Reglan) if ineffective.

Compazine 10 mg, IV Push, Injection, Once, PRN nausea/vomiting

Shivering/Rigors Demerol HCl

12.5 mg, IV Push, Injection, Once, PRN shivering/rigors (DEF)* Comments: Hold if O2 Sats less than 92% or Respiratory Rate less than 10.

25 mg, IV Push, Injection, Once, PRN shivering/rigors Comments: Hold if O2 Sats less than 92% or Respiratory Rate less than 10.

Other Medications atropine

0.4 mg, IV Push, Injection, every 1 min for 2 doses, PRN other (see comment) Comments: PRN Heart Rate LESS than 50 beats per min. Max dose 0.8 mg.

Robinul 0.2 mg, IV Push, Injection, every 5 min, PRN other (see comment)

Comments: PRN Heart Rate LESS than 50 beats per minute. Max dose 0.8 mg. HYPOtension Lactated Ringers Bolus

500 mL, IV Bolus, Soln-IV, As Directed, PRN other (see comment) Comments: Infuse over 30 minutes. For Systolic Blood Pressure LESS than 80 mmHg and/or mean Blood Pressure LESS than 50

Sodium Chloride 0.9% Bolus 500 mL, IV Bolus, Soln-IV, As Directed, PRN other (see comment)

Comments: Infuse over 30 minutes. For Systolic Blood Pressure LESS than 80 mmHg and/or mean Blood Pressure LESS than 50

ePHEDrine 25 mg/5 mL-NaCl 0.9% intravenous solution 5 mg, IV Push, Injection, every 5 min for 2 doses, PRN other (see comment) (DEF)*


10 mg, IV Push, Injection, every 5 min for 2 doses, PRN other (see comment) Comments: For Systolic Blood Pressure LESS than 80 mmHg and/or Mean Arterial Pressure LESS than 50

Neo-Synephrine 100 mcg, IV Push, Syringe-inj, As Directed, PRN other (see comment)


HYPERtension labetalol

5 mg, IV Push, Injection, every 5 min for 2 doses, PRN other (see comment) (DEF)* Comments: For Systolic Blood Pressure GREATER than 180 mmHg and/or Diastolic Blood Pressure GREATER than 90 mmHg


hydrALAZINE 5 mg, IV Push, Injection, every 15 min for 2 doses, PRN other (see comment) (DEF)*



Respiratory Medications albuterol 2.5 mg/3 mL (0.083%) inhalation solution

2.5 mg, NEB, Device: Aerosol, Soln-Inhalation, Once, PRN respiratory distress Xopenex CONC 1.25 mg/0.5 mL inhalation sol

1.25 mg, NEB, Device: Aerosol, Soln-Inhalation, Once, PRN respiratory distress Asthmanefrin 2.25% inhalation solution

0.5 mL, NEB, Device: Aerosol, Soln-Inhalation, Once, PRN respiratory distress Laboratory CBC without Diff

Blood, Stat, T;N PT (with INR)


Blood, Stat, T;N BMP Basic Metabolic Panel

Blood, Stat, T;N POC Arterial Blood Gas (ABG) POC Metabolic Panel Ionized CA (Chem 8) Blood Glucose Monitoring POC Diagnostic Tests XR Chest 1 View Portable

Stat, Reason: Line placement (DEF)* Stat, Reason: Respiratory distress Stat, Reason: Chest pain

Card/Vasc/Neuro ECG 12 Lead

Stat, Reason: Arrhythmia(s), symptomatic (DEF)* Stat, Reason: Chest Pain Stat, Reason: Dyspnea


SpO2 goal 90% or GREATER (DEF)* SpO2 goal 90 - 94 % SpO2 goal 89 - 94 %

BIPAP FI02: 40, 15, 5, Protocols BiPAP Protocol

CPAP CPAP 8 cmH20

Ventilator - Volume Control A/C Ventilator - Volume Control SIMV Anesthesia Phase II (SDS) Recovery Patient Care Forced Air Blanket

PRN, for patient comfort (DEF)* PRN, to keep body temperature greater than 36 degrees Celsius

Peripheral IV Discontinue

If patient is an outpatient Medications Pain Management Tylenol

650 mg, Oral, Tab, every 6 hours., PRN pain, mild (scale 1-3) Norco 5 mg-325 mg oral tablet

1 tab, Oral, Tab, every 4 hours., PRN pain, moderate (scale 4-6) Norco 10 mg-325 mg oral tablet

1 tab, Oral, Tab, every 4 hours., PRN pain, severe (scale 7-10) OxyIR

5 mg, Oral, Tab, every 4 hours., PRN pain, severe (scale 7-10) Nausea/Vomiting Zofran ODT

4 mg, Oral, Tab-Dis, Once, PRN nausea/vomiting Zofran

4 mg, IV Push, Injection, Once, PRN nausea/vomiting Pruritis Benadryl

25 mg, Oral, Cap, every 6 hours., PRN itching/rash (DEF)* 25 mg, IV Push, Injection, every 6 hours., PRN itching/rash 12.5 mg, IV Push, Injection, every 6 hours., PRN itching/rash


SpO2 goal 90% or GREATER, Nasal Cannula (DEF)* SpO2 goal 90 - 94 %, Nasal Cannula SpO2 goal 89 - 94 %, Nasal Cannula


Unique Plan Description: ANES Pediatric Inpatient Plan Selection Display: ANES Pediatric Inpatient PlanType: Medical Version: 1 Begin Effective Date: 5/12/2017 15:17 End Effective Date: Current Available at: KD Med Cntr Day of Surgery PRE-Op Patient Care Peripheral IV Port-a-Cath Access

Access and use for medication administration PICC Line Care

Use PICC for medication administration Emla 2.5%-2.5% topical cream

1 app, Topical, Cream, As Directed, PRN other (see comment) [Less Than 3 months and Less Than 5 kg] (DEF)*

Comments: For lab draws and IV Sticks. Apply 1-2 hrs prior to procedure. Max dose = 1 g. Max application area = 10 cm2. Max application time = 1 hr. Assess & document pain prior & after procedure

1 app, Topical, Cream, As Directed, PRN other (see comment) [3 - 12 months and Greater Than or Equal To 5 kg]

Comments: For lab draws and IV Sticks. Apply 1-2 hrs prior to procedure. Max dose = 2 g. Max application area = 20 cm2. Max application time = 4 hrs. Assess & document pain prior & after procedure

1 app, Topical, Cream, As Directed, PRN other (see comment) [1 - 6 years and Greater Than or Equal To 10 kg]



Comments: For lab draws and IV Sticks. Apply 1-2 hrs prior to procedure. Max dose=20 g. Max application area = 200 cm2. Max application time = 4 hrs. Assess & document pain prior & after procedure

Continuous Infusions Maintenance IV Fluid Rate Calculation: -Patient Weight 11 to 20 kg: 40 + (2 mL/kg) for each kg over 11 kg -Patient Weight GREATER than 20 kg: 60 + (1 mL/kg) for each kg over 20 kg(NOTE)*

Lactated Ringers Injection 500 mL, IV, mL/hr

For sodium chloride 0.9% use 1.5 TIMES the calculated maintenance rate(NOTE)* Sodium Chloride 0.9%

500 mL, IV, mL/hr Medications Sedation Versed

0.5 mg/kg, Oral, Syrup, PREOP for 1 doses (DEF)* Comments: Maximum dose 20 mg.

0.1 mg/kg, IV Push, Injection, PREOP for 4 doses Comments: Maximum dose 2 mg. May repeat q3min

0.3 mg/kg, Nasal, Injection, PREOP for 1 doses Comments: Maximum dose 10 mg

Pain Management Tylenol

15 mg/kg, Oral, Liquid, PREOP for 1 doses (DEF)*

Comments: Maximum dose 650 mg. 40 mg/kg, PR, Supp, PREOP for 1 doses

Comments: Maximum dose 650 mg. Laboratory HCG Qualitative Serum HCG Qualitative Urine Anesthesia Phase I (PACU) Recovery Patient Care Capnography Discontinue Arterial Line

If patient is not going to a criticial care area Warming Measures Blood Glucose Monitoring POC

Notify anesthesiologist if blood glucose LESS than 60 or GREATER than or EQUAL to 150 mg/dL Medications Pain Management - Parenteral

Mild Pain(NOTE)* morphine PEDS/NICU inj

0.025 mg/kg, IV Push, Injection, every 5 min, PRN pain, mild (scale 1-3) Comments: Maximum single dose not to exceed 4 mg. Maximum total morphine dose = 0.2 mg/kg

fentaNYL PEDS/NICU 0.25 mcg/kg, IV Push, Syringe inj, PED, every 5 min for 8 doses, PRN pain, mild (scale 1-3)

Comments: Maxium total dose of 3 mcg/kg Moderate Pain(NOTE)*

morphine PEDS/NICU inj 0.05 mg/kg, IV Push, Injection, every 5 min, PRN pain, moderate (scale 4-6)

Comments: Maximum single dose not to exceed 4 mg. Maximum total morphine dose = 0.2 mg/kg

fentaNYL PEDS/NICU 0.5 mcg/kg, IV Push, Syringe inj, PED, every 5 min for 8 doses, PRN pain, moderate (scale 4-6)

Comments: Maxium total dose of 3 mcg/kg Toradol

0.5 mg/kg, IV Push, Injection, Once, PRN pain, moderate (scale 4-6) Comments: Max dose = 15 mg

Severe Pain(NOTE)* morphine PEDS/NICU inj

0.1 mg/kg, IV Push, Injection, every 5 min, PRN pain, severe (scale 7-10) Comments: Maximum single dose not to exceed 4 mg. Maximum total morphine dose = 0.2 mg/kg

fentaNYL PEDS/NICU 0.75 mcg/kg, IV Push, Syringe inj, PED, every 5 min for 8 doses, PRN pain, severe (scale 7-10)


1 mg/kg, IV Push, Injection, Once, PRN pain, severe (scale 7-10) Comments: Max dose = 15 mg

Pain Management - Non Parenteral Mild Pain(NOTE)*

Tylenol 15 mg/kg, Oral, Liquid, Once, PRN pain, mild (scale 1-3) (DEF)*

Comments: Max dose = 650 mg. 40 mg/kg, PR, Supp, Once, PRN pain, mild (scale 1-3)

Comments: Max dose = 650 mg ibuprofen

10 mg/kg, Oral, Susp-Oral, Once, PRN pain, mild (scale 1-3) [Less Than 18 years] (DEF)* Comments: Max dose = 600 mg.

200 mg, Oral, Tab, Once, PRN pain, mild (scale 1-3) Comments: Max dose = 600 mg.



Moderate Pain(NOTE)* fentaNYL PEDS/NICU

1.5 mcg/kg, Nasal, Syringe inj, PED, Once for 1 doses, PRN pain, moderate (scale 4-6) Comments: Loading Dose. If no IV Access. Max single dose not to exceed 50 mcg. Maximum total Fentanyl dose = 3 mcg/kg

fentaNYL PEDS/NICU 0.5 mcg/kg, Nasal, Syringe inj, PED, every 5 min for 1 doses, PRN pain, moderate (scale 4-6)

Comments: If no IV Access. Max single dose not to exceed 50 mcg. Maximum total Fentanyl dose = 3 mcg/kg

Hycet 7.5 mg-325 mg/15 mL oral solution 0.3 mL/kg, Oral, Soln, Once for 1 doses, PRN pain, moderate (scale 4-6)

Comments: Max total dose = 20 mL (10 mg of Hydrocodone) Sedation Versed

0.05 mg/kg, IV Push, Injection, every 5 min for 3 doses, PRN agitation Comments: Maximum single dose 2 mg

Valium 0.05 mg/kg, IV Push, Injection, Once, PRN spasm

Comments: Maximum single dose 5 mg. Nausea/Vomiting

If metoclopramide (Reglan) ordered together with ondansetron (Zofran), metoclopramide (Reglan) will be administered if ondansetron (Zofran) if ineffective.(NOTE)*

Zofran 0.1 mg/kg, IV Push, Injection, Once for 1 doses, PRN nausea/vomiting

Comments: Maximum single dose 4 mg. Use first line if metoclopramide (Reglan) also ordered.

Reglan PEDS/NICU 0.1 mg/kg, IV Push, Syringe inj, PED, Once for 1 doses, PRN nausea/vomiting

Comments: Maximum single dose 10 mg. Second line if ondansetron (Zofran) is also odered Respiratory Medications Asthmanefrin 2.25% inhalation solution

0.5 mL, NEB, Device: Aerosol, Soln-Inhalation, Once, PRN stridor Proventil 2.5 mg/3 mL (0.083%) inhalation solution

2.5 mg, NEB, Device: Aerosol, Soln-Inhalation, Once, PRN wheezing Respiratory Oxygen Therapy

Routine, Titrate O2 to maintain Oxygen Saturation GREATER than or EQUAL to 95%, or maintains patients baseline. If LESS than 44 weeks gestation titrate to keep Oxygen Saturation 88-94%

Communication Order Pateint to remain intubated, obtain ventilator

*Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note

Unique Plan Description: ANES Pediatric Outpatient Plan Selection Display: ANES Pediatric Outpatient PlanType: Medical Version: 1 Begin Effective Date: 8/24/2017 09:38 End Effective Date: Current Available at all facilities Day of Surgery PRE-Op Patient Care Peripheral IV Port-a-Cath Access

Access and use for medication administration PICC Line Care

Use PICC for medication administration Emla 2.5%-2.5% topical cream

1 app, Topical, Cream, As Directed, PRN other (see comment) [Less Than 3 months and Less Than 5 kg] (DEF)*

Comments: For lab draws and IV Sticks. Apply 1-2 hrs prior to procedure. Max dose = 1 g. Max application area = 10 cm2. Max application time = 1 hr. Assess & document pain prior & after procedure

1 app, Topical, Cream, As Directed, PRN other (see comment) [3 - 12 months and Greater Than or Equal To 5 kg]





Comments: For lab draws and IV Sticks. Apply 1-2 hrs prior to procedure. Max dose=20 g. Max application area = 200 cm2. Max application time = 4 hrs. Assess & document pain prior & after procedure

Continuous Infusions Maintenance IV Fluid Rate Calculation: -Patient Weight 11-20 kg: 40 + (2 mL/kg) for each kg over 11 kg -Patient Weight more than 20 kg: 60 + (1 mL/kg) for each kg over 20 kg(NOTE)*

Lactated Ringers Injection 500 mL, IV, mL/hr

For sodium chloride 0.9% use 1.5 TIMES the calculated maintenance rate(NOTE)* Sodium Chloride 0.9%

500 mL, IV, mL/hr Medications Sedation Versed

0.5 mg/kg, Oral, Syrup, PREOP for 1 doses (DEF)* Comments: Maximum dose 20 mg.

0.1 mg/kg, IV Push, Injection, PREOP for 4 doses Comments: Maximum dose 2 mg. May repeat q3min

0.3 mg/kg, Nasal, Injection, PREOP for 1 doses Comments: Maximum dose 10 mg

Pain Management Tylenol

15 mg/kg, Oral, Liquid, PREOP for 1 doses (DEF)*

Comments: Maximum dose 650 mg. 40 mg/kg, PR, Supp, PREOP for 1 doses

Comments: Maximum dose 650 mg. Laboratory HCG Qualitative Serum HCG Qualitative Urine Anesthesia Phase I (PACU) Recovery Patient Care Capnography Discontinue Arterial Line

If patient is not going to a criticial care area Warming Measures Blood Glucose Monitoring POC

Notify anesthesiologist if blood glucose LESS than 60 or GREATER than or EQUAL to 150 mg/dL Medications Pain Management - Parenteral

Mild Pain(NOTE)* morphine PEDS/NICU inj

0.025 mg/kg, IV Push, Injection, every 5 min, PRN pain, mild (scale 1-3) Comments: Maximum single dose not to exceed 4 mg. Maximum total morphine dose = 0.2 mg/kg

fentaNYL PEDS/NICU 0.25 mcg/kg, IV Push, Syringe inj, PED, every 5 min for 8 doses, PRN pain, mild (scale 1-3)

Comments: Maxium total dose of 3 mcg/kg Moderate Pain(NOTE)*

morphine PEDS/NICU inj 0.05 mg/kg, IV Push, Injection, every 5 min, PRN pain, moderate (scale 4-6)

Comments: Maximum single dose not to exceed 4 mg. Maximum total morphine dose = 0.2 mg/kg

fentaNYL PEDS/NICU 0.5 mcg/kg, IV Push, Syringe inj, PED, every 5 min for 8 doses, PRN pain, moderate (scale 4-6)


0.5 mg/kg, IV Push, Injection, Once, PRN pain, moderate (scale 4-6) Comments: Max dose = 15 mg

Severe Pain(NOTE)* morphine PEDS/NICU inj

0.1 mg/kg, IV Push, Injection, every 5 min, PRN pain, severe (scale 7-10) Comments: Maximum single dose not to exceed 4 mg. Maximum total morphine dose = 0.2 mg/kg

fentaNYL PEDS/NICU 0.75 mcg/kg, IV Push, Syringe inj, PED, every 5 min for 8 doses, PRN pain, severe (scale 7-10)


1 mg/kg, IV Push, Injection, Once, PRN pain, severe (scale 7-10) Comments: Max dose = 15 mg

Pain Management - Non Parenteral Mild Pain(NOTE)*

Tylenol 15 mg/kg, Oral, Liquid, Once, PRN pain, mild (scale 1-3) (DEF)*

Comments: Max dose = 650 mg. 40 mg/kg, PR, Supp, Once, PRN pain, mild (scale 1-3)

Comments: Max dose = 650 mg ibuprofen

10 mg/kg, Oral, Susp-Oral, Once, PRN pain, mild (scale 1-3) [Less Than 18 years] (DEF)* Comments: Max dose = 600 mg.

200 mg, Oral, Tab, Once, PRN pain, mild (scale 1-3) 400 mg, Oral, Tab, Once, PRN pain, mild (scale 1-3) 600 mg, Oral, Tab, Once, PRN pain, mild (scale 1-3)

Moderate Pain(NOTE)* fentaNYL PEDS/NICU

1.5 mcg/kg, Nasal, Syringe inj, PED, Once for 1 doses, PRN pain, moderate (scale 4-6) Comments: Loading Dose. If no IV Access. Max single dose not to exceed 50 mcg. Maximum total Fentanyl dose = 3 mcg/kg

fentaNYL PEDS/NICU 0.5 mcg/kg, Nasal, Syringe inj, PED, every 5 min for 1 doses, PRN pain, moderate (scale 4-6)

Comments: If no IV Access. Max single dose not to exceed 50 mcg. Maximum total Fentanyl dose = 3 mcg/kg


Comments: Max total dose = 20 mL (10 mg of Hydrocodone) Sedation Versed

0.05 mg/kg, IV Push, Injection, every 5 min for 3 doses, PRN agitation Comments: Maximum single dose 2 mg

Valium 0.05 mg/kg, IV Push, Injection, Once, PRN spasm

Comments: Maximum single dose 5 mg. Nausea/Vomiting

If metoclopramide (Reglan) ordered together with ondansetron (Zofran), metoclopramide (Reglan) will be administered if ondansetron (Zofran) if ineffective.(NOTE)*

Zofran 0.1 mg/kg, IV Push, Injection, Once for 1 doses, PRN nausea/vomiting

Comments: Maximum single dose 4 mg. Use first line if metoclopramide (Reglan) also ordered.

Reglan PEDS/NICU 0.1 mg/kg, IV Push, Syringe inj, PED, Once for 1 doses, PRN nausea/vomiting

Comments: Maximum single dose 10 mg. Second line if ondansetron (Zofran) is also odered Respiratory Medications Asthmanefrin 2.25% inhalation solution

0.5 mL, NEB, Device: Aerosol, Soln-Inhalation, Once, PRN stridor Proventil 2.5 mg/3 mL (0.083%) inhalation solution

2.5 mg, NEB, Device: Aerosol, Soln-Inhalation, Once, PRN wheezing Respiratory Oxygen Therapy

Routine, Titrate O2 to maintain Oxygen Saturation GREATER than or EQUAL to 95%, or maintains patients baseline. If LESS than 44 weeks gestation titrate to keep Oxygen Saturation 88-94%

Communication Order Pateint to remain intubated, obtain ventilator

Anesthesia Phase II (SDS) Recovery Patient Care Peripheral IV Discontinue

If patient is an outpatient getting discharged home. Forced Air Blanket

PRN, for patient comfort (DEF)* PRN, to keep body temperature greater than 36 degrees Celsius

Medications Pain Management Tylenol Childrens

15 mg/kg, Oral, Liquid, Once for 1 doses, PRN pain, mild (scale 1-3) Tylenol

40 mg/kg, PR, Supp, Once for 1 doses, PRN pain, mild (scale 1-3) Comments: If oral also ordered, give rectal if unable to tolerate oral


Comments: Maximum single dose 15 mL. Nausea/Vomiting Zofran

0.1 mg/kg, IV Push, Injection, Once Comments: Max single dose not to exceed 4 mg

Decadron PEDS/NICU 0.5 mg/kg, IV Push, Injection, Once

Comments: Max single dose not to exceed 8 mg Reglan PEDS/NICU

0.1 mg/kg, IV Push, Syringe inj, PED, Once Comments: Max single dose not to exceed 10 mg

Benadryl 1 mg/kg, IV Push, Injection, Once

Comments: Max single dose not to exceed 50 mg. Use if Zofran, Decadron, and Reglan ineffective


Unique Plan Description: ANES Open Heart Surgery Anesthesia POST-Op Plan Selection Display: ANES Open Heart Surgery Anesthesia POST-Op PlanType: Medical Version: 1 Begin Effective Date: 5/24/2017 04:43 End Effective Date: Current Available at: KD Med Cntr ANES Open Heart Surgery Anesthesia POST-Op Medications POSToperative Medications Ofirmev

1,000 mg, IV Piggyback, Soln-IV, every 6 hours. for 3 doses tranexamic acid 5,000 mg/Sodium Chloride 0.9% 250 mL Drip (IVS)* Sodium Chloride 0.9%

250 mL, IV, 0.1 mL/hr, Do NOT titrate - continue OR rate, Order Duration: 1 doses, Start Date: T+1;0600

Comments: D/C 2 hours post arrival to CVICU. CONC = 20 mg/mL. tranexamic acid IV additive

5,000 mg, EB, mg/kg/hr aminocaproic acid (Amicar) 15 g/Sodium Chloride 0.9% 90 mL (IVS)* Sodium Chloride 0.9%*

90 mL, IV, Titration instructions: Do NOT titrate - cont OR rate. DC when bag is finished, Goal: n/a

aminocaproic acid IV additive 15 g, EB, 10 mg/kg/hr

clevidipine (Cleviprex) 50 mg/100 mL Premix (IVS)* Premix*

100 mL, IV, Titration instructions: Do NOT Titrate, Goal: N/A, Continue OR Rate Comments: Concentration: 0.5 mg/mL.

clevidipine IV additive 50 mg, 1 mg/hr

magnesium sulfate 2 g, IV Piggyback, Soln-IV, Once, Administer over: 2 hr

Comments: Premixed in Sterile Water potassium chloride IVPB

20 mEq, IV Piggyback, Soln-IV, As Directed, PRN other (see comment) Comments: Central Line ONLY | PRN Potassium LESS than 4.5. Infuse then recheck potassium

albumin human 5% intravenous solution 12.5 g, IV Piggyback, Soln-IV, As Directed for 4 doses, PRN other (see comment)

Comments: If HCT GREATER than 22% and HGB GREATER than 7.5g. May repeat x 4 to maintain heart rate 60-120 bpm, Systolic Blood Pressure 90-140 mmHg, CVP 5-15, PAD 10-22 and CI GREATER than 2.2

Peridex 0.12% mucous membrane liquid 15 mL, Oral, Liquid, BID

Comments: Brush teeth, tongue, gums, and tooth surfaces x 30 seconds. Discontinue upon extubation

Sedation Diprivan (propofol) 1,000 mg/100 mL Premix (IVS)* Premix*

100 mL, IV, Titration instructions: Adjust 5-10 mcg/kg/min every 5 minutes, Max Dose: 50 mcg/kg/min, Goal: RASS -2 to 0, Continue OR Rate

Comments: Concentration: 10mg/mL. Patient on mechanical ventilator only. Limit use of MORE than 1 sedating med. Discontinue 2 hours after arriving on unit.

propofol IV additive

1,000 mg, EB, 5 mcg/kg/hr dexmedetomidine (Precedex) 200 mcg/Sodium Chloride 0.9% 50 mL (IVS)* Premix Sodium Chloride 0.9%*

50 mL, IV, Titration instructions: Titrate 0.1 mcg/kg/hr Q15min, Max Dose: 1.2 mcg/kg/hr, Goal: RASS -2 to 0.

Comments: Concentration: 4 mcg/mL. Patient on mechanical ventilator only. Limit use of MORE than 1 sedating med. Discontinue 2 hours after arriving on unit.

dexmedetomidine IV additive 200 mcg, EB, 0.2 mcg/kg/hr

Laboratory POC Arterial Blood Gas (ABG)

T;N, every 4 hr Rapid Rteg and Rtegh

Blood, Stat, T;N, Nurse collect *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

Unique Plan Description: NICU DOBUTamine Plan Selection Display: NICU DOBUTamine PlanType: Medical Version: 1 Begin Effective Date: 11/30/2016 15:12 End Effective Date: Current Available at all facilities Plan Comment: IV Set built and added 3/27/17 dsm; meds reviewed 3/28/17 dsm; stakeholder reviewed 8/2/17 dsm; NICU DOBUTamine Patient Care Cardiorespiratory Monitoring

Continuous Vital Signs

every 15 min, Duration: 2 hr, If Arterial line not in place, monitor and document vital signs every 15 minutes, prior to, and 15 minutes after any changes to EPINEPHrine infusion rate for 2 hours, then per standard of care

Communication Order Document vital signs every 15 minutes, prior to, and 15 minutes after any changes to infusion rate

for neonates on Dobutamine Peripheral Perfusion Checks

every 2 hr, Assess and document peripheral perfusion minimally every 2 hours Continuous Infusions

<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"><HTML><HEAD><META content="text/html; charset=windows-1252" http-equiv=Content-Type><STYLE> BODY margin:0; P margin:0 </STYLE><META name=GENERATOR content="MSHTML 11.00.9600.18763"></HEAD><BODY>Starting Rate = 2 mcg/kg/minute</BODY></HTML>(NOTE)*

DOBUTamine PEDS/NICU 30 mg/Dextrose 5% Water 30 mL* (IVS)* Syringe Inj - PEDS*

30 mL, IV, Titration instructions: Titrate by 1mcg/kg/min every 15 minutes, Max Dose: 25 mcg/kg/min, mcg/kg/min

DOBUTamine IV additive 30 mg, EB, 2 mcg/kg/min

Communication Orders Notify Treating Practitioner

Inability to maintain ordered blood pressure parameters within titration orders Notify Treating Practitioner Vital Signs Non Categorized Initial Approval Date Annual Review Date *Report Legend: DEF - This order sentence is the default for the selected order GOAL - This component is a goal IND - This component is an indicator INT - This component is an intervention IVS - This component is an IV Set NOTE - This component is a note Rx - This component is a prescription SUB - This component is a sub phase

ISBARQ Date: March 9, 2016 *Updated August 2017

Introduction: The Electrolyte Protocol was developed to assist both physicians and nurses in the critical care areas to safely provide needed electrolyte replacement once patients met inclusion criteria. Situation: Recommendation from Intensivist to revise and update the Electrolyte protocol. Background: The Electrolyte protocol provides electrolyte replacement parameters, dosing as well as repeat labs once replacement is complete. Assessment An interdisciplinary group of physicians, nurses and pharmacists reviewed the Electrolyte protocol and made recommendations. Recommendation: Recommendation was to revise the Electrolyte Protocol to include decreasing the amount of labs ordered, and update and revise table as needed (per Pharmacist recommendations). Other changes:

Changed Phosphorous replacement to sodium phosphate only (no longer replacing with K-Phos). Changed inclusion criteria for electrolytes To match phosphorous replacement, removed the potassium phosphate instruction.

Questions:

Page 1 of 4

Kaweah Delta Health Care District 400 West Mineral King – Visalia, CA 93291-6263 – 559.624.2000 PROTOCOL

ELECTROLYTE REPLACEMENT PROTOCOL

I. CIRCUMSTANCES FOR IMPLEMENTATION OF PROTOCOL

1. SETTING: Critical Care Units, Intermediate Critical Care Units, Emergency Department

2. PATIENT CONDITION/MEDICAL CONDITIONS:

• Potassium less than 3.8 mmol/L and serum creatinine less than or equal to 2.5mg/dl • Potassium less than 3.0 mmol/L and serum creatinine greater than 2.5 mg/dl • Calcium (ionized) less than 1 mmol/L • Magnesium less than 1.9 mg/dL • Phosphorus less than 1.4 mg/dL

II. TREATMENT PLAN:

1. When patient has met condition/medical conditions for electrolyte replacement protocol;

a. Give initial ordered dose b. Recheck lab as indicated in table c. Repeat electrolyte supplementation as necessary until the electrolyte level is above the replacement

threshold. 2. If patient has functioning GI tract and no abdominal pain, give K+Potassium replacement per PO or gastric

tube (GT) 3. If patient does not have a functioning GI tract or has abdominal pain, give K+Potassium replacement per

intravenous route. 4. .

5.4. Ca++Calcium (ionized) supplementation: if serum phosphorus is greater than 5 mg/dl, call physician before replacing Ca++.Calcium

5. Potassium less than 2.5 mmol/L, call physician. 6. Magnesium less and 1 mg/dl, call physician.

Commented [A1]:


Page 2 of 4

Electrolyte Replacement

Threshold Serum Creatinine ≤ 2.5 mg/dL

Serum Creatinine > 2.5 mg/dL

Recheck

Potassium

K+ 3.1 to 3.7 mmol/L

PO/NG/GT: 40mEq KCl liquid x1 dose

None

If initial K+ < 3.5, recheck renal panel II one hour after dose. If initial K+ ≥ 3.50, do not recheck. Consult with physician

Central IV: 20mEq/50mL IVPB over 1 hour x2 doses

If initial K+ < 3.5, renal panel II immediately after completion. If initial K+ ≥ 3.50, do not recheck. Consult with physician.

Peripheral IV: 10mEq/50mL IVPB over 1 hour x4 doses

K+ 2.5 to 3 mmol/L

PO/NG/GT: 40mEq KCl liquid q2h x2 doses

PO/NG/GT: 20 mEq KCl liquid x1 dose

Renal panel II one hour after completion of administration

Central IV: 20mEq/50mL IVPB over 1 hour x4 doses

Central IV: 20mEq /50mL IVPB over 1 hour x1 dose

Renal panel II immediately after infusion completion completed



K+ < 2.5mmol/L Call physician

Magnesium

Mag++ 1.5 to 1.9 mg/dL

Magnesium sulfate 2gm IVPB over 1 hour x1 dose


Recheck following day with a.m. labs

Mag++ 1 to 1.49mg/dL

Magnesium sulfate 2gm IVPB over 1 hour x2 doses


Renal panel II after infusion completed.

Mag++ < 1 mg/dL Call physician

Calcium, ionized If serum

phosphorous is > 5 mg/dL, call

physician (before replacing Ca++)

Ca++ < 1 mmol/L but ≥ 0.5 mmol/L If serum phosphorous is > 5 mg/dL, call physician

1 gram calcium gluconate IV PB over 1 hour Ionized calcium level after infusion completed. ICU panel acceptable Ca++ < 0.5 mmol/L

If serum phosphorus is > 5mg/dL, call physician

2 grams calcium gluconate IVPB over 1 hour

Phosphorous

P < 1.4 mg/dL Give 30 mmol sodium phosphate IVPB over 4 hours

Renal panel II two hours after infusion completed.



Page 3 of 4

Page 4 of 4

Last Reviewed: 03/29/11 Initial Approval: 05/17/11 Next Annual Approval: 12/05/2015

PATIENT LABEL or Patient Name: Acct #: DOB:

Kaweah Delta Medical Center 400 West Mineral King—Visalia, CA 93291-6263—559-624-2000

COMMUNICATION FORM ELECTROLYTE REPLACEMENT PROTOCOL INITIATION FOR

HYPOCALCEMIA

Hypocalcemia replacement protocol initiated for ionized calcium less than 1 mmol/L Ordering Physician is: ______________________________________. The following is administered per protocol: (CHECK ONE)

• Repeat electrolyte supplementation as necessary. • Recheck labs PER PROTOCOL. • Report lab values to physician PER PROTOCOL VENOUS ICU PANEL @_______________ ARTERIAL ICU PANEL @______________ LAB DRAW IONIZED CALCIUM @______________. ____________________ Per Protocol/RN_________________________________ Date & Time RN Signature Patient Label or

Patient Name: Acct # DOB: Next Annual approval 11/17/2016

IONIZED CALCIUM < 0.50 mmol/L • If serum phosphorous is > 5 mg/dl, call physician before replacing Calcium • Central Line or Peripheral Line

2 grams Calcium Gluconate IVPB over 1 hour. IONIZED CALCIUM < 1 mmol/L but ≥ 0.50 mmol/L • If serum phosphorous is > 5 mg/dl, call physician before replacing Calcium • Central Line or Peripheral Line 1 gram Calcium Gluconate IVPB dose over 1 hour.

Formatted: Left







Kaweah Delta Health Care District 400 West Mineral King – Visalia, CA 93291-6263 – 559.624.2000 _________________________________________________________________________________________________

[Type text] 12/05/2016

HYPOKALEMIA COMMUNICATION FORM ELECTROLYTE REPLACEMENT PROTOCOL INITIATION FOR

Patient/Medical Condition: Serum K+ < 3.8 mmol/l and Serum Creatinine ≤ 2.5 or > 2.5 mg/dl Ordering Physician is: ______________________________________. The following is administered per protocol: (CHECK ONE)

• Recheck labs PER PROTOCOL. NURSE DRAW: Date: _______________ Time: ______________ RENAL PANEL II LAB DRAW: Date: _________________ Time: ______________ _______________ _______________________________ Date & Time RN Signature Next Annual approval: 11/17/2016 PATIENT LABEL or

Patient Name: Acct #: DOB:

• K+ 3.1 to 3.7 mmol/L and Serum creatinine LESS THAN OR EQUAL TO 2.5 mg/dl. PO/NG/GT 40mEq KCl liquid x1 dose diluted in water or juice. CENTRAL LINE 20mEq/50mL IVPB over 1 hour x 2 doses. PERIPHERAL LINE 10mEq/50mL IVPB over 1 hour x 4 doses.

• K+ 2.5 to 3 mmol/L and Serum creatinine LESS THAN OR EQUAL TO 2.5 mg/dL. PO/NG/GT 40mEq KCl liquid q2h x 2 doses diluted in water or juice. CENTRAL LINE: 20mEq/50mL IVPB over 1 hour x 4 doses.

PERIPHERAL LINE: 10mEq/50mL IVPB over 1 hour x 8 doses.

• K+ 2.5 to 3 mmol/L and Serum creatinine GREATER THAN 2.5 mg/dL.

PO/NG/GT 20 mEq KCl liquid x1 dose diluted in water or juice. CENTRAL LINE 20mEq/50mL IVPB over 1 hour x 1 dose.

PERIPHERAL LINE 10mEq/50mL IVPB over 1 hour x 2 doses.

Kaweah Delta Medical Center 400 West Mineral King—Visalia, CA 93291-6263—559-624-2000 ________________________________________________________________________


HYPOPHOSPHATEMIA

Hypophosphatemia protocol initiated for Serum Phosphorus less than 1.4 mg/dl Ordering Physician is:______________________________________. If Potassium and Phosphorus are both low, correct Phosphorus first (is this needed if we are replacing phosphorous with Sodium (not potassium) phos?).

• Repeat electrolyte supplementation as necessary. • Recheck labs PER PROTOCOL. • Report lab values to physician PER PROTOCOL Renal Panel 2 Nurse Draw Date: _____________ Time: _____

Lab Draw Date:@______________ Time: ________________ ____________________ Per Protocol/RN_________________________________ Date & Time RN Signature

Next Annual approval 11/17/2016

Patient Label or Patient Name: Acct # DOB:

The following is administered per protocol:

Give 30 mmol sodium phosphate IVPB over 4 hours. CENTRAL OR PERIPHERAL IV

Formatted: Font: Bold, Italic, Font color: Red

Kaweah Delta Medical Center 400 West Mineral King—Visalia, CA 93291-6263—559-624-2000 _______________________________________________________________________


HYPOMAGNESEMIA

Hypomagnesemia replacement protocol initiated for Serum Magnesium < 1.9 mg/dl.

Ordering Physician: ___________________________.

• Repeat electrolyte supplementation as necessary. • Recheck labs PER PROTOCOL. • Report lab values to physician PER PROTOCOL.

NURSE DRAW: Date: ____________ Time: _____________ RENAL PANEL II LAB DRAW: Date: ______________ Time: ____________ ____________________________ Per Protocol/RN____________________________ Date & Time Next Annual Approval 11/17/2016

PATIENT LABEL or Patient Name: Acct# DOB:

The following is administered per protocol (CHECK ONE): Serum Creatinine ≤ 2.5 mg/dl • Mag++ 1.5 to 1.9 mg/dl

Magnesium sulfate 2gm IVPB over 1 hour x 1 dose

• Mag++ 1 to 1.49 mg/dl

Magnesium sulfate 2gm IVPB over 1 hour x 2 doses

The following is administered per protocol (CHECK ONE): Serum Creatinine > 2.5 mg/dL • Mag++ 1.5 to 1.9 mg/dl


• Mag++ 1 to 1.49 mg/dl


ISBARQ Order Set

Introduction: Judy Jimenez PICC RN, Jana Ritchie PICC RN, Ella Schales PICC RN Situation: Orders maintain a consistent flow of PICC/Midline care and maintenance regimen Background:

Requested by: PICC nurses to improve appropriate ordering of post PICC line care.

Assessment Category of Change Requested: Minimal Recommendation

Update Post PICC Insertion orders to include PICC and Midline flushes, discharge instructions and alteplase instructions.

Questions: PICC nurses ext . 5447, pager 501-0391

Before

AFTER:

For Orders Review Committee officers to complete

Change category (circle one): 1-Standard, 2-Minor, 3-Urgent or Very Minor

New or change to KDNET order set: ____________

Choose one: ____CPOE & Downtime Order set ____Paper Order Set only

ISBARQ [Frequency of Vitals – Comfort Care Orderset]

[8/21/17]

Introduction: Sabrina Orique, PhD(c), RN, AOCNS, OCN Clinical Nurse Specialist – Oncology/Renal Services Kaweah Delta Health Care District 400 W. Mineral King Ave. Visalia, CA 93291 (559) 624-5925

Situation: Current comfort care order set needs to include frequency of vitals and unnecessary diagnostics.

Background:

Patients with a designated code status are generally initiated on the comfort care order set. Prior to CPOE, the paper comfort care order set indicated the following:

• Discontinue the following diagnostics: finger sticks, labs, pulse oximetry, weights, blood pressure, physical therapy, telemetry, x-rays, blood products, EKG, Dialysis, and Intake/Output

• Vital signs: pulse, respirations, and pain checks at least every 4 hours (do not wake for routine care). Blood pressure prn family request only.

When the comfort care order set was built in CPOE, this order was not placed.

Assessment Category of Change Requested: Enhancement Suggested changes to order sets: Addition of order regarding frequency of vitals for patients’ that are comfort care as indicated in the paper order set. Recommendation Add the following orders to the current CPOE comfort care order set:

• Discontinue the following diagnostics: finger sticks, labs, pulse oximetry, weights, and telemetry. • Vital signs: assess respirations, RASS, and pain at least every 4 hours (do not wake for routine

care). Assess pulse and temperature once a shift. Assess blood pressure prn family request only.

Recommended Communication/Education for affected disciplines: Nursing will be the primary affected discipline. The education can be facilitated using an education bundle.

Questions:

Sabrina Orique, PhD(c), RN, AOCNS, OCN

For Orders Review Committee officers to complete

Change category (circle one): 1-Standard, 2-Minor, 3-Urgent or Very Minor

New or change to KDNET order set: ____________

Choose one: ____CPOE & Downtime Order set ____Paper Order Set only

Clinical Nurse Specialist – Oncology/Renal Services Kaweah Delta Health Care District 400 W. Mineral King Ave. Visalia, CA 93291 (559) 624-5925

ISBARQ Change to Cardiac Cath Lab Post Interventional Order Set

[9/2017]

Introduction: This is an update to the current order set to allow for a nursing order to be added. A new medication was added to formulary which will be used only during the procedure but will require the infusion to be discontinued most often after the procedure is completed. This process has been discussed with Dr. Harry Lively and agrees to this nursing order to allow for discontinuation of the medication after the procedure. Situation: Cangrelor is a direct P2Y12 platelet-receptor inhibitor that blocks ADP induced platelet activation and aggregation. This product was discussed and approved with provisional formulary status at P&T. This product in cath lab will be started just prior to PCI and will continue through the procedure and stopped either at two hours or at the end of the infusion, whichever is longer. It is the nursing order to stop the infusion that needs to be updated to the order set as the cangrelor will be given in cath lab during the procedure like other antiplatelet agents. Background: Justification: Due the possibility of the infusion running longer than the procedure as many interventions do not take 2 hours a nursing order to discontinue will be required. Assessment Description of issues the changes will resolve and implications: This addition is to make sure the infusion will be stopped at the appropriate time. Recommendation

• Nursing care order to state (Cardiac Cath Post): If cangrelor infusion continued post procedure please d/c after 2 hours from initial start of the infusion. (This should be pre-checked at all times)

Questions: Amanda Bringe-Pharmacist (x 4538)

Please Check One: {X} Revision of an existing order set /protocol { } New physician orders /protocol

ISBARQ Emergency Change request

Oxytocin 30units/LR premix change to NS 9/14/17

Introduction: Blake Bartlett, Pharm.D. IT pharmacist

Situation: • Oxytocin 30 units/500ml LR is currently unavailable. • Pharmacy is now dispensing oxytocin 30 units/500ml NS

Background:

Drug Shortage issue. Assessment

- Currently 3 order sets in Sorian have this order with the LR in the description in the medication order

o Cesarean Section PostOperative Orders o Labor Orders o Routine Post Partum Orders

Recommendation

- Emergency Change Request due to shortage - Updates in Sorian have occurred 9/14/17 and communication with OB providers and nursing already

occurred.

Questions: Blake Bartlett, Pharm.D., IT pharmacist Amanda Bringe, Lead Pharmacist

Anesthesia 1 Approved 6.26.17

Privileges in Anesthesia

Name: ____________________________________________________________ Date: _________________ Please Print

ANESTHESIA PRIVILEGE CRITERIA Initial Criteria: Successfully completed a post-graduate residency program in Anesthesiology approved by the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA); AND Documentation of provision of inpatient care to at least 250 anesthesia patients over the past 24 months; AND current certification or active participation in the examination process leading to certification in Anesthesiology by the ABOA or the AOBA or active participation in the examination process leading to certification in 5 years. Active enrollment in Maintenance of Certification in Anesthesiology (not required for those with lifetime certification)

Certification: ACLS

ADULT AND ADOLESCENT CORE PRIVILEGES Request Procedure Renewal Criteria FPPE Approve

Performance of H&P; Assessment of, consultation for, and preparation of patients for anesthesia; Clinical management of

cardiac & pulmonary resuscitation; Evaluation of respiratory function and application of respiratory therapy; Monitoring and maintenance of normal physiology during the perioperative period; Relief and prevention of pain during and following surgical, obstetrical, therapeutic, and diagnostic

procedures using sedation/analgesia, general anesthesia, and regional anesthesia Diagnosis and treatment of acute, chronic, and cancer-related pain Image-guided procedures; Management of critically ill patients; Supervision of CRNAs Treatment of patients for pain management (excluding chronic pain management) Anesthetic management of patients for cardiac pacemaker and automatic implantable cardiac

defibrillator placement, surgical treatment of cardiac arrhythmias, cardiac catheterization, and cardiac electrophysiological diagnostic/therapeutic procedures

Minimum of 250 cases required in the past two years

AND

Maintain current certification or active participation in the examination process leading to certification in Anesthesiology by the ABOA or the AOBA

6 retrospective or concurrent reviews with a Minimum of one direct observation of 6 chart reviews

ADULT CARDIOTHORACIC CORE PRIVILEGES Request Procedure Initial Criteria Renewal Criteria FPPE Approve

Performance of H&P Anesthetic management for patients undergoing minimally invasive

cardiac surgery for congenital/Non-congenital cardiac procedures including off pump procedures

Anesthetic management of patients undergoing surgery on the ascending or descending thoracic aorta requiring full cardiopulmonary bypass (CPV), left heart bypass, and/or deep hypothermic circulatory arrest

Anesthetic management of patients undergoing non cardiac thoracic surgery; Image-guided procedures

Management of intra-aortic balloon counter pulsation Management of nonsurgical cardiothoracic patients Management of cardiothoracic surgical patients in a critical care (ICU)

setting; Swan Ganz Catheter; Transesophageal echocardiography (TEE)

Anesthetic Management for insertion of Ventricular Assist Devices

Initial Core Criteria AND Completion of Cardiac Anesthesia fellowship AND Board Certification in Perioperative Echocardiography within 2 years of Medical Staff appointment (Current members of Department of Anesthesia with adult cardiothoracic core privileges will have 2 years to obtain Board Certification) AND a minimum of 100 open heart surgeries in the past two years

Minimum 50 cases required in the past two years; AND Maintenance of Perioperative Echocardiography Board Certification up to age 65 AND 10 CMEs per year pertaining to Peri-Operative TEE AND Maintenance of ACLS

10 observation 10 chart reviews 6 retrospective or concurrent reviews with a Minimum of one direct observation

OBSTETRIC CORE PRIVILEGES Request Procedure Initial Criteria Renewal Criteria FPPE Approve

Performance of H&P; Consultation and management for pregnant patients requiring non-obstetric surgery

General anesthesia for cesarean deliver; Image-guided procedures All types of neuraxial analgesia (including epidural, spinal, combined

spinal, and epidural analgesia) and different methods of maintaining analgesia such as bolus, continuous infusion, and patient-controlled epidural analgesia

Anesthetic management of both spontaneous and operative vaginal delivery, retained placenta, cervical dilation, and uterine curettage, as well as postpartum tubal ligation, cervical cerclage, and assisted reproductive endocrinology interventions

Initial Core Criteria AND A minimum of 15 epidural anesthetics AND A minimum of 15 spinal anesthetics

Minimum of 15 cases required in the past two years.

6 retrospective or concurrent reviews with a Minimum of one direct observation 10 chart reviews

Formatted Table

Formatted Table


Interpretation of antepartum and intrapartum fetal surveillance tests First 10 Cases

PEDIATRIC CORE PRIVILEGES Request Procedure Initial Criteria Renewal Criteria FPPE Approve

Performance of H&P; Consultation for medical and surgical patients; Interpretation of laboratory results

Management of normal perioperative fluid therapy and massive fluid and/or blood loss

Management of children requiring general anesthesia for elective and emergent surgery for a wide variety of surgical conditions, including neonatal surgical emergencies, and congenital disorders

Image-guided procedures Management of normal and abnormal airways

Initial Core Criteria AND Pediatric subspecialty training or equivalent experience ; AND PALS certification AND at least 10 pediatric procedures in the last 24 month

Minimum of 25 pediatric cases required in the past two years AND Maintenance of PALS certification

2 retrospective or concurrent reviews with a minimum of one direct observation 5 chart reviews

ADDITIONAL PRIVILEGES

Procedure Initial Criteria Renewal Criteria FPPE Approve

Supervision of a technologist using fluoroscopy equipment

Current and valid Fluoroscopy supervisor and Operator Permit or a Radiology Supervisor and Operator Permit

Maintenance of Fluoroscopy Permit

None

Trans Thoracic Echo Cardiography (TTE)

1) Completion of an ACGME or AOA approved residency training program that included training specific to TTE; OR 2) Documentation of completion of a training course specific to point of care ultrasound that includes TTE. (Module must be a minimum of 8 hours and include the physics of ultrasound and hands on-training.) AND Documentation of a minimum of 20 TTEs IF training completed prior to the last 24 months

Minimum of 10procedures in the past 24 months

10 3 direct observation and 10 5 over-reads

Trans Esophageal Echo Cardiography (TEE)

1) Completion of an ACGME or AOA approved residency training program that included training specific to TEE; OR 2) Documentation of completion of a training course specific to point of care ultrasound that includes TEE. (Module must be a minimum of 50 hours and include the physics of ultrasound and hands on-training.) AND Documentation of a minimum of 50 TEEs IF training completed prior to the last 24 months

Minimum of 50 procedures in the past 24 months

5 direct observation and 5 over-reads 10 observation 25 over-reads

Swan Ganz Catheters 1) Completion of an ACGME or AOA approved residency training program that included training specific to SGC. Document of a minimum of 12 SGC placements if training completed prior to the last 24 months; OR 2) Documentation of successful placement of 6 SGCs by direct concurrent observation of a member of the Medical Staff with SGC privileges.

Minimum of 6 procedures in the past 24 months

6 observation A minimum of 1 direct observation

Outpatient Services at a Kaweah Delta Health Care District Rural Health or 1206(d) Clinics. Please identify: __ Dinuba __ Exeter __Lindsay __ Woodlake ___Family Medicine Clinic __ Chronic Disease Management Center __ Sequoia Cardiology Clinic

Executed contract with Kaweah Delta Health Care District or KDHCD ACGME Family Medicine Program

Maintain initial criteria None

Acknowledgment of Practitioner:


I have requested only those privileges for which by education, training, current experience and demonstrated performance I am qualified to perform and for which I wish to exercise and I understand that (a) In exercising any clinical privileges granted, I am constrained by any Hospital and Medical Staff policies

and rules applicable generally and any applicable to the particular situation. (b) Emergency Privileges – In case of an emergency, any member of the medical staff, to the degree permitted

by his/her license and regardless of department, staff status, or privileges, shall be permitted to do everything reasonably possible to save the life of a patient from serious harm.

Signature: ________________________________________________________________ _________________ Applicant Date Signature ________________________________________________________________ _________________ Department of Anesthesia Chair Date

Cardiovascular Medicine

Cardiovascular Medicine Approved: 8/23/16 1

Privileges in Cardiovascular Medicine Name: _____________________________________________________________________________________

Please Print

CARDIOVASCULAR PRIVILEGES

Education & Training: M.D. or D.O. and Successful completion of an ACGME or AOA-accredited fellowship in cardiovascular disease. ANDCurrent certification or active participation in the examination process leading to certification within 5 years in Cardiovascular Disease by the American Board of Internal Medicine or the American Osteopathic Board of Internal Medicine (unless waived under Medical Staff Bylaws prior to 2016) Current Clinical Competence: Documentation of having cared for a minimum of 100 cardiology patients within the past 2 years of a broad cross-section of procedures corresponding to the privileges being requested. Renewal Criteria: Minimum of 10 cases required in the past two years FPPE Requirement: Minimum of 6 chart reviews Request Core Privileges Approve

Evaluate, diagnose, consult, treat, perform history and physical exam, and provide treatment of adolescent and adult patients presenting with diseases of the heart, lungs, and blood vessels and management of complex cardiac conditions. Cardiologists may provide care to patients in the intensive care setting in conformance with unit policies, and may assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges include the following procedures list and such other procedures that are extensions of the same techniques and skills:

Adult transthoracic echocardiography; Ambulatory electrocardiology monitor interpretation; Cardioversion, electrical and elective; EKG interpretation, including signal average EKG; Infusion and management of Gp IIb/IIIa, thrombolytic, and antithrombolytic agents; Insertion and management of central venous catheters, pulmonary artery catheters, and arterial lines; Noninvasive hemodynamic monitoring; Pericardiocentesis; Stress echocardiography (exercise and pharmacologic stress); Tilt table testing; Transcutaneous external pacemaker placement; Transthoracic 2-D echocardiography, Doppler and color flow; Temporary trans-venous pacemaker placement Cardiac Catheterization -includes abdominal aorta; Common External Iliac; Femoropoliteal; Infrapopliteal; Coronary

Angiogram (including vein drops and Lima)

Admitting Privileges (must request Active or Courtesy staff status)

ADVANCED PRIVILEGES (Must meet the criteria for Cardiovascular Core Privileges)

Request Procedure Initial Criteria Renewal Criteria FPPE Requirement Approve

Cardiac Assist Devices (i.e., Impella), insertion and managment

Certificate of training OR Completion of 5 procedures using device in the last 2 years

A minimum of 3 procedures in the last 2 years.

Direct observation of the first 2 cases

Carotid angiography * - includes: Common Carotid, Vertebral aa (diagnostic only) Internal Carotid (diagnostic only) Prerequisite: Peripheral Angiography

Completion of Cardiovascular Disease fellowship in the last 12 months OR 30 diagnostic carotid angiograms (at least 15 as primary) in the last 2 years

25 Diagnostic carotid angiograms in the last 2 years


Mgmt of uncomplicated mechanical ventilator for up to 48

5 ventilator cases within the previous 2 years or completion of an airway management course

5 ventilator cases in the last 2 years or completion of airway management course


Permanent Pacemaker/ Implantable Cardiovertor Defibrillator (ICD) Placement and removal

A minimum of 15 procedures as primary operator in the last 2 years.

A minimum of 10 Pacemaker and/or AICD procedures in the last 2 years


Peripheral Angiography - Includes: Subclavian, Axillary, Brachial (not by axillary approach) Renals Prerequisite: Fluoroscopy

Completion of Cardiovascular Disease fellowship in the last 12 months OR Documentation of 100 diagnostic angiograms (at least 50 as primary) in the last 2 years.

25 Diagnostic angiograms in the last 2 years




Percutaneous Intra-aortic balloon placement and monitoring

Completion of Cardiovascular Disease fellowship in the last 12 months OR Certificate of training OR Completion of 5 procedures using device in the last 2 years

A minimum of 3 procedures in the last 2 years.


INTERVENTIONAL CARDIOLOGY PRIVILEGES

Initial Criteria Education & Training: MD or DO; Completion of an ACGME or AOA accredited training program in interventional cariology or equivalent practice experience if training occurred prior to 2003 & hold a subspecialty certification in interventional cardiology by the ABIM or AOBIM; AND Certificate of training for newly developed cardiac assist devices. Renewal Criteria: Maintenance of Board Certification and 150 percutaneous intervention procedures in the last 2 years FPPE Requirement: Retrospective chart review of 3 diverse admissions. Request Core Privileges Approve

Evaluate, provide an H&P, treat and provide consultation to adolescent and adult patients by use of specialized imaging and other diagnostic techniques to evaluate blood flow and pressure in the coronary arteries and chambers of the hear, as well as technical procedures, including the following procedure list and such other procedures that are extensions of the same techniques and skills: Cardiac Assist Devices, insertion and management Endomyocardial biopsy Femoral, brachial, or radial axillary cannulation for diagnostic angiography or percutaneous coronary intervention Interpretation of coronary arteriograms, ventriculography, and hemodynamics Intracoronary foreign body retrieval Intracoronary infusion of pharmacological agents, including thrombolytics Intracoronary mechanical thrombectomy Intracoronary stents Intravascular ultrasound of coronaries Management of mechanical complications of percutaneous intervention Performance of balloon angioplasty, stents and other commonly used interventional devices Percutaneous transluminal septal myocardial ablation Use of intracoronary Doppler and flow wire Use of vasoactive agents for pericardial and microvascular spasm


ADVANCED PRIVILEGES (Must meet the criteria for Interventional Cardiology Core Privileges)

Request Procedure Criteria Renewal Criteria FPPE Approve

Peripheral Vascular Interventions (peripheral balloon, stent placement and arthrectomy). Includes:Abdominal Aorta; Use of approved atherectomy devices Femoropopliteal Subclavian, Axillary, Brachial (not by axillary approach) Infrapopliteal Renals Prerequisite: Peripheral Angiography

Meets initial training criteriaCompletion of Interventional Cariology fellowship in the last 12 months OR, if trained before 1995, must have performed at least 50 peripheral balloon angioplasties (25 as primary operatior within the last 2 years.

25 balloon angioplasties and/ or stent placements in the last 2 years

Direct observation of the 3 cases (at least 2 at KDHCD)

Percutaneous PFO/ASD Closure Completion of Interventional Cariology fellowship in the last 12 months and/or 10 procedures in the last 2 years

20 procedures in the last 2 years.


Carotid Interventions (Includes: carotid stenting and angiography)

Completion of Interventional Cariology fellowship in the last 12 monthsMeets initial training criteria OR documentation of 30 Cervico-cerbral angiograms (15 as primary) & 25 carotid stent procedures (13 as primary) & completion of FDA training program in device used in carotid artery stenting procedures.

10 procedures in the last two years.


ADVANCED PRIVILEGES (Must meet the criteria for Interventional Cardiology Core Privileges)

Request Procedure Initial Criteria Renewal Criteria FPPE Approve

Trans-Esophageal Echocardiography (TEE) Training in residency or documentation of 50 category 1

10 cases in the last 2 years

Direct Observation



CME hrs in the last 12 months ANDhave 20 TEE cases proctored by a physician currently holding TEE privileges OR Documentation of having passed the ASE exam OR case list of 20 procedures performed during the past 24 months

of the first 3 cases

CLINICAL CARDIAC ELECTROPHYSIOLOGY PRIVILEGES Initial Training Criteria: Completion of an ACGME or AOA accredited training program in ccep OR EQUIVALENT PRACTICE EXPERIENCE /Training if training occurred prior to 1998, and/or current subspecialty certification or active participation in the examination process leading to certification withing 5 years in CCEP by the ABIM or completion of a CAQ in CCEP by the AOBIM. Current Clinical Competence: Documentation of a minimum of 100 procedures in the last 2 years. Renewal Criteria: Maintenance of subspecialty certification or active participation in the examination process leading to certification withing 5 years in CCEP by the ABIM or completion of a CAQ in CCEP by the AOBIM AND A minimum of 50 procedures in the last two years FPPE: Direct observation of 1 device implantation and 1 EP/ablation And 2 retrospective chart reviews Request Core Privileges Approve

Core privileges include evaluate, provide H&P, treat, and provide consultation to acute and chronically ill adolescent and adult patients with heart rhythm disorders, including the performance of invasive diagnostic and therapeutic cardiac electrophysiology procedures; including the following procedures and other procedures that are extensions of the same techniques and skills: Intracardiac echo Transseptal catherization Implantation and removal of cardioverter defibrillators and pacemakers Venous angioplasty Interpretation of activation sequence mapping recordings, Therapeutic catheter ablation procedures Electrophysiologic studies including endocardial electrogram recording Imaging studies including chest radiograph, tilt testing, ECGs and ECG recordings (all)


ADDITIONAL PRIVILEGES

Request Procedure Initial Criteria Renewal Criteria FPPE Approve

Outpatient Services at a Kaweah Delta Health Care District Rural Health or 1206(d) Clinics. Please identify: __ Dinuba __ Exeter __Lindsay __ Woodlake ___Family Medicine Clinic __ Chronic Disease Management Center __ Sequoia Cardiology Clinic

Executed contract with Kaweah Delta Health Care District or KDHCD ACGME Family Medicine Program

Maintain initial criteria

None

Admit, treat, or provide follow-up care for inpatients ages 14 years or younger. (excluding patients 6 months or ASA > 3)

Board Certification in Pediatric Medicine or Pediatric Cardiology

Minimum of 20 cases required in the past two years

3 Chart Reviews

Administration of Procedural Sedation

Successful completion of KDHCD sedation exam

Successful completion of KDHCD sedation exam

None

Fluoroscopy and/or supervision of a technologist using fluoroscopy equipment

Fluoroscopy Supervisor and Operator Permit or a Radiology Supervisor & Operator Permit

Maintenance of Supervisor & Operator Permit

None

Acknowledgment of Practitioner:

I have requested only those privileges for which by education, training, current experience and demonstrated performance I am qualified to perform and for which I wish to exercise and; I understand that: (a) In exercising any clinical privileges granted, I am constrained by any Hospital and Medical Staff policies

and rules applicable generally and any applicable to the particular situation.



(b) Emergency Privileges – In case of an emergency, any member of the medical staff, to the degree permitted by his/her license and regardless of department, staff status, or privileges, shall be permitted to do everything reasonably possible to save the life of a patient from serious harm.

Name: ____________________________________________________ __________________ Print Date

___________________________________________________________ ___________________ Applicant Signature Date

___________________________________________________________ ___________________ Department of Cardiovascular Services Chairman Signature Date

Kaweah Delta Health Care 2017 Employee Voice Survey Board Executive Overview

Lisa Daul, MBA, RD Employee and Physician Engagement Services October 2017

2 © 2017 Press Ganey Associates, Inc.

Executive Summary: Engagement

Year Engagement Indicator

Natl HC Avg Percentile

AHA-9 Emp Avg

Percentile

2017 (n=3,659, 90%)

4.20 63rd 70th

Note – In this presentation GREEN/RED notes a statistically significant difference.

Where to focus

• Teamwork/cooperation/collaboration

• Providing high-quality care/service (KD)

Recognizing High Performance

• Satisfaction with benefits

• Survey will be used to make improvements

• Work/job fit

Key Messages

Natl HC Avg +/- .04 AHA-9 Emp Avg +/- .04


Addressing Key Messages

Tactics to Improve

• Identify specific actions that will enhance/improve teamwork

• Have employees and work units define what constitutes high-quality care and service (Key Driver)

How to Recognize High Performance Areas

• Thank employees for providing feedback through survey participation

• Celebrate positive perceptions of benefits and person/job fit

• Communicate how survey feedback will be used to make improvements


Unified Strategy For Improving the Patient Experience

Reliability Operating System

Organizational Culture and Talent

Safety Quality Experience

of Care

Process & Performance Improvement


Employee Voice Model

Workforce

Engagem

ent

Organization Domain

Manager Domain

Employee Domain

Action Planning

Readiness (APR)

Tier Score

High Performance Organization *

• Quality/Safety • Fewer Hospital Acquired

Infections/Conditions • Shorter length of stay • Fewer readmissions

• Patient Experience • Higher scores across HCAHPS

domains

• Finances • Higher net margins • Lower per-patient spend for

readmissions

• Organizational Culture • Productivity • Retention/Talent Attraction • Community Image

*www.pressganey.com – Strategic Insights; Achieving Excellence: The Convergence of Safety, Quality, Experience and Caregiver Engagement

http://healthcare.pressganey.com/2017-Strategic-Insights?s=White_Paper-PGHero

Survey Results


Engagement

Difference from:

Engagement Item 2017 KDHC

% Unfav

Natl HC Avg

AHA-9 Emp Avg

57. Overall, I am a satisfied employee. 4.16 4% +.14 +.19 56. I would recommend Kaweah Delta as a good place to work. 4.23 3% +.13 +.15

48. I would like to be working at Kaweah Delta three years from now. 4.28 3% +.12 +.12

36. I would stay with Kaweah Delta if offered a similar position elsewhere. 3.99 7% +.08 +.12

35. I am proud to tell people I work for Kaweah Delta. 4.34 2% +.06 +.07

44. I would recommend Kaweah Delta to family and friends who need care. 4.22 3% -.04 +.01

2017 Engagement 4.20 - +.08 +.11


Engagement by Primary Responsibilities

Line indicates your 2017 KDHC Engagement Score of 4.20

4.03

4.09

4.12

4.13

4.15

4.19

4.20

4.28

4.35

4.45

4.60

4.78

1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 5.00

Advanced Practice Provider (32)

Nursing - RN (1,020)

Service (507)

Clinical Professional (226)

Licensed Technical (335)

Non-clinical Professional (261)

Security (26)

Clerical (564)

Nursing - Other (435)

Skilled Maintenance (49)

Management (198)

Senior Management (6)


KDHC Key Drivers of Engagement

Difference from: KEY DRIVERS of Engagement (in order of influence)

Domain 2017 KDHC

% Unfav

Natl HC Avg

AHA-9 Emp Avg

12. Kaweah Delta provides high-quality care and service. ORG 4.17 3% -.09 -.01

30. Kaweah Delta treats employees with respect. ORG 4.05 5% +.11 +.21

52. My work gives me a feeling of accomplishment. EMP 4.30 3% +.07 +.16

58. I respect my director. MGR 4.31 3% N/A N/A

26. Kaweah Delta makes employees in my work unit want to go above and beyond.

EMP 3.71 13% +.11 +.21

Key Observations 1. Key Drivers are the most important factors that drive improved engagement. 2. Leverage key drivers for organization-wide initiatives. 3. Key Driver themes: High-quality care, mutual respect, job-person fit.


Highest Performing Items vs. Natl HC Avg

Difference from:

Item Domain 2017 KDHC

% Unfav

Natl HC Avg

AHA-9 Emp Avg

11. I am satisfied with my benefits. ORG 3.94 9% +.27 +.16 50. I am satisfied with the information I receive about what is going on at Kaweah Delta.

ORG 4.11 4% +.18 N/A

19. Information from this survey will be used to make improvements. ORG 3.82 11% +.14 +.26

46. I get the tools and resources I need to provide the best care/service for our customers/patients.

ORG 4.06 6% +.12 +.20

37. My job makes good use of my skills and abilities. EMP 4.25 4% +.12 +.19

49. My job responsibilities are clear. MGR 4.33 3% +.12 +.19 55. My work is meaningful. EMP 4.54 1% +.12 +.14


Lowest Performing Items vs. Natl HC Avg

Difference from:

Item Domain 2017 KDHC

% Unfav

Natl HC Avg

AHA-9 Emp Avg

14. Physicians and staff work well together. ORG 3.82 8% -.15 -.08

13. My work group leadership cares about quality improvement. MGR 4.15 5% -.12 -.03

12. Kaweah Delta provides high-quality care and service. ORG 4.17 3% -.09 -.01

43. My workgroup leadership values great customer service. MGR 4.28 2% -.05 +.03

10. Employees in my work unit help others to accomplish their work. EMP 4.16 6% -.03 +.02

KD = Key Driver

KD

Segmenting Units for Tailored Support


Press Ganey’s Tier Approach

Tier 1

• Fewest Obstacles Less need for formal action planning

• Power Items scores

>4.15

Tier 2

• Some Obstacles Would benefit from group action planning

• Power Item scores

>3.80 and <4.15

Tier 3

• Greatest Obstacles Would benefit most from action planning support

• Power Items Scores <3.80

Tier helps organizations determine support /focus needed at the unit level • Tier is a team score rather than simply a measure of manager performance

• Based on 15 Power Items (longstanding national drivers of engagement) • Used consistently across all PG clients • Includes items from all three survey domains (ORG, MGR, EMP)


KDHC Tier Distribution

Power Items Score™ ≥ 4.15

Power Items Score™ ≥ 3.80 and < 4.15

Power Items Score™ < 3.80

0%

20%

40%

60%

80%

100%

Tier 1 Tier 2 Tier 3

38% 47%

15%

50 WU 20 WU 62 WU


Press Ganey’s Action Planning Readiness Score™

APR helps organizations determine support /focus needed in the manager-employee relationship

• Based on 6 Manager Domain Items • Used consistently across all PG clients • Reported on a 100 pt scale, similar to a grade in school

High Readiness APR scores

> 90

Moderately High

Readiness APR scores

80-89

Moderate Readiness APR scores 70 - 79

Moderately Low

Readiness APR Scores

60-69

Low Readiness APR Scores below 60

• Group is ready to have discussions for improvement with manager

• Group may be ready for discussions– Manager may benefit from guidance

• Build relationships between managers and employees prior to discussions


KDHC Action Planning Readiness™ Distribution

0%

20%

40%

60%

80%

100%

High Moderately High Moderate Moderately Low Low

43% 45%

6% 4% 2%

7 out of 8 groups with Low Action Planning Readiness

are also Tier 3 groups.

57 WU 3 WU 5 WU 8 WU 59 WU

Next Steps


Recommendations

Celebrate & Share

Thank employees for their willingness to provide feedback through participating in the survey

Recognize, celebrate and leverage high performance, especially related to: Benefits Viewing the survey as a tool for positive change Employee work/job fit: having the necessary tools & resources; work uses skills/abilities, is

meaningful; responsibilities are clear

Reinforce the survey as a tool for positive change by: Promptness in sharing, discussing and using results for positive change Implement KDHC’s process for communicating results and action planning Document, regularly update and share action plans and progress Schedule specific dates to review/update progress and seek feedback regarding

effectiveness of action plans – Is this working? – Are we getting the desired results? – Is this doing what we intended?


Recommendations

Focus & Follow -up Foster teamwork, cooperation and communication between all team members (staff

and physician) Conduct focus groups with employees to understand gaps in teamwork, recognizing that

perceptions around this item could be unit-based – “We need to really push more teamwork in the workplace and strive for a positive work

environment.” – “Better teamwork. Providers should respect their staff.”

Determine communication gaps between staff and physicians; address 1-2 gaps until improved

Design and implement team-building activities for physicians and staff Regularly communicate with physicians and staff regarding quality improvement efforts KDHC

is pursing. Solicit feedback on effectiveness and any additional solutions

Amplify efforts and focus on high-quality care (Key Driver) Determine, through staff/physician feedback, the perceived gaps in quality of care and current

barriers to achieving higher quality; work collaboratively to eliminate barriers with patients the center of focus

Make specific quality and safety goals a focus of regular conversations with employees, and connect this to patient experience efforts

Encourage employees to report any concerns, issues, or errors that would detract from quality care and a positive patient experience. Commit to investigation, follow-up, and resolution

Capture and share quality/care improvement stories across the organization


Our Challenge…Our Responsibility

Safe

High Quality

Patient-Centered Patient Experience

Engaged, Resilient Care Teams

TeleHealth Physician Acute Post Acute Home Virtual Visits

Hospice

CONTINUUM OF CARE


Keys for Improvement Success

Communicate survey results

Share results in person Thank team members for participating

Meet regularly with the goal to “solve work unit problems”

The focus is not activity, but making things better for patients and caregivers Involve team members in selection of issues and developing solutions Implement solutions developed by team

Report on progress and challenges

Continue meeting regularly to provide updates and discuss challenges or changes needed

Report through a cohesive chain of accountability: – Teams Managers Directors VP’s Execs, etc.

Continue problem solving cycle

Once sufficient progress is made on team priorities, choose next issues to solve


Discussion

2017 Audit Results:Kaweah Delta Health Care District

2

Dear Board of Directors Members:

Thank you for your continued engagement of Moss Adams LLP. We are pleased to have the opportunity to meet with you to discuss the results of our audit of the consolidated financial statements of Kaweah Delta Health Care District (“the District”) for the year ended June 30, 2017.

The accompanying report, which is intended solely for the use of the Board of Directors and management, presents important information regarding the Kaweah Delta Health Care District consolidated financial statements and our audit that we believe will be of interest to you. It is not intended and should not be used by anyone other than these specified parties.

We conducted our audit with the objectivity and independence that you expect. We receive the full support and assistance of the Kaweah Delta Health Care District personnel. We are pleased to serve and be associated with the Kaweah Delta Health Care District as its independent public accountants and look forward to our continued relationship.

We look forward to discussing our report or any other matters of interest with you during this meeting.

Board of DirectorsKaweah Delta Health Care District

3

• Auditor Opinions and Reports• Communication with Those Charged

with Governance

Agenda

Better Together: Moss Adams & Kaweah Delta Health Care District

Auditor Opinion & Report

5

We have performed the following services for KaweahDeltaHealthCareDistrict:

• Annual consolidated financial statement audit for the year ending June 30, 2017

Scope of Services

We have also performed the following non-attest services:

• Assisted in the drafting of the consolidated financial statements of Kaweah Delta Health Care District

6

Unmodified Opinion

• Consolidated financial statements are presented fairly and in accordance with US GAAP

Auditor Report on the Financial Statements

Better Together: Moss Adams & Kaweah Delta Health Care District

Communication with Those Charged with Governance

8

• Our responsibility

• Planned scope and timing of audit

• Significant accounting policies & unusual transitions

• Management judgment & accounting estimates

• Significant audit adjustments & unadjusted differences considered by management to be immaterial

• Areas of audit emphasis

• Deficiencies in internal control

• Potential effect on the consolidated financial statements of any significant risks & exposures

• Difficulties encountered in performing the audit

• Material uncertainties related to events & conditions

• Fraud & noncompliance with laws and regulations

• Other material written communications

• Management’s consultation with other accountants

Required Communications

Financial Ratios and Metrics

Balance Sheet

11

• Liquidityindicator• MeasurestheabilityoftheHospitaltosustainoperationswithexistingcash

• Thehigherthenumber– themorecashreservesavailable

• (Unrestrictedcashandinvestmentsplusfundsdesignatedforcapitalimprovementsx365)/(totaloperatingexpenses– depreciationandamortizationexpenses)

Cash On Hand (days)

Cash On Hand (Days)

0

50

100

150

200

250

300

2015 2016 2017 A1 Baa1

206

166169

242

175

Moody’s*

* Moody’s Ratings: 2016 Median Ratios for Nonprofit Hospitals and Healthcare Systems

13

• Liquidityindicator• Measurestheaveragenumberofdaysthataccountsreceivableareoutstanding

• Lowernumberindicatesthatoutstandingbalancesarebeingcollectedwithinashorterduration

• (Netaccountsreceivable)/(netpatientrevenue/365)

Days In Accounts Receivable

Days In Accounts Receivable

0102030405060708090

100

2015 2016 2017 A1 Baa1

59 5660

49 47

Moody’s *


15

• Leverageindicator• Indicatesextentassetsarefinancedwithdebtasopposedtopaidforwithcash

• Lowernumberindicatesassetsare“boughtandpaidfor”

• (Long‐termandcurrentportionofdebt)/(long‐termandcurrentportionofdebtplusnetassets)

Debt to Capitalization

Debt to Capitalization

0%

10%

20%

30%

40%

50%

2015 2016 2017 A1 Baa1

26.00%

35.00% 34.00%30.00%

44.00%

Moody’s *


Operations

Operating margin(Operating Income / Total Revenue)

0%

4%

8%

2015 2016 2017 A1 Baa1

5.4%

4.0%3.0%

4.1%

2.5%

Moody’s *


The material appearing in this presentation is for informational purposes only and should not be construed as advice of any kind, including, without limitation, legal, accounting, or investment advice.

This information is not intended to create, and receipt does not constitute, a legal relationship, including, but nor limited to, an accountant-client relationship. Although this information may have been prepared

by professionals, it should not be used as a substitute for professional services. If legal, accounting, investment, or other professional advice is required, the services of a professional should be sought.

Assurance, tax, and consulting offered through Moss Adams LLP. Wealth management offered through Moss Adams Wealth Advisors LLC. Investment banking offered through Moss Adams Capital LLC.

19

Brian [email protected](209) 955-6114

Adam [email protected](916) 503-8217

Report of Independent Auditors and Consolidated Financial Statements

Kaweah Delta Health Care District June 30, 2017 and 2016 Dra

ft

CONTENTS

MANAGEMENT’S DISCUSSION AND ANALYSIS 1

REPORT OF INDEPENDENT AUDITORS 19

CONSOLIDATED FINANCIAL STATEMENTS

Consolidated Statements of Net Position 22

Consolidated Statements of Revenues, Expenses, and Changes in Net Position 24

Consolidated Statements of Cash Flows 26

Notes to Consolidated Financial Statements 28

Supplemental Pension Information 58

Dra

ft

1

MANAGEMENT’S DISCUSSION AND ANALYSIS

Kaweah Delta Health Care District’s (the “District”) discussion and analysis is designed to assist the reader in focusing on significant financial issues, provide an overview of the District’s financial activity, identify changes in the District’s financial position, and identify any material deviations from the financial plan (the approved budget). Unless otherwise noted, all discussion and analysis pertains to the District’s financial condition, results of operations, and cash flows as of and for the year ended June 30, 2017. Please read it in conjunction with the consolidated financial statements in this report.

FINANCIAL HIGHLIGHTS

• The District’s net position increased by $20.4 million, or 5.1%, primarily attributable to the year’s positive net income (income before contributions). Total assets increased by $24.5 million, or 3.0%. Cash and investments increased by $4.2 million, or 1.1%, primarily in board designated assets. Capital assets increased $17.0 million to $299.9 million with $39.5 million in net additions to buildings, equipment, and construction-in-progress exceeding a $22.5 million net increase in accumulated depreciation.

• The District’s total operating revenues increased to $643.8 million, a 5.5% increase from the prior year, while total operating expenses increased to $624.4 million, an increase of 6.6%. The current year increase in total operating revenues is primarily due to a $20.4 million increase in net patient service revenue and a $11.3 million increase in other operating revenue. This increase in net patient service revenue is attributable to the overall increase in inpatient and outpatient volumes, an increase in intergovernmental and direct grant funding as discussed below, and the District’s continuous efforts to improve clinical documentation, the result of which better reflects the acuity of patients and appropriately-higher reimbursement rates. The increase in other operating revenue is primarily due the Public Hospital Redesign and Incentives in Medi-Cal (“PRIME”) program revenue recognized in fiscal year 2017.

• Capital contributions to Kaweah Delta Hospital Foundation (the “Foundation”) were $1.7 million, an increase of $288,000, or 21.0%, from last year’s contributions of $1.4 million.

• During the fiscal year, the District made the following significant capital expenditures:

o implementation of a new information technology platform (Cerner) and other information systems hardware and software upgrades and replacements

o construction costs related to the expansion of the ambulatory surgery area o construction costs related to the expansion of the emergency department o expansion and remodel of the rural health clinic o construction and equipment costs for a new interventional radiology suite o construction costs related to the infill of the fifth and sixth floors and new second floor OB

surgery suite in the Acequia Wing of the Medical Center o land acquisition and construction costs for a new urgent care center

The source of funding for these projects was derived from operations, capital contributions, bond project funds, and funds reserved for capital acquisition.

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REQUIRED CONSOLIDATED FINANCIAL STATEMENTS

The consolidated financial statements of the District include: (a) a consolidated statement of net position, (b) a consolidated statement of revenues, expenses, and changes in net position, and (c) a consolidated statement of cash flows. The consolidated statement of net position includes information about the nature of the District’s assets and liabilities and classifies them as current or non-current. It also provides the basis for evaluation of the capital structure of the District and for assessing the liquidity and financial flexibility of the District. The District’s revenues and expenses are accounted for in the consolidated statement of revenues, expenses, and changes in net position. This statement measures the District’s operations and can be used to determine whether the District has been able to recover all of its operating costs from patient services and other operating revenue sources. The primary purpose of the consolidated statement of cash flows is to provide information about the District’s cash from operating, non-capital financing, capital and related financing, and investing activities. It provides answers to such questions as what were the District’s sources of cash, what was cash used for, and what was the change in cash balances during the reporting period.

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TABLE 1 Financial Analysis of the District

Condensed Consolidated Statements of Net Position (in thousands)

A summary of the District’s consolidated statements of net position is presented in Table 1 below:

June 30, June 30, Dollar Total %2017 2016 Change Change

Current and other assets 543,199$ 535,789$ 7,410$ 1.4%Capital assets 299,911 282,862 17,049 6.0%

Total assets 843,110 818,651 24,459 3.0%

Deferred outflows 12,719 28,361 (15,642) -55.2%

Total assets and deferred outflows 855,829$ 847,012$ 8,817$ 1.0%

Current and other liabilities 157,443$ 161,514$ (4,071)$ -2.5%Long-term debt outstanding 276,831 284,370 (7,539) -2.7%

Total liabilities 434,274 445,884 (11,610) -2.6%

Net investment in capital assets 99,956 93,903 6,053 6.4%Restricted 30,479 26,805 3,674 13.7%Unrestricted 291,120 280,420 10,700 3.8%

Total net position 421,555 401,128 20,427 5.1%

Total liabilities and net position 855,829$ 847,012$ 8,817$ 1.0%

As reflected in Table 1, net position increased $20.4 million to $421.6 million for the year ended June 30, 2017, primarily attributable to the District’s $18.8 million income before contributions.

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TABLE 2 Financial Analysis of the District (continued)

Condensed Consolidated Statements of Net Position (in thousands)

A summary of the District’s consolidated statements of net position is presented in Table 2 below:


Current and other assets 535,789$ 417,721$ 118,068$ 28.3%Capital assets 282,862 262,067 20,795 7.9%

Total assets 818,651 679,788 138,863 20.4%

Deferred outflows 28,361 9,203 19,158 208.2%

Total assets and deferred outflows 847,012$ 688,991$ 158,021$ 22.9%

Current and other liabilities 161,514$ 124,540$ 36,974$ 29.7%Long-term debt outstanding 284,370 189,664 94,706 49.9%

Total liabilities 445,884 314,204 131,680 41.9%

Net investment in capital assets 93,903 76,073 17,830 23.4%Restricted 26,805 26,534 271 1.0%Unrestricted 280,420 272,180 8,240 3.0%

Total net position 401,128 374,787 26,341 7.0%

Total liabilities and net position 847,012$ 688,991$ 158,021$ 22.9%

As reflected in Table 2, net position increased $26.3 million to $401.1 million for the year ended June 30, 2016, primarily attributable to the District’s $25.0 million income before contributions. D

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Condensed Consolidated Statements of Revenues, Expenses, and Changes in Net Position (in thousands)

The following table presents a summary of the District’s revenues, expenses, and changes in net position:


Net patient services revenue 557,885$ 537,447$ 20,438$ 3.8%Management services revenue 27,142 25,101 2,041 8.1%Premium revenue 27,908 28,358 (450) -1.6%Other operating revenue 30,885 19,588 11,297 57.7%

Total operating revenues 643,820 610,494 33,326 5.5%

Salaries and benefits 319,340 301,056 18,284 6.1%Medical and other supplies 123,079 118,112 4,967 4.2%Medical and other fees

and services 112,400 99,537 12,863 12.9%Maintenance, utilities, and rent 33,132 31,312 1,820 5.8%Depreciation and amortization 23,509 22,046 1,463 6.6%Other 12,894 13,796 (902) -6.5%

Total operating expenses 624,354 585,859 38,495 6.6%

Operating income 19,466 24,635 (5,169) -21.0%Non-operating revenues –

net of non-operating expenses (699) 334 (1,033) 309.3%

Income before contributions 18,767 24,969 (6,202) -24.8%Capital contributions 1,660 1,372 288 21.0%Change in net position 20,427 26,341 (5,914) -22.5%

Net position – beginning of year 401,128 374,787 26,341 7.0%Net position – end of year 421,555$ 401,128$ 20,427$ 5.1%

Years Ended

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Condensed Consolidated Statements of Revenues, Expenses, and Changes in Net Position (in thousands)

The following table presents a summary of the District’s revenues, expenses, and changes in net position:


Net patient services revenue 537,447$ 475,470$ 61,977$ 13.0%Management services revenue 25,101 22,446 2,655 11.8%Premium revenue 28,358 6,831 21,527 315.1%Other operating revenue 19,588 13,393 6,195 46.3%



and services 99,537 64,485 35,052 54.4%Maintenance, utilities, and rent 31,312 25,740 5,572 21.6%Depreciation and amortization 22,046 20,346 1,700 8.4%Other 13,796 12,059 1,737 14.4%


Operating income 24,635 27,804 (3,169) -11.4%Non-operating revenues –

net of non-operating expenses 334 (849) 1,183 139.3%

Income before contributions 24,970 26,955 (1,985) -7.4%Capital contributions 1,372 729 643 88.2%Change in net position 26,341 27,684 (1,343) -4.9%

Net position – beginning of year 374,787 347,103 27,684 8.0%Net position – end of year 401,128$ 374,787$ 26,341$ 7.0%

Years Ended

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SOURCES OF REVENUE

Operating revenues – For fiscal year 2017, the District derived 99.0% of its total revenues from operations. Operating revenues include, among other items, patient care revenue from Medicare, Medi-Cal, and other federal, state, and local government programs, and commercial insurance payers and patients; management services revenue associated with the District’s forty-five percent (45%) ownership in SRCC-Medical Oncology, LLC, a management services organization providing staff, facilities, and administrative services to a medical oncology physician group; premium revenue associated with a capitated Medicare Advantage (Part C) contract; cafeteria sales; PRIME program revenue; membership sales and dues from a District-owned health and fitness center; and minority ownership interests in a free-standing ambulatory surgery center, an assisted living center, and a memory care facility. Non-operating revenues – For fiscal year 2017, the District derived 1.0% of its total revenues from investment income and property tax revenue including that associated with the general obligation bonds as well as an allocation of general property taxes assessed by the County of Tulare on properties residing within the District’s geographical boundaries.

OPERATING AND FINANCIAL PERFORMANCE

The following summarizes the District’s consolidated statements of revenues, expenses, and changes in net position between 2017 and 2016: Acute admissions increased by 1,108, or 4.5%, to 25,919 while acute patient days decreased by 260, or 0.2%, to 124,143. Skilled nursing and long-term subacute patient days increased to 21,196 in 2017 from 20,895 in 2016. Outpatient equivalent patient day, a measure of overall outpatient activity, were 9,612, or 7.3%, above 2016 levels. The addition of the Kaweah Delta Medical Foundation (“KDMF”) in November 2015, with its first full year of operation in 2017, as well as significant increases in outpatient surgeries, ultrasound and CAT procedures, urgent care and prompt care center visits, and rural health and other clinic visits contributed to the overall increase in outpatient activity for 2017. Net patient services revenue increased $20.4 million, or 3.8%, in 2017. The increase in net patient services revenue can mainly be attributed to the overall increase in inpatient and outpatient volumes, an increase in intergovernmental transfer and direct grant funding as discussed below, as well as the District’s continuous efforts to improve clinical documentation, the result of which better reflects the acuity of patients and appropriately-higher reimbursement rates. D

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SOURCES OF REVENUE (CONTINUED)

The District participates in various supplemental payment programs administered by the State of California and therefore receives payments under the Quality Assurance Fee (“QAF”) Managed Care Medi-Cal program. The California Hospital Fee Program (the “Program”) was signed into law by the Governor of California and became effective on April 1, 2009. The Program is ongoing but periodically requires an extension or revision of the methodology approved by CMS. The Program required a “hospital fee” or “Quality Assurance Fee” to be paid by certain hospitals to a State fund established to accumulate the assessed QA Fees and receive matching federal funds. QA Fees and corresponding matching federal funds are then paid to participating hospitals in two supplemental payment methodologies: a fee-for-service (“FFS”) methodology and a managed care plan methodology. In the 2009-10 Program, the District, as a non-designated public hospital (“NDPH”) in California, was not subject to the QA Fee assessment according to the legislation, but rather received net supplemental payments. The Program evolved in 2010 through 2014 with District hospitals participating in a variety of ways. Currently, legislation for the Program that ran from January 1, 2014 through December 31, 2016 allows for direct grant funding for rural District hospitals and additional funding available in the form of Intergovernmental Transfer (“IGT”) payments offered for a match of funding. A new program is in the process of being outlined with the State that will provide for direct grants for all District hospitals as well as the IGT-generated funding. This new QAF program is expected to run from January 1, 2017 through June 30, 2019 once approvals are obtained from the State and federal regulatory agencies. In fiscal years 2017 and 2016, the District recognized QAF program related net patient services revenue of $14.8 million and $12.6 million, respectively. The District also receives AB113 IGT FFS Medi-Cal Inpatient payments. Legislation in March 2011 (“SB 90”) extended the QAF Program for the period from January 1, 2011 through June 30, 2011; however, the extension under SB 90 included only private hospitals and thus excluded the District related to the FFS portion of the QAF Program. As an alternative, the NDPH IGT Program was established under AB 113 in 2011 to allow NDPH facilities to access additional federal funds. Under this legislation, the District recognized net patient services revenue of $7.6 million and $2.5 million related to this program in fiscal years 2017 and 2016, respectively. Additionally, the District receives “Rate Range” IGT Managed Medi-Cal payments. Federal rules allow that NDPH facilities may access managed care rate range room as determined by negotiations with Medi-Cal managed care plans. As defined by law, rate range room is the difference between the amount that the State pays the managed care plans, referred to as a “lower bound” rate, and the maximum allowed, or the “upper bound” rate. This difference, or rate range, is then available through supplemental IGT payments to public entities that participate in the program in each county. The District recognized net patient services revenue of $4.3 million and $6.7 million related to this program in fiscal years 2017 and 2016, respectively. Management services revenue increased $2.0 million, or 8.1%, from 2016. The increase in revenue is primarily associated with the increase in revenue generated by the SRCC-Medical Oncology joint venture.

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Premium revenue associated with a capitated Medicare Advantage contract decreased by $450,000, or 1.6%, from 2016 as the contract floor minimum reimbursement ended on December 31, 2016. After that date the District was fully at risk for all costs related to the lives of the enrolled population covered by the contract. Other operating revenue consists primarily of PRIME program revenue, cafeteria sales, equity ownership in an ambulatory surgery center, assisted living center and memory care facility, contributions, and health and fitness center membership sales and dues. Other operating revenue increased by $11.3 million, or 57.7%. This increase is primarily due the $15.6 million of PRIME program revenue recognized in fiscal year 2017 as compared to the $3.9 million recognized in the prior year, the first year of the District’s participation in the program. The PRIME program was approved as a part of the Medi-Cal 2020 Section 1115 demonstration waiver. The program participants include both designated public hospitals and district and municipal public hospitals. PRIME supported activities encourage participants to improve the manner in which care is delivered in order to maximize health care value and also to position participants to successfully transition managed care payments to alternative payment methodologies. The District’s participation in the program in 2016 and 2017 included creating the five-year implementation plan, completing related process measures and developing PRIME project infrastructure. Future years’ participation includes submission of baseline data and the measurement and achievement of quality improvement metrics. Salaries and benefits expense increased $18.3 million, or 6.1%. Salaries and wages increased $12.7 million, or 5.4%, and employee benefits expense increased $5.5 million, or 8.5%, from 2016. The increase in salaries and wages was mainly attributable to an increase in patient volumes, as discussed above, and wage related adjustments, while the increase in employee benefits was mainly driven by a $4.3 million increase in the cost of the self-insured employee health insurance plan. Medical and other supplies increased $5.0 million, or 4.2%, from 2016 due to an increase in the cost of general medical supplies associated with the increase in patient volumes, as well as an increase in pharmaceutical costs associated with SRCC-Medical Oncology volume and a new retail pharmacy. Medical and other fees and services increased $12.9 million, or 12.9%, due to an increase in physician fees related to KDMF’s first full year of operations in 2017 as compared to eight months in 2016, an increase in contract labor, consulting fees for the replacement of IT staff dedicated to the Cerner implementation project, and health care services costs associated with a Medicare Advantage contract for which the District receives revenue on a capitation basis. Maintenance, utilities, and rent increased by $1.8 million, or 5.8%, during 2017 primarily due to increases in maintenance costs related to information systems, and to rent expense related to KDMF’s first full year of operation. Depreciation and amortization expense increased $1.5 million, or 6.6%.

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Other expenses decreased $902,000, or 6.5%, resulting mainly from a decrease in professional liability expense. Total operating expenses increased by $38.5 million, or 6.6%. Non-operating revenues of $6.5 million for fiscal year 2017 are comprised of $4.2 million of tax revenue received from the County of Tulare and $2.3 million in investment income on cash and investments. Tax revenue decreased by $135,000, or 3.1%, in 2017. Investment income represents interest income and realized and unrealized gains and losses on District and Foundation investments. District investments by law may only be invested in high-grade, governmental and commercial fixed income securities and money market funds. Investment income for 2017 decreased $3.4 million, or 60.2%, from 2016 due to an increase in unrealized losses associated with the District’s fixed income investments. Non-operating expenses represent interest on the District’s short and long-term debt consisting of revenue and general obligation bonds and capital leases, loss on disposal of capital assets, and bond issuance expense. Total interest expense of $7.0 million decreased by $549,000, or 7.3%, from 2016. Bond issuance expense decreased by $695,000 in 2017, and loss on disposal of capital assets decreased by $1.3 million. For fiscal year 2017, capital contributions of $1.7 million represent amounts received from Foundation donors to support specific capital purposes. The Foundation exists to support the needs of the District and to help build support for the District and our community. The following summarizes the District’s consolidated statements of revenues, expenses, and changes in net position between 2016 and 2015: Acute admissions increased by 1,715, or 7.4%, to 24,811, while acute patient days increased by 7,867, or 6.7%, to 125,403. Skilled nursing and long-term subacute patient days decreased to 20,895 in 2016 from 20,915 in 2015. Outpatient procedures and emergency room visits were 429,000, or 31.2%, above 2015 levels. The addition of KDMF in November 2015 as well as significant increases in lab procedures, urgent care and prompt care center visits, rural health, and other clinic visits contributed to the overall increase in outpatient activity for 2016. Net patient services revenue increased $62.0 million, or 13.0%, in 2016. The increase in net patient services revenue can mainly be attributed to the overall increase in inpatient and outpatient volumes, an increase in intergovernmental transfer and direct grant funding as discussed below, as well as the District’s continuous efforts to improve clinical documentation, the result of which better reflects the acuity of patients and appropriately-higher reimbursement rates.

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The District participates in various supplemental payment programs administered by the State of California as discussed above. In fiscal years 2016 and 2015, the District recognized net patient services revenue of $12.6 million and $5.0 million related to the QAF Managed Care Medi-Cal program; $2.5 million and $5.5 million related to the AB113 IGT FFS Medi-Cal Inpatient program; and $6.7 million and $6.9 million related to the Rate Range IGT Managed Medi-Cal program, respectively. Management services revenue increased $2.7 million, or 11.8%, from 2015. The increase in revenue is primarily associated with the increase in revenue generated by the SRCC-Medical Oncology joint venture. Premium revenue associated with a capitated Medicare Advantage contract increased by $21.5 million, or 315.1%, from 2015 due to an increase in the associated covered lives of the enrolled population, as well as the fact that the entire current fiscal year included the associated capitated contract payments compared to only six months of the prior fiscal year. Other operating revenue consists primarily of PRIME program revenue, cafeteria sales, equity ownership in an ambulatory surgery center, assisted living center and memory care facility, contributions, and health and fitness center membership sales and dues. Other operating revenue increased by $6.2 million, or 46.3%. Other operating income was positively impacted by the recognition of $3.9 million of PRIME program revenue during 2016, the first year that the District participated in the program.

Salaries and benefits expense increased $35.1 million, or 13.2%. Salaries and wages increased $24.8 million, or 11.8%, and employee benefits expense increased $10.3 million, or 18.5%, from 2015. The increase in salaries and wages was mainly attributable to an increase in patient volumes, as discussed above, and wage related adjustments, while the increase in employee benefits was mainly driven by a $9.0 million increase in pension expense related to the defined benefit pension plan and the amount recognized for actuarial changes in assumptions and investment experience during 2016.

Medical and other supplies increased $16.4 million, or 16.1%, from 2015 due to an increase in the cost of general medical supplies associated with the increase in patient volumes, as well as an increase in pharmaceutical costs associated with SRCC-Medical Oncology volume.

Medical and other fees and services increased $35.1 million, or 54.4%, partly due to increases in physician fees related to KDMF, urgent care, prompt care and graduate medical education family medicine clinics, anesthesiology, neurosurgery, and various hospitalist programs. The increase in medical and other fees and services was also attributable to an increase in contract labor and health care services costs associated with a Medicare Advantage contract for which the District receives revenue on a capitation basis.

Maintenance, utilities, and rent increased by $5.6 million, or 21.6%, during 2016 primarily due to increases in maintenance costs related to information systems and facilities, and to rent expense related to KDMF.

Depreciation and amortization expense increased $1.7 million, or 8.4%.

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Other expenses increased $1.7 million, or 14.4%, resulting mainly from an increase in professional liability expense.

Total operating expenses increased by $95.5 million, or 19.5%.

Non-operating revenues of $10.1 million for fiscal year 2016 are comprised of $4.4 million of tax revenue received from the County of Tulare and $5.7 million in investment income on cash and investments. Tax revenue increased by $490,000, or 12.6%, in 2016. Investment income represents interest income and realized and unrealized gains and losses on District and Foundation investments. District investments by law may only be invested in high-grade, governmental and commercial fixed income securities and money market funds. Investment income for 2016 increased $2.7 million, or 86.7%, from 2015 due to an increase in interest income and an increase in unrealized gains associated with the District’s fixed income investments.

Non-operating expenses represent interest on the District’s short and long-term debt consisting of revenue and general obligation bonds and capital leases, loss on disposal of capital assets, and bond issuance expense. Total interest expense of $7.6 million decreased by $231,000, or 3.0%, from 2015. Bond issuance expense increased by $903,000 in 2016 due to the issuance of the 2015A and 2015B revenue bonds, and loss on disposal of capital assets increased $1.3 million.

For fiscal year 2016, capital contributions of $1.4 million represent amounts received from Foundation donors to support specific capital purposes. The Foundation exists to support the needs of the District and to help build support for the District and our community.

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BUDGET RESULTS

The Board of Directors approves the annual operating budget of the District. The budget remains in effect the entire year, but is updated as needed for internal management use to reflect changes in activity and approved variances. A fiscal year 2017 budget comparison and analysis is presented below.

TABLE 5 Actual vs. Budget

(in thousands)

2017 2017 Dollar Total %Actual Budget Variance Variance

Net patient services revenue 557,885$ 548,202$ 9,683$ 1.8%Management services revenue 27,142 26,286 856 3.3%Premium revenue 27,908 29,978 (2,070) -6.9%Other operating revenue 30,885 32,903 (2,018) -6.1%



and services 112,400 109,553 2,847 2.6%Maintenance, utilities, and rent 33,132 31,900 1,232 3.9%Depreciation and amortization 23,509 25,744 (2,235) -8.7%Other 12,894 12,825 69 0.5%


Operating income 19,466 17,892 1,574 8.8%Non-operating revenues –

net of non-operating expenses (699) 1,081 (1,780) -164.7%

Income before contributions 18,767$ 18,973$ (206)$ -1.1%

Years Ended June 30,

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BUDGET RESULTS (CONTINUED)

In comparing actual versus budgeted 2017 results, the following is noted : The District completed its fiscal year 2017 $206,000, or 1.1%, short of budgeted income before contributions of $19.0 million. Although operating income exceeded budget expectations, the shortfall of profitability compared to budget is attributable to non-operating income which fell short of budget by $1.8 million due to unrealized losses on the District’s investment portfolio. The District’s operating income surpassed budget expectations by $1.6 million, or 8.8%. Net patient services revenue exceeded budget by $9.7 million, or 1.8%, mainly due to higher-than-expected patient volumes. Management services revenue also exceeded budget by 856,000, or 3.3%. Both premium revenue and other operating revenue fell short of budget expectations by $2.1 million, or 6.9%, and $2.0 million, or 6.1%, respectively. The District realized an unfavorable variance in total operating expenses of $4.9 million, or 0.8%, in fiscal year 2017. This unfavorable expense variance was due to salaries and benefits; medical and other supplies; medical and other fees and services, and maintenance, utilities and rent expense which were $1.9 million, or 0.6%; $1.0 million, or 0.9%; $2.8 million, or 2.6%; and $1.2 million, or 3.9%, higher than expected, respectively. The unfavorable variance in salaries, medical and other fees and services, and supplies expense is related to the higher patient volumes experienced in 2017. The variance in benefits expense relates to an unexpected increase in health insurance costs. Maintenance expense exceeded budget primarily due to higher-than-expected information systems support cost.

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CAPITAL ASSETS

At June 30, 2017, the District had $299.9 million invested in a variety of capital assets, as reflected in the following schedule (in thousands), which represents a net increase (additions less retirements and depreciation) of $17.1 million from the end of the prior year.


Land 15,758$ 15,232$ 526$ 3.5%Buildings and improvements 322,413 316,509 5,904 1.9%Equipment 193,439 180,243 13,196 7.3%Construction in progress 47,257 27,372 19,885 72.6%

578,867 539,356 39,511 7.3%Less accumulated depreciation 286,441 265,785 20,656 7.8%

292,426 273,571 18,855 6.9%Property under capital leases –

less accumulated amortization 7,485 9,291 (1,806) -19.4%

Capital assets, net 299,911$ 282,862$ 17,049$ 6.0%

Material additions during fiscal year 2017 included (in thousands):

Construction and equipment costs related to:Implemenation of a new IT platform (Cerner) 10,763$ Ambulatory surgery services expansion 4,802$ Emergency department expansion 2,866$ Rural health clinic expansion and remodel 2,883$ Information systems upgrades and replacements 1,877$ New interventional radiology suite 1,764$ Infill of Acequia Wing fifth and sixth floors 1,708$ Acequia Wing second floor OB surgery suites 1,096$ New urgent care center 1,028$

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LONG-TERM DEBT

At June 30, 2017, the District had approximately $285.0 million in capital lease obligations, and revenue and general obligation bonds outstanding as described in Notes 8 and 9 of the consolidated financial statements. The general obligation bonds represent the general obligation of the District. The District has the power and is obligated to cause annual ad valorem taxes to be levied upon all property within the District, subject to taxation by the District, and collected by the County of Tulare for payment, when due, of the principal and interest on the bonds. The bond indenture agreements contain various restrictive covenants which include, among other things, minimum debt service coverage, maintenance of minimum liquidity, restrictions on certain additional indebtedness, and requirements to maintain certain financial ratios. 2015A Bonds – During October 2015, the District issued $19,361,000 of Kaweah Delta Health Care District Revenue Bonds, Series 2015A. The 2015A revenue bonds bear interest at a rate of 2.975%. The net proceeds were used to prepay existing debt, including a portion of the 2006 and 2011B revenue bonds as well as the outstanding amount of the 2003A, and 2011A revenue bonds. The 2015A revenue bonds maturing on or after June 1, 2025 are subject to redemption at the option of the District prior to their respective stated maturities at a price equal to the principal amount of the bonds, without premium. The current refunding of the 2003A and 2006 bonds and the advanced refunding of the 2011A and 2011B bonds resulted in decreased debt service payments of approximately $3.9 million over the next 18 years and an economic gain (difference between the present value of the debt service payments on the old and new debt) of approximately $3.0 million. 2015B Bonds – During December 2015, the District issued $98,425,000 of Kaweah Delta Health Care District Revenue Bonds, Series 2015B. The 2015B revenue bonds bear interest rates of 3.25% to 5.0%. The net proceeds for the acquisition, construction, installation and equipping of the second, fifth, and sixth floors of the Kaweah Delta Medical Center’s Acequia Wing expansion and improvement of the emergency department, expansion of outpatient endoscopy services, acquisition and implementation of a new information technology platform (Cerner), acquisition and construction of a new urgent care center, improvements to the Exeter Health Clinic campus, and other projects. The 2015B revenue bonds maturing on or after June 1, 2025 are subject to redemption at the option of the District, prior to their respective stated maturities at a price equal to the principal amount of the bonds, without premium. 2017A and 2017B Bonds – During April 2017, the District issued $13,700,000 Series 2017A and $20,000,000 Series 2017B of Kaweah Delta Health Care District Revenue Bonds. Both the 2017A and the 2017B revenue bonds bear interest at a rate of 3.24%. The net proceeds were used to prepay existing debt, including the remaining outstanding amounts of the 2006 and 2011B revenue bonds. The 2017A and 2017B revenue bonds maturing on or after June 1, 2029 are subject to redemption at the option of the District prior to their respective stated maturities at a price equal to the principal amount of the bonds, without premium. The current refunding of the 2006 and 2011B bonds resulted in decreased debt service payments of approximately $8.0 million over the next 17 years and an economic gain (difference between the present value of the debt service payments on the old and new debt) of approximately $4.3 million.

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ECONOMIC OUTLOOK

The District’s Board of Directors and management considered many factors when setting the fiscal year 2018 budget. Of primary importance in setting the 2018 budget is the status of the California economy, the fiscal policy of the state and federal governments, the availability and affordability of labor, the general rise of health care related costs, and local and regional competition for health care services. Specific factors and assumptions incorporated in the District’s fiscal year 2018 budget include:

• Inpatient utilization is projected to increase by 2.7% from 2017 levels reflecting an average daily patient census of 431. Outpatient activity expressed in equivalent inpatient days is projected to increase 2.8% from 2017.

• A 1.4% increase in gross patient services revenue due to increased patient care volume, although no retail price increase was budgeted.

• A Medicare general acute care rate increase (market-basket update of 2.4% reduced by a cumulative 1.7% for numerous reductions mandated by the Affordable Care Act and the American Tax Relief Act) of approximately 0.7%, an increase of 1.6% for outpatient services, an increase of 0.8% for skilled nursing and subacute services, a decrease of 0.7% for home health services, an increase of 1.2% for rural health clinic services, an increase of 0.4% for acute rehabilitation, and no change for acute psychiatric services.

• A 6.3% increase in Medi-Cal fee-for-service acute medical/surgical and a 0.6% decrease in rehabilitation services reimbursement rates effective July 1, 2017, with no change in reimbursement anticipated for skilled nursing, subacute, psychiatric, home health, and outpatient fee-for-service reimbursement. Includes $7.3 million in disproportionate share payments, $7.3 million in anticipated fee-for-service intergovernmental transfer revenue and $13.4 million in provider fee intergovernmental transfer and grant revenue.

• Medi-Cal managed care reimbursement rate increases of approximately 4.3% based on scheduled rate increases included in multi-year contracts. Includes $4.6 million of Medi-Cal managed care rate range program intergovernmental transfer revenue.

• Annual scheduled rate increases for non-government managed care payers for contracts negotiated in prior years as well as expected new negotiated increases with managed care plans averaging 1.4%.

• The successful implementation of seven health care delivery system improvement initiatives under the PRIME program resulting in the recognition of $13.9 million in related revenue.

• Overall expense per adjusted patient day is projected to increase by 2.9% from the prior year.

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ECONOMIC OUTLOOK (CONTINUED)

Through the first two months of fiscal year 2018, the District has posted an unaudited operating income of $4.4 million, a 3.9% operating margin, $1.3 million in excess of the District’s budgeted operating income for the period. Through August 31, 2017, the District experienced a net income before contributions of $5.3 million, a 4.8% excess margin, representing a positive variance of $1.3 million from its year-to-date budgeted income before contributions of $4.0 million. Although the District experienced lower-than-expected patient volumes and related net patient services revenue during the first two months of the fiscal year, the positive variance in operating expenses resulted in the overall positive variance in operating income for the period.

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Report of Independent Auditors

Board of Directors Kaweah Delta Health Care District

Report on Financial Statements

We have audited the accompanying consolidated financial statements of Kaweah Delta Health Care District, which comprise the consolidated statements of net position as of June 30, 2017 and 2016, and the related consolidated statements of revenues, expenses, and changes in net position, and cash flows for the years then ended, and the related notes to the consolidated financial statements.

Management’s Responsibility for the Financial Statements

Management is responsible for the preparation and fair presentation of these consolidated financial statements in accordance with accounting principles generally accepted in the United States of America; this includes the design, implementation, and maintenance of internal control relevant to the preparation and fair presentation of consolidated financial statements that are free from material misstatement, whether due to fraud or error.

Auditor’s Responsibility

Our responsibility is to express an opinion on these consolidated financial statements based on our audits. We conducted our audits in accordance with auditing standards generally accepted in the United States of America and the California Code of Regulations, Title 2, Section 1131.2, State Controller’s Minimum Audit Requirements for California Special Districts. Those standards require that we plan and perform the audits to obtain reasonable assurance about whether the consolidated financial statements are free from material misstatement.

An audit involves performing procedures to obtain audit evidence about the amounts and disclosures in the consolidated financial statements. The procedures selected depend on the auditor’s judgment, including the assessment of the risks of material misstatement of the consolidated financial statements, whether due to fraud or error. In making those risk assessments, the auditor considers internal control relevant to the entity’s preparation and fair presentation of the consolidated financial statements in order to design audit procedures that are appropriate in the circumstances, but not for the purpose of expressing an opinion on the effectiveness of the entity’s internal control. Accordingly, we express no such opinion. An audit also includes evaluating the appropriateness of accounting policies used and the reasonableness of significant accounting estimates made by management, as well as evaluating the overall presentation of the consolidated financial statements.

We believe that the audit evidence obtained is sufficient and appropriate to provide a basis for our audit opinion.

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Opinion

In our opinion, the consolidated financial statements referred to above present fairly, in all material respects, the financial position of Kaweah Delta Health Care District as of June 30, 2017 and 2016, and the results of its operations and its cash flows for the years then ended in accordance with accounting principles generally accepted in the United States of America.

Other Matter

Accounting principles generally accepted in the United States of America require that the Management’s Discussion and Analysis on pages 1 through 18 and the supplemental pension information on pages 58 and 59 be presented to supplement the basic consolidated financial statements. Such information, although not a part of the basic consolidated financial statements, is required by the Governmental Accounting Standards Board who considers it to be an essential part of financial reporting for placing the basic consolidated financial statements in an appropriate operational, economic, or historical context. We have applied certain limited procedures to the required supplementary information in accordance with auditing standards generally accepted in the United States of America, which consisted of inquiries of management about the methods of preparing the information and comparing the information for consistency with management's responses to our inquiries, the basic consolidated financial statements, and other knowledge we obtained during our audit of the basic consolidated financial statements. We do not express an opinion or provide any assurance on the information because the limited procedures do not provide us with sufficient evidence to express an opinion or provide any assurance.

Stockton, California __________, 2017 D

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CONSOLIDATED FINANCIAL STATEMENTS

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22 See accompanying notes

CONSOLIDATED STATEMENTS OF NET POSITION

2017 2016CURRENT ASSETS

Cash and cash equivalents 3,992,275$ 3,913,821$ Current portion of Board designated and trusteed assets 12,147,686 12,801,734 Accounts receivable

Net patient accounts 92,049,995 81,793,688 Other 20,986,104 17,207,762

113,036,099 99,001,450 Inventories 8,168,590 7,135,817 Medicare and Medi-Cal settlements 26,326,424 37,856,883 Prepaid expenses 8,375,461 6,607,103

Total current assets 172,046,535 167,316,808 NON-CURRENT CASH AND INVESTMENTS –

less current portionBoard designated assets 269,913,339 247,679,504 Bond assets held in trust 81,830,759 99,765,318 Assets in self-insurance trust fund 5,642,575 5,197,714

357,386,673 352,642,536 CAPITAL ASSETS


578,866,737 539,356,443 Less accumulated depreciation 286,440,763 265,785,127

292,425,974 273,571,316 Property under capital leases –

less accumulated amortization 7,485,184 9,290,213 299,911,158 282,861,529

OTHER ASSETSProperty not used in operations 3,420,518 3,274,394 Health-related investments 3,342,533 1,736,847 Other 7,002,445 10,818,916

13,765,496 15,830,157 Total assets 843,109,862 818,651,030

DEFERRED OUTFLOWSUnamortized loss on defeasance of debt 3,225,574 3,287,326 Unamortized goodwill 453,333 507,733 Change in assumptions and actuarial losses 9,040,517 24,565,522

Total deferred outflows 12,719,424 28,360,581 855,829,286$ 847,011,611$

JUNE 30,

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CONSOLIDATED STATEMENTS OF NET POSITION

2017 2016

CURRENT LIABILITIESAccounts payable and accrued expenses 31,349,095$ 31,189,360$ Accrued payroll and related liabilities 40,928,648 36,110,206 Long-term debt – current portion 8,180,021 7,640,700

Total current liabilities 80,457,764 74,940,266

LONG-TERM DEBT – less current portionBonds payable 259,960,479 265,118,404 Capital leases 16,870,609 19,251,748

276,831,088 284,370,152



Total liabilities 434,273,971 445,883,327

NET POSITIONNet investments in capital assets 99,956,382 93,903,320 Restricted:

Expendable 20,873,098 19,081,797 Non-expendable – minority interest 2,048,949 1,778,264 Non-expendable – permanent endowments 7,556,702 5,945,185

Unrestricted 291,120,184 280,419,718

Total net position 421,555,315 401,128,284

855,829,286$ 847,011,611$

JUNE 30,

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CONSOLIDATED STATEMENTS OF REVENUES, EXPENSES, AND CHANGES IN NET POSITION

2017 2016

OPERATING REVENUESNet patient services revenue 557,885,689$ 537,446,928$ Other revenues

Management services revenue 27,141,761 25,101,212 Premium revenue 27,907,922 28,358,079 Other 30,885,155 19,587,294

Total other revenues 85,934,838 73,046,585

Total operating revenues 643,820,527 610,493,513

OPERATING EXPENSESSalaries and wages 248,224,924 235,483,168 Employee benefits 71,115,015 65,572,561

Total employment expenses 319,339,939 301,055,729

Medical and other supplies 123,079,345 118,111,821 Medical and other fees 79,522,477 71,040,486 Purchased services 32,877,061 28,496,326 Repairs and maintenance 22,345,972 21,926,840 Utilities 5,284,112 5,023,271 Rents and leases 5,501,733 4,362,388 Depreciation and amortization 23,508,988 22,045,794 Other 12,894,516 13,796,142

Total operating expenses 624,354,143 585,858,797

OPERATING INCOME 19,466,384 24,634,716

NON-OPERATING (EXPENSES) REVENUESTax revenue 4,238,068 4,373,326 Investment income 2,275,152 5,710,476 Bond issuance expense (208,163) (902,836) Interest expense (7,005,759) (7,555,180) Gain (Loss) on disposal of capital assets 1,339 (1,291,588)

Total non-operating (expenses) revenues (699,363) 334,198

INCOME BEFORE CAPITAL CONTRIBUTIONS 18,767,021 24,968,914 CAPITAL CONTRIBUTIONS 1,660,010 1,371,769

Change in net position 20,427,031 26,340,683

NET POSITION – beginning of year 401,128,284 374,787,601

NET POSITION – end of year 421,555,315$ 401,128,284$

YEARS ENDED JUNE 30,

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CONSOLIDATED STATEMENTS OF CASH FLOWS

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2017 2016

CASH FLOWS FROM OPERATING ACTIVITIESCash received from net patient services revenue $558,963,737 515,848,125$ Cash received from management services and

other operating revenues 87,800,405 59,143,087 Cash payments for salaries, wages, and related benefits (316,953,235) (299,299,059) Cash payments for other operating expenses (278,477,533) (247,424,047)

Net cash from operating activities $51,333,374 28,268,106

CASH FLOWS FROM NON-CAPITALFINANCING ACTIVITIES

Tax revenue 1,204,411 1,155,480

CASH FLOWS FROM CAPITAL AND RELATEDFINANCING ACTIVITIES

Bond issuance costs (208,163) (902,836) Interest payments on bonds payable and capital leases (11,547,912) (9,687,958) Principal payments on bonds payable and capital leases (41,309,124) (26,052,467) Proceeds from revenue bonds 33,700,000 120,153,365 Contributions received for capital expenditures 1,660,010 1,371,769 Tax revenue related to general obligation bonds 3,033,657 3,217,846 Purchase of capital assets (35,779,976) (41,969,195) Proceeds from disposal of capital assets 32,175 3,614

Net cash from (used for) capital and related financing activities (50,419,333) 46,134,138

CASH FLOWS FROM INVESTING ACTIVITIESInterest income on investments 4,354,770 3,753,285 Purchase of investments (110,043,670) (169,316,685) Net Health-related investment (contributions) distributions (526,800) 1,639,000 Purchased of property not used in operations (180,972) - Proceeds from sales and maturities of investments 123,684,617 106,443,113

Net cash used for investing activities 17,287,945 (57,481,287)

NET CHANGE IN CASH AND CASH EQUIVALENTS 19,406,397 18,076,437

CASH AND CASH EQUIVALENTS AT BEGINNING OF YEAR 110,980,385 92,903,948

CASH AND CASH EQUIVALENTS AT END OF YEAR 130,386,782$ 110,980,385$


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2017 2016

RECONCILIATION OF CASH AND CASHEQUIVALENTS TO THE STATEMENT OF NET POSITIONCash and cash equivalents in current assets 3,992,275$ 3,913,821$ Cash and cash equivalents in

non-current cash and investmentsBoard designated cash and investments 89,370,275 78,630,833 Bond assets held in trust 37,013,406 28,411,420 Assets in self-insurance trust fund 10,826 24,311

130,386,782$ 110,980,385$

RECONCILIATION OF OPERATING INCOME TONET CASH PROVIDED BY OPERATING ACTIVITIESOperating income 19,466,384$ 24,634,716$ Adjustments to reconcile operating income to

net cash provided by operating activities:Depreciation and amortization 23,508,988 22,045,794 Provision for bad debts 15,296,215 11,846,281

Changes in:Increase in accounts receivable (29,330,864) (30,618,376) Decrease (increase) in inventories, prepaid expenses,

and other assets 11,990,573 (19,056,551) Increase in accounts payable and accrued

expenses, accrued payroll and related liabilities, and other long-term liabilities 10,402,078 19,416,242

Net cash from operating activities 51,333,374$ 28,268,106$


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NOTES TO CONSOLIDATED FINANCIAL STATEMENTS

NOTE 1 – BASIS OF PRESENTATION AND ACCOUNTING POLICIES

A summary of significant accounting policies applied in the preparation of the accompanying consolidated financial statements follows: Reporting entity – Kaweah Delta Health Care District (the “District”) is a political subdivision of the state of California, organized and existing under the State of California Local Health Care District Law as set forth in the Health and Safety Code of the state of California. The District is governed by a separately- elected Board of Directors. The accounting policies of the District conform to those recommended by the Health Care Committee of the American Institute of Certified Public Accountants. The District’s consolidated financial statements are presented in accordance with the pronouncements of the Governmental Accounting Standards Board (“GASB”), and the Financial Accounting Standards Board (“FASB”) when applicable. The District is not generally subject to state and federal income taxes. The District provides health care services to individuals who reside primarily in the local geographic area. Principles of consolidation – The consolidated financial statements of the District include the accounts of the District, Kaweah Delta Hospital Foundation (the “Foundation”), Kaweah Delta Medical Foundation (“KDMF”), Sequoia Regional Cancer Center, LLC (“SRCC”), Sequoia Regional Cancer Center – Medical Oncology, LLC (“SRCC-MO”), and TKC Development, LLC (“TKC”). KDMF, SRCC, SRCC-MO, TKC, and the Foundation are component units that have been blended for presentation purposes. The District has a 75% interest in TKC, which leases real estate and equipment from the District and then subleases the real estate and equipment to SRCC and SRCC-MO. The District has a 75% interest in SRCC and a 45% interest in SRCC-MO, management services organizations providing staff, facilities, and administration services to the radiation oncology department of the District and a medical oncology physician group, respectively. The District provides key management, administrative, and support services to SRCC and SRCC-MO, including all of their employees, leased buildings and equipment, accounting, human resources, information technology, housekeeping, risk management, and maintenance services. The Foundation was established in March 1980 as an exempt organization under Internal Revenue Code Section 501(c)(3) to raise funds to support the operation of the District. The Foundation’s bylaws provide that all funds raised be distributed to or be held for the benefit of the District. The Foundation’s general funds, which represent the Foundation’s unrestricted resources, will be distributed to the District in amounts and in periods determined by the Foundation’s Board of Trustees. Effective November 1, 2015, the District and its subsidiary, Kaweah Delta Health Care, Inc., a California non-profit 501(c)(3) public benefit corporation, doing business as KDMF, entered into an affiliation with Visalia Medical Clinic (“VMC”), a California professional medical corporation. VMC is the largest multi-specialty medical group in Visalia and has been in existence for over 75 years. KDMF provides primary and specialty care health services to patients. The District is the sole corporate member of KDMF, with the non-profit entity operating as a California medical foundation pursuant to section 1206(l) of the California Health and Safety Code. VMC transferred its personal property, payor agreements, and non-physician staff, among other assets, to KDMF. All physicians and mid-level providers will continue to be employed by VMC. VMC has entered into a professional services agreement with KDMF and provides medical services to patients of KDMF.

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KAWEAH DELTA HEALTH CARE DISTRICT NOTES TO CONSOLIDATED FINANCIAL STATEMENTS

29

NOTE 1 – BASIS OF PRESENTATION AND ACCOUNTING POLICIES (CONTINUED)

Principles of consolidation (continued) – All intercompany transactions have been eliminated in the District’s consolidated financial statements. Use of estimates – The preparation of consolidated financial statements in conformity with accounting principles generally accepted in the United States of America, requires management to make estimates and assumptions that affect the reported amounts of assets and liabilities and disclosures of contingent assets and liabilities, at the date of the consolidated financial statements and the reported amounts of revenues and expenses during the reporting period. Actual results could differ from those estimates. Accounting standards – Pursuant to Government Accounting Standard Board (“GASB”) Statement No. 62, Codification of Accounting and Financial Reporting Guidance Contained in Pre-November 30, 1989 Financial Accounting Standards Board (“FASB”) and American Institute of Certified Public Accountants (“AICPA”) Pronouncements, the District’s proprietary fund accounting and financial reporting practices are based on all applicable GASB pronouncements as well as codified pronouncements issued on or before November 30, 1989. Net patient services revenue and patient accounts receivable – Net patient services revenue is reported at the estimated net realizable amount from patients, governmental programs, health maintenance, and preferred provider organizations, and insurance contracts under applicable laws, regulations, and program instructions. Net realizable amounts are generally less than the District’s established rates. Final determination of certain amounts payable is subject to review by appropriate third party representatives. Subsequent adjustments, if any, arising from such reviews are recorded in the year final settlement becomes known. Significant concentrations of net patient accounts receivable at June 30, 2017 and 2016 include Medicare, 26.64% and 27.70%, respectively, and Medi-Cal, 29.59% and 28.94%, respectively. The District provides for estimated losses on amounts receivable directly from patients based on historical bad debt experience. Interest is not charged on past due balances. Past due status is based on the date the account is determined to be payable directly from the patient. When the account is deemed uncollectible in accordance with District policy, it is written off to bad debt expense. Recoveries from previously written-off accounts are recorded when received. At June 30, 2017 and 2016, the District provided allowances for losses on amounts receivable directly from patients totaling $22,913,000 and $20,542,000, respectively. Amounts written off to bad debt expense included in net patient services revenue totaled approximately $15,296,000 and $11,846,000 for 2017 and 2016, respectively. D

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Net patient services revenue and patient accounts receivable (continued) – The District renders service to patients under contractual arrangements with the Medicare and Medi-Cal programs. Medicare payments are primarily prospective for inpatients while Medicare payments for outpatients are based on a combination of a fee-for-service schedule and prospective reimbursement. Medi-Cal inpatient payments are subject to the state’s prospective payment system. Medi-Cal outpatient services are reimbursed on a fee-for-service schedule. The Programs’ administrative procedures preclude final determination of amounts due for services to program patients until after the cost reports are audited or otherwise reviewed by and settled with the respective administrative agencies. Medicare cost reports for 2015 through 2017, and Medi-Cal cost reports for 2016 and 2017, are subject to audit and possible adjustment. Net Medicare and Medi-Cal program patient services revenue amounted to approximately $340,733,000 and $363,932,000 in 2017 and 2016, respectively. The District recognized in the consolidated statements of revenues, expenses, and changes in net position increases of approximately $2,021,000 and $3,669,000 in 2017 and 2016, respectively, in net patient services revenue pertaining to the settlement of previous years’ cost reports. Proprietary fund accounting – The District utilizes the proprietary fund method of accounting whereby all revenue and expenses are recognized on the accrual basis. Substantially all revenue and expenses are subject to accrual. Cash and cash equivalents – Cash and cash equivalents include cash in bank checking, savings, and time deposit accounts, money market funds, and investments in highly liquid debt instruments with a maturity of three months or less when purchased. Charity care – The District provides care without charge or at amounts less than its established rates to patients who meet certain criteria under its charity care policy. The District accepts all patients regardless of their ability to pay. Partial payments to which the District is entitled from public assistance programs on behalf of patients that meet the District’s charity care criteria are reported as net patient service revenue. Charity care, which is excluded from recognition as receivables or revenue in the consolidated financial statements, provided in 2017 and 2016, measured on the basis of uncompensated cost, was $3,438,000 and $3,176,000, respectively. In addition to its charity care program, the District also provides significant care to low income and indigent patients reimbursed under the state’s Medi-Cal program or local county programs where the cost of providing such care far exceeds reimbursement received by the District from these programs. The unreimbursed cost of care provided to patients covered by these programs amounted to $21,578,000 and $6,292,000 in 2017 and 2016, respectively. Inventories – Inventories are reported at cost (determined by the first-in, first-out method), which is not in excess of market value. Prepaid expenses – Certain payments to vendors reflect costs applicable to future accounting periods and are recorded as prepaid expenses.

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Investments – Investments are reported at fair value, based on quoted market prices when applicable and realized and unrealized gains and losses are included in non-operating revenues as investment income. The fair market value of money market funds, guaranteed investment contracts, and investments in the Local Agency Investment Funds (“LAIF”), an external investment pool for government agencies administered by the state of California, approximates cost due to the liquid nature of these investments. Non-current cash and investments – Non-current cash and investments include unrestricted cash and investments designated by the Board of Directors for future capital improvements, over which the Board retains control and may at its discretion subsequently use for other purposes; cash and investments held by trustees under bond indentures; and cash and investments held in the District’s self-insurance trust fund. Intangible asset – The District has contributed $2.0 million of the 2004 general obligation bond proceeds to the city of Visalia (the “City”) for the construction of a parking garage in exchange for 84 parking spaces for District use (see Note 9). The District’s use of the parking spaces is indefinite and the District is amortizing the asset over the estimated 25-year useful life of the parking garage. Amortization began in 2007 when the parking garage was completed and placed into service by the City. Capital assets – Property, plant, and equipment are reported on the basis of cost or, in the case of donated items, on the basis of fair market value at the date of donation. Routine maintenance and repairs are charged to expense as incurred. Expenditures which increase values, change capacities, or extend useful lives are capitalized. The District capitalizes interest cost net of any interest earned on temporary investments of the proceeds for construction projects funded by tax-exempt borrowings. Interest expense is also capitalized for projects financed with operating funds. Depreciation expense and amortization of property under capital leases are combined in the consolidated statements of revenues, expenses, and changes in net position and are computed by the straight-line method for financial reporting purposes over the estimated useful lives of the assets or the life of the lease, whichever is less, which range from 5 to 40 years for buildings and improvements and 3 to 25 years for equipment and leasehold improvements. At times the District may dispose of capital assets prior to the end of the assets’ projected useful life. In cases when an associated gain or loss is recognized due to the disposal, the related gain or loss is shown as a non-operating revenue or expenditure in the consolidated statement of revenue, expenses, and change in net position. Consolidated statements of revenues, expenses, and changes in net position – All revenues and expenses directly related to the delivery of health care services are included in operating revenues and expenses in the consolidated statements of revenues, expenses, and changes in net position. Non-operating revenues and expenses consist of those revenues and expenses that are related to financing and investing types of activities and result from non-exchange transactions or investment income.

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Medical malpractice and general liability self-insurance – The District maintains a policy of self-insurance against malpractice and comprehensive general liability loss with supplemental coverage for losses in excess of $4.0 million per incident and $6.0 million in aggregate with a coverage limit of $20.0 million per incident and in aggregate. The current portion of the related liability is reported in accounts payable and accrued expenses on the consolidated balance sheet, while the long-term portion is included in other long-term liabilities. The District has established an irrevocable trust for the purpose of appropriating assets to cover such losses. Under the trust agreement, the trust assets can only be used for payment of malpractice losses, general liability losses, related expenses, and the cost of administering the trust. The assets of the trust and related liabilities are reported on the consolidated balance sheet. Income from the trust assets, estimated losses from claims, and administrative costs are reported in the consolidated statements of revenues, expenses, and changes in net position. Losses from asserted and unasserted claims identified under the District’s incident reporting system are accrued based on estimates that incorporate the District’s past experience, as well as other considerations including the nature of each claim or incident and relevant trend factors. The District’s accrued malpractice losses also include an estimate of possible losses attributable to incidents that may have occurred, but have not been identified under the incident reporting system. The District has employed independent actuaries to estimate the ultimate costs, if any, of the settlement of such claims. Estimated future payments relating to malpractice losses have been discounted at a 3.0% rate. Workers’ compensation self-insurance – The District maintains a policy of self-insurance against workers’ compensation losses with supplemental coverage for losses in excess of $1.5 million. The Board has designated funds for the payment of workers’ compensation claims. The current portion of the related liability is reported in accrued payroll and related liabilities on the consolidated balance sheet, while the long-term portion is included in other long-term liabilities. Losses from asserted and unasserted claims identified under the District’s incident reporting system are accrued based on estimates that incorporate the District’s past experience, as well as other considerations including the nature of each claim or incident and relevant trend factors. The District’s accrued workers’ compensation losses also include an estimate of possible losses attributable to incidents that may have occurred, but have not been identified under the incident reporting system. The District has employed independent actuaries to estimate the ultimate costs, if any, of the settlement of such claims. Estimated future payments relating to workers’ compensation losses have been discounted at a 2.3% rate. Medical benefits self-insurance – The District maintains a policy of self-insuring medical costs up to $800,000 per employee. The related liability is reported in accrued payroll and related liabilities on the consolidated balance sheet. Losses from asserted and unasserted claims identified under the District’s reporting system are accrued based on estimates that incorporate the District’s past experience and relevant trend factors. The District’s accrued medical insurance liability also includes an estimate of possible losses attributable to incidents that may have occurred, but have not been reported.

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Compensated absences – The District’s benefits-eligible employees earn vacation, short-term illness, and holiday leave, referred to as Paid Time Off (“PTO”) at varying rates based upon qualifying-service hours. Employees may accumulate PTO up to a specified maximum. Accrued PTO is paid to the employee upon termination of employment or upon conversion to non-benefits eligible status. The estimated amount of PTO payable to employees is reported as a current liability in both 2017 and 2016. Extended Illness Bank (“EIB”) time is also earned at a specific rate per qualified-service hour. Employees who were vested in the District’s defined benefit retirement plan as of June 30, 2011 (the effective date it was “frozen”) were offered a one-time opportunity to have their accrued EIB time applied to length of service up to a maximum of one year service credit. However, no payment is made for accrued EIB time when employment is terminated. Premium revenue and health care services cost recognition – The District contracts with a Medicare Advantage company (Humana) to provide health care services for certain members for which it receives revenue on a capitated basis. Under this agreement, the District receives monthly capitation payments based upon the number of participants covered under the agreements, regardless of services actually performed by the District or others under the agreements. Revenue is recognized during the period in which the District is obligated to provide service to the participants. The agreement for which the District is compensated on a capitated basis requires that the District provide or arrange for certain covered health care services to all members covered under the contract which results in the District compensating other providers on a fee-for-services basis for the services. The cost of these services is accrued in the period the services are provided to the members based, in part, on estimates by management. The accrual of expense for such services provided includes an estimate of services provided but not reported to the District as of the fiscal year end. Reclassifications – Certain reclassifications have been made to prior year balances to conform to the current year presentation. Net position – Net position is divided into three components: net investment in capital assets; restricted; and unrestricted.

These classifications are defined as follows:

Net investment in capital assets – This component of net position consists of capital assets, including restricted capital assets, net of accumulated depreciation and reduced by the outstanding balances of any bonds, mortgages, notes, or other borrowings that are attributable to the acquisition, construction, or improvement of those assets. Restricted – This component of net position consists of restricted expendable net position whose use is restricted through external constraints imposed by creditors (such as through debt covenants), grantors, contributors, laws or regulations of other governments, or constraints imposed by law through constitutional provisions or enabling legislation and includes assets in self-insurance trust funds, revenue bond reserve fund assets, and net position restricted to use by donors. Restricted non-expendable net position equals the principal portion of permanent endowments as well as minority interest.

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Net position (continued) – Unrestricted – This component of net position consists of net position that does not meet the definition of “restricted” or “invested in capital assets, net of related debt.”

New accounting pronouncements – In February 2015, the GASB issued Statement No. 72, Fair Value Measurement and Application. Statement No. 72 is intended to address accounting and financial reporting issues related to fair value measurements. The definition of fair value is the price that would be received to sell an asset or paid to transfer a liability in an orderly transaction between market participants at the measurement date. This Statement provides guidance for determining a fair value measurement for financial reporting purposes. This Statement also provides guidance for applying fair value to certain investments and disclosures related to all fair value measurements. This guidance was effective for and adopted by the District in the year ended June 30, 2016. In June 2015, the GASB issued Statement No. 73, Accounting and Financial Reporting for Pensions and Related Assets That Are Not within the Scope of GASB Statement 68, and Amendments to Certain Provisions of GASB Statements 67 and 68. Statement No. 73 is intended to improve the usefulness of information about pensions included in the general purpose external financial reports of state and local governments for making decisions and assessing accountability. This Statement results from a comprehensive review of the effectiveness of existing standards of accounting and financial reporting for all postemployment benefits with regard to providing decision-useful information, supporting assessments of accountability and interperiod equity, and creating additional transparency. The District has reviewed and evaluated this pronouncement and has determined no material impact to the consolidated financial statements for the fiscal year ended June 30, 2016.

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NOTE 2 – NON-CURRENT CASH AND INVESTMENTS

Non-current cash and investments required for obligations classified as current liabilities are reported as current assets. The composition of non-current cash and investments is as follows:

2017 2016

Board designated assets:Cash and cash equivalents 89,370,275$ 78,630,833$ U.S. Treasury obligations 63,984,028 63,202,462 Federal agency obligations 24,974,745 20,283,085 Municipal obligations 8,829,458 11,544,988 Corporate obligations 58,885,894 54,869,713 Equity securities 9,351,035 7,906,540 Mutual funds 2,338,194 2,140,082 Asset and mortgage-backed securities 17,198,602 14,698,926 Alternative investments 1,211,603 1,032,769 Interest receivable 866,889 721,490 Current portion (7,097,384) (7,351,384)

269,913,339$ 247,679,504$

Bond assets held in trust:Cash and cash equivalents 37,013,406$ 28,411,420$ U.S. Treasury obligations 1,997,192 2,767,132 Federal agency obligations 21,091,073 20,541,219 Corporate obligations 25,762,023 52,101,436 Interest receivable 269,125 247,289 Current portion (4,302,060) (4,303,178)

81,830,759$ 99,765,318$

Assets in self-insurance trust fund:Cash and cash equivalents 10,826$ 24,311$ U.S. Treasury obligations 2,114,780 2,479,222 Federal agency obligations 989,762 333,736 Municipal obligations 656,988 904,767 Corporate obligations 1,882,193 1,795,928 Asset and mortgage-backed securities 711,922 779,700 Interest receivable 24,346 27,222 Current portion (748,242) (1,147,172)

5,642,575$ 5,197,714$

June 30,

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NOTE 3 – FAIR VALUE OF ASSETS AND LIABILITIES

Fair value is defined as the price that would be received to sell an asset or paid to transfer a liability in an orderly transaction between market participants at the measurement date. A fair value hierarchy requires an entity to maximize the use of observable inputs and minimize the use of unobservable inputs when measuring fair value. The three levels of inputs that may be used to measure fair value within the fair value hierarchy are:

Level 1 Quoted prices in active markets for identical assets or liabilities

Level 2 Observable inputs other than Level 1 prices, such as quoted prices for similar assets or liabilities; quoted prices in markets that are not active; or other inputs that are observable or can be corroborated by observable market data for substantially the full term of the assets or liabilities

Level 3 Unobservable inputs that are supported by little or no market activity and that are significant to the fair value of the assets or liabilities

Where quoted market prices are available in an active market, securities are classified within Level 1 of the valuation hierarchy. If quoted market prices are not available, then fair values are estimated by using pricing models, quoted prices of securities with similar characteristics, or discounted cash flows.

The following tables present the fair value measurements of assets recognized in the accompanying consolidated statements of net position reported at fair value on a recurring basis and the level within the fair value hierarchy in which the fair value measurements fall:

Level 1 Level 2 Level 3Investments held at net asset value Balance

Cash and cash equivalents 99,251,955$ -$ -$ 20,618,813$ 119,870,768$ U.S. Treasury obligations 68,096,000 - - - 68,096,000 Federal agency obligations - 47,055,580 - - 47,055,580 Municipal obligations - 9,486,446 - - 9,486,446 Corporate obligations - 86,530,110 - - 86,530,110 Asset and mortgage-backed securities - 17,910,524 - - 17,910,524 Other Foundation assets 11,689,229 - - 1,211,603 12,900,832

179,037,184$ 160,982,660$ -$ 21,830,416$ 361,850,260$

Level 1 Level 2 Level 3Investments held at net asset value Balance

Cash and cash equivalents 81,311,760$ -$ -$ 20,574,664$ 101,886,424$ U.S. Treasury obligations 68,448,816 - - - 68,448,816 Federal agency obligations - 41,158,040 - - 41,158,040 Municipal obligations - 12,449,755 - - 12,449,755 Corporate obligations - 108,767,076 - - 108,767,076 Asset and mortgage-backed securities - 15,478,628 - - 15,478,628 Other Foundation assets 10,046,622 - - 1,032,769 11,079,391

159,807,198$ 177,853,499$ -$ 21,607,433$ 359,268,130$

June 30, 2017

Description

June 30, 2016

Description

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NOTE 4 – BANK DEPOSITS

At June 30, 2017 and 2016, the District had bank balances totaling $10,499,000 and $9,076,000, respectively, which approximate book balances. Of these balances, $4,966,000 and $3,620,000 were insured by the Federal Deposit Insurance Corporation at June 30, 2017 and 2016, respectively, and the remainder was collateralized. The California Government Code (the “Code”) requires financial institutions to secure the District’s deposits, in excess of insured amounts, by pledging government securities as collateral. The fair value of pledged securities must equal at least 110% of the District’s deposits.

NOTE 5 – INVESTMENTS

GASB Statement No. 40 requires the District to disclose its deposit and investment policies related to investments with credit risk or deposits with custodial credit risk, the credit ratings and maturities of its investments (other than U.S. government obligations or obligations guaranteed by the U.S. government), and additional disclosures related to uninsured deposits. A summary of scheduled maturities by investment type at June 30, 2017 follows:

Fair Value Less than 1 1 - 5 More than 5

U.S. Treasury obligations 68,096,000$ 1,997,192$ 65,977,240$ 121,568$ Federal agency obligations 47,055,580 7,129,588 39,832,836 93,156 Corporate obligations 86,530,109 20,254,635 66,194,120 81,355 Municipal obligations 9,486,446 2,188,087 7,298,359 - Asset and mortgage-backed securities 17,910,524 579,537 17,330,987 - Local Agency Investment Funds 82,623,058 82,623,058 - - CalTRUST 20,618,813 20,618,813 - - CAMP 14,589,116 14,589,116 - - Money market funds 2,039,781 2,039,781 - -

348,949,428 152,019,807$ 196,633,542$ 296,079$

Other Foundation assetsEquity securities 9,351,035 Alternative investments 1,211,603 Mutual funds 2,338,194

361,850,260$

Investment Maturities (in years)

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NOTE 5 – INVESTMENTS (CONTINUED)

A summary of scheduled maturities by investment type at June 30, 2016 follows:

Fair Value Less than 1 1 - 5 More than 5

U.S. Treasury obligations 68,448,816$ -$ 68,343,249$ 105,567$ Federal agency obligations 41,158,040 - 41,139,384 18,656 Corporate obligations 108,767,076 34,895,147 73,784,225 87,704 Municipal obligations 12,449,755 2,559,499 9,890,256 - Asset and mortgage-backed securities 15,478,628 - 15,478,628 - Local Agency Investment Funds 71,643,573 71,643,573 - - CalTRUST 20,574,664 20,574,664 - - CAMP 8,210,945 8,210,945 - - Money market funds 1,457,242 1,457,242 - -

348,188,739 139,341,070$ 208,635,742$ 211,927$

Other Foundation assetsEquity securities 7,906,540 Alternative investments 1,032,769 Mutual funds 2,140,082

359,268,130$

Investment Maturities (in years)

Investment activities of the District are governed by sections of the California Government Code (the “Code”), which specify the authorized investments that may be made by the District. The District’s investment policy (the “Policy”) requires that all investing activities of the District comply with the Code and also sets forth certain additional restrictions which exceed those imposed by the Code. The Foundation is governed by the Internal Revenue Code; therefore, its investment activities are not subject to the same requirements as the District. Interest rate risk is the risk that changes in interest rates will adversely affect the fair value of an investment. Investments held for longer periods are subject to increased risk of adverse interest rate changes. The District’s investment policy provides that no investment shall be made in any security having a term remaining to maturity exceeding five years at the time of investment. The Foundation’s investment policy allows for longer-term investments. D

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NOTE 5 – INVESTMENTS (CONTINUED)

Credit risk is the risk that an issuer or other counterparty to an investment will not fulfill its obligations. The Policy requires that, to be eligible for investment, corporate notes shall be rated “A,” or its equivalent, or better by a nationally-recognized rating service at the time of purchase. The Policy also limits investment in collateralized mortgage obligations to obligations rated “AA,” or its equivalent, or better. All of the District’s investments in corporate obligations and collateralized mortgage obligations met these requirements as of June 30, 2017. The Policy allows for investments in LAIF up to the maximum amount allowed by the state of California. The investment in LAIF is sufficiently liquid to permit withdrawal of cash at any time without prior notice or penalty. The state of California Treasurer’s office has regulatory oversight of LAIF. The Policy includes no limitations or restrictions related to investments in United States Treasury or federal agency obligations. The Policy also allows for investment in shares of beneficial interest issued by a joint power authority (“JPA”) organized pursuant to the Code that invests in the securities and obligations authorized under the Code. The Code requires that the JPA issuing the shares shall have retained an investment adviser with appropriate size and experience as outlined in the Code. The District is a participant in a JPA, the Investment Trust of California, commonly known as CalTRUST, for the purpose of pooling local agency assets for investing. Participation in the CalTRUST program is open to any public agency in California. CalTRUST is measured at Net Asset Value, which is calculated daily, and redemptions may be made monthly on the last business day with 5 days’ notice. The JPA is governed by a Board of Trustees, all of whom are experienced investment officers or employees of the public agency members. The Trustees are responsible for setting the overall policies and procedures for the JPA and for overall administration of the JPA. Concentration of credit risk is the risk of loss attributed to the magnitude of the District’s investment in a single issuer. At June 30, 2017 and 2016, more than 5% of the District’s total investment portfolio was invested in LAIF. The market value of LAIF investments represented 22.83% and 19.9% of the District’s total investment market value at June 30, 2017 and 2016, respectively. At June 30, 2017 and 2016, more than 5% of the District’s total investment portfolio was invested in CalTRUST. The market value of CalTRUST investments represented 5.7% of the District’s total investment market value at June 30, 2017 and 2016.

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NOTE 6 – CAPITAL ASSETS

A summary of changes in capital assets during 2017 is as follows (in thousands):

Beginning EndingBalance Balance

2016 Additions Deletions Transfers 2017

Land 15,232$ 526$ -$ -$ 15,758$ Buildings and improvements 316,508 557 - 5,348 322,413 Equipment 180,244 11,363 (916) 2,747 193,438 Construction in progress 27,372 27,980 - (8,095) 47,257 Property under capital leases 37,492 - - - 37,492

576,848 40,426 (916) - 616,358 Accumulated depreciation

and amortization 293,986 23,332 (871) - 316,447

282,862$ 17,094$ (45)$ -$ 299,911$

A summary of changes in capital assets during 2016 is as follows (in thousands):


2015 Additions Deletions Transfers 2016

Land 14,582$ 650$ -$ -$ 15,232$ Buildings and improvements 310,895 793 (1,210) 6,030 316,508 Equipment 164,695 15,918 (2,469) 2,100 180,244 Construction in progress 10,227 25,275 - (8,130) 27,372 Property under capital leases 36,210 1,282 - - 37,492

536,609 43,918 (3,679) - 576,848 Accumulated depreciation

and amortization 274,542 21,868 (2,424) - 293,986

262,067$ 22,050$ (1,255)$ -$ 282,862$

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NOTE 7 – HEALTH-RELATED INVESTMENTS

The following table summarizes the District’s health-related investments recorded on the equity method at June 30:

2017 2016

Cypress Company, LLC 870,851$ 880,937$ Sequoia Surgery Center, LLC 985,212 855,910 Northwest Visalia Senior Housing, LLC 450,000 - Sequoia Integrated Health Plan, LLC 1,036,470 -

3,342,533$ 1,736,847$

Investment in Cypress Company, LLC (“CyCo”) – In August 2010, Cypress Surgery Center formed CyCo, a real estate holding company organized as a California limited liability company, and transferred all of its real property and associated real estate debt, along with certain other assets and liabilities, to CyCo. The District holds a 40% investment in CyCo and has a guarantee payment obligation for CyCo’s outstanding real estate debt equal to its ownership percentage. The current outstanding balance of CyCo’s real estate debt, held with a local commercial bank, is approximately $524,400. Investment in Sequoia Surgery Center, LLC (formerly Cypress Surgery Center) – At June 30, 2017, the District held a 31% investment in a free-standing ambulatory surgery center located within the District. In August 2010, Cypress Surgery Center completed a “merger” with the Center for Ambulatory Medicine and Surgery (“CAMS”), a local ambulatory surgery center, and changed its legal name to Sequoia Surgery Center, LLC as well as its organizational structure from a California limited partnership to a California limited liability company. To effect the merger, Cypress Surgery Center acquired 100% of the assets and outstanding ownership interests of CAMS in exchange for approximately 52% ownership in Cypress Surgery Center (now Sequoia Surgery Center, LLC). As a result of this acquisition, the District’s ownership interest in Sequoia Surgery Center, LLC was diluted from 64.9% to approximately 31%. Sequoia Surgery Center leases its ambulatory surgery center facility from Cypress Company, LLC. Investment in Northwest Visalia Senior Housing, LLC – The District made its initial capital contribution to establish its investment in a joint-venture company. Northwest Visalia Senior Housing, LLC was formed in furtherance of the members’ elder care mission and to put into practice innovative approaches to care of the elderly, simultaneously addressing the housing and healthcare needs of the elderly. This will be accomplished in part by constructing, developing, owning, maintaining, and operating a full service assisted living retirement facility in Visalia, California. Northwest Visalia Senior Housing, LLC is owned 33.33% by the District, 33.33% by Shannon Senior Care, LLC, 20% by BTV Senior Housing, LLC, and 13.34% by Millennium advisors, Inc. The District has recorded its interest in the joint-venture based upon its initial capital contributions.

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NOTE 7 – HEALTH-RELATED INVESTMENTS (CONTINUED)

Investment in Sequoia Integrated Health, LLC – The District made its initial capital contribution to establish its investment in a joint-venture company formed in furtherance of the members’ common purpose to better serve and coordinate healthcare services for the communities of Tulare and Kings Counties, and to own and operate an Integrated Delivery Network in California and activities incident thereto. Sequoia Integrated Health, LLC is owned 50% by the District, 25% by Key Medical Group, Inc., and 25% by Foundation for Medical Care of Tulare and Kings Counties, Inc. The District has recorded its interest in the joint-venture based upon its initial capital contributions. Investment in Quail Park Retirement Village, LLC – The District holds an investment in a joint-venture company that operates an assisted-living facility in Visalia, California. The joint-venture company, Quail Park Retirement Village, LLC is owned 44% by the District and 56% by Living Care Visalia, LLC and its affiliated investors. Under the terms of the joint-venture agreement, the District has an option to purchase an additional 5% of Living Care Visalia, LLC’s equity interest at fair market value determined at the time of sale. Distributions have exceeded initial capital contributions resulting in a deficit equity position for Quail Park Retirement Village, LLC. The District has recorded its interest in the joint-venture company at $0 in accordance with Generally Accepted Accounting Principles as the District is not liable for obligations of the joint-venture company. Investment in Laurel Court at Quail Park, LLC – In June 2011, the District made its initial capital contribution to establish its investment in a joint-venture company formed to construct, develop, own, maintain, and operate a full service memory care retirement facility in Visalia, California. The joint-venture company, Laurel Court at Quail Park, LLC is owned 44% by the District and 56% by Living Care Visalia, LLC. Distributions have exceeded initial capital contributions resulting in a deficit equity position for Laurel Court at Quail Park, LLC. The District has recorded its interest in the joint-venture company at $0 in accordance with Generally Accepted Accounting Principles as the District is not liable for obligations of the joint-venture company. Income or loss from equity method investments is included in other revenues in the corresponding consolidated statement of revenues, expenses, and changes in net position.

NOTE 8 – CAPITAL LEASES

In April 2011, the District entered into a $12.3 million tax-exempt master lease agreement for the purpose of refinancing the $10.3 million principal balance outstanding of an existing tax-exempt lease and to provide for $2.0 million of additional funds to be deposited into escrow and used to purchase various equipment within a subsequent 24-month period. The lease provides for interest only monthly payments through June 1, 2017, principal and interest payments beginning July 1, 2017, and a final principal payment of $11.6 million on April 1, 2021. The lease is secured by a security interest in the equipment purchased with the proceeds of the original lease. The refunding of the capital lease resulted in increased debt service payments by approximately $3.5 million over the next ten years and an economic loss (difference between the present value of the debt service payments on the old and new debt) of approximately $23,000.

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NOTE 8 – CAPITAL LEASES (CONTINUED)

In September 2011, the District entered into an $18.1 million tax-exempt master lease agreement for the purpose of refunding $18.0 million of Series 2005 revenue bonds outstanding. The lease provides for equal monthly payments of principal and interest beginning on October 22, 2011 and ending on March 22, 2020. The lease is secured by a security interest in the equipment funded by the 2005 revenue bonds as well as other equipment purchased by the District. The refunding of the Series 2005 bonds resulted in decreased debt service payments of approximately $2.2 million over the next 8.5 years and an economic gain (difference between the present value of the debt service payments on the old and new debt) of approximately $1.8 million. Future minimum payments, by year and in the aggregate, for all capital leases consist of the following at June 30, 2017:

Years ending June 30,2018 3,550,725$ 2019 3,558,805 2020 2,693,427 2021 12,059,131 2022 47,645

Future minimum lease payments 21,909,733 Less amount representing interest 2,128,104

Present value of minimum lease payments 19,781,629 Less current portion 2,911,020

16,870,609$

Capital assets include the following amounts that have been initially or are currently capitalized under the leases at June 30:

2017 2016

Buildings and improvements 402,705$ 402,705$ Equipment 37,088,616 37,088,616

37,491,321 37,491,321 Less accumulated depreciation 30,006,137 28,201,108

7,485,184$ 9,290,213$

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NOTE 8 – CAPITAL LEASES (CONTINUED)

A summary of changes in capital lease obligations during 2017 and 2016 is as follows (in thousands):


2016 Additions Payments 2017

Capitalized lease obligations 21,649$ 817$ 2,684$ 19,782$


2015 Additions Payments 2016

Capitalized lease obligations 22,644$ 1,281$ 2,276$ 21,649$

NOTE 9 – BONDS PAYABLE

In June 2003, the District issued $10,720,000 of Kaweah Delta Health Care District Revenue Bonds, Series 2003A and $16,000,000 of Kaweah Delta Health Care District Revenue Bonds, Taxable Series 2003B. The 2003A and 2003B bonds bear interest at rates of 2.15% to 4.75% and 3.30% to 6.00%, respectively. The net proceeds of the 2003A bonds were used to construct and equip a new five-story support services building. The net proceeds of the 2003B bonds were used to construct a combined outpatient cancer and imaging facility. The 2003 bonds maturing on or after June 1, 2009, are subject to redemption at the option of the District prior to their respective stated maturities at amounts ranging from 100% to 102% of face value. The 2003A bonds require the District to make minimum sinking fund payments beginning in June 2026. The 2003A revenue bonds were refunded in October 2015 and the 2003B revenue bonds were refunded in July 2012 as noted below. During December 2006, the District issued $33,935,000 of Kaweah Delta Health Care District Revenue Bonds, Series 2006, at rates of 3.5% to 4.5%, to advance refund $27,045,000 of outstanding Series 2004 Revenue Bonds with an interest rate of 6.0%, and to provide for the acquisition of clinical information software. The 2006 bonds maturing on or after June 1, 2012, are subject to redemption at the option of the District prior to their respective stated maturities at amounts ranging from 100% to 102% of face value. The 2006 bonds require the District to make minimum sinking fund payments beginning in June 2020. A portion of the 2006 revenue bonds were refunded in October 2015 and the remainder was refunded in April 2017 as noted below.

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NOTE 9 – BOND PAYABLE (CONTINUED)

During May 2011, the District issued $5,255,000 of Kaweah Delta Health Care District Revenue Bonds, Series 2011A and $8,235,000 of Kaweah Delta Health Care District Revenue Bonds, Series 2011B. The Series A and Series B bonds bear interest at rates of 5.4% to 5.5% and 3.8% to 5.4%, respectively. The net proceeds of the Series A bonds, were to be used for electrical and plumbing infrastructure in the original hospital wing and various other improvements to the District’s facilities. The net proceeds from the Series B bonds were used to redeem specific maturities of Series 1999 bonds. The 2011 bonds are subject to redemption prior to their respective stated maturities at the option of the District on or after June 1, 2016, at the principal amount of the bonds redeemed, without premium. The remaining 2011A and a portion of the 2011B revenue bonds were refunded in October 2015, and the remaining 2011B revenue bonds were refunded in April 2017 as noted below. During July 2012, the District issued $75,800,000 of Kaweah Delta Health Care District Revenue Bonds, Series 2012. The 2012 revenue bonds bear interest at rates of 2.0% to 5.0%. Approximately $9.8 million of the net proceeds of the bonds were used by the District to expand its ambulatory surgery services, to complete capital improvements related to the graduate medical education program, and for other infrastructure improvements. Approximately $68.0 million of the net proceeds was used to prepay existing debt, including the 1999A, 2003B, and 2004 revenue bonds. The 2012 revenue bonds maturing on or after June 1, 2017, are subject to redemption at the option of the District prior to their respective stated maturities at amounts ranging from 100% to 102% of face value. The 2012 revenue bonds require the District to make minimum sinking fund payments beginning in June 2036. During January 2014, the District issued $48.9 million of Kaweah Delta Health Care District General Obligation Refunding Bonds, Series 2014, at rates of 3.6% to 4.1%, solely to advance refund $47.3 million of the outstanding 2004 General Obligation bonds, bearing interest rates of 5.0% to 5.5%. Mandatory sinking fund redemption payments on the bonds began on August 1, 2015. The final maturity of the bonds is August 1, 2034. The advance refunding of the 2004 bonds resulted in decreased debt service payments of approximately $6.3 million over the next 21 years and an economic gain (difference between the present value of the debt service payments on the old and new debt) of approximately $4.3 million. The general obligation bonds represent the general obligation of the District. The District has the power and is obligated to cause annual ad valorem taxes to be levied upon all property within the District, subject to taxation by the District, and collected by the County for payment, when due, of the principal and interest on the bonds.

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During October 2015, the District issued $19,361,000 of Kaweah Delta Health Care District Revenue Bonds, Series 2015A. The 2015A revenue bonds bear interest at a rate of 2.975%. The net proceeds were used to prepay existing debt, including a portion of the 2006 and 2011B revenue bonds as well as the outstanding amount of the 2003A and 2011A revenue bonds. The 2015A revenue bonds maturing on or after June 1, 2025 are subject to redemption at the option of the District prior to their respective stated maturities at a price equal to the principal amount of the bonds, without premium. The current refunding of the 2003A and 2006 bonds and the advanced refunding of the 2011A and 2011B bonds resulted in decreased debt service payments of approximately $3.9 million over the next 18 years and an economic gain (difference between the present value of the debt service payments on the old and new debt) of approximately $3.0 million. During December 2015, the District issued $98,425,000 of Kaweah Delta Health Care District Revenue Bonds, Series 2015B. The 2015B revenue bonds bear interest rates of 3.25% to 5.0%. The net proceeds were for the acquisition, construction, installation and equipping of the second, fifth, and sixth floors of the Kaweah Delta Medical Center’s Acequia Wing, expansion and improvement of the emergency department, expansion of outpatient endoscopy services, acquisition and implementation of a new information technology platform (Cerner), acquisition and construction of a new urgent care center, improvements to the Exeter Health Clinic campus, and other projects. The 2015B revenue bonds maturing on or after June 1, 2025 are subject to redemption at the option of the District, prior to their respective stated maturities at a price equal to the principal amount of the bonds, without premium. 2017A and 2017B Bonds – During April 2017, the District issued $13,700,000 Series 2017A and $20,000,000 Series 2017B of Kaweah Delta Health Care District Revenue Bonds. Both the 2017A and the 2017B revenue bonds bear interest at a rate of 3.24%. The net proceeds were used to prepay existing debt, including the remaining outstanding amounts of the 2006 and 2011B revenue bonds. The 2017A and 2017B revenue bonds maturing on or after June 1, 2029 are subject to redemption at the option of the District prior to their respective stated maturities at a price equal to the principal amount of the bonds, without premium. The current refunding of the 2006 and 2011B bonds resulted in decreased debt service payments of approximately $8.0 million over the next 17 years and an economic gain (difference between the present value of the debt service payments on the old and new debt) of approximately $4.3 million. D

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Principal and interest payments due on the revenue and general obligation bonds over the next five years, and in five-year increments thereafter, calculated at the interest rate in effect at June 30, 2017 are as follows (in thousands):

Years ending June 30, Principal Interest

2018 5,269$ 10,278$ 2019 5,571 10,043 2020 6,746 9,795 2021 8,524 9,507 2022 6,627 9,159 2023 – 2027 48,885 41,303 2028 – 2032 59,075 30,723 2033 – 2037 38,528 22,155 2038 – 2042 47,400 13,194 2043 – 2045 33,635 2,726

260,260 158,883$

Unamortized premium 4,969

265,229 Less current portion 5,269

259,960$

The bond indenture agreements contain various restrictive covenants which include, among other things, minimum debt service coverage, maintenance of minimum liquidity, restrictions on certain additional indebtedness, and requirements to maintain certain financial ratios. The District incurred approximately $11,548,000 and $9,688,000 in interest in 2017 and 2016, respectively, on all debt including revenue and general obligation bonds, capital leases, and notes payable. The District capitalized interest expense of $4,534,000 and $2,500,000 in 2017 and 2016, respectively. A summary of changes in bonds payable for the years ended June 30 is as follows (in thousands):

Beginning EndingBalance Additions Payments Balance

2017 265,185$ 33,700$ 38,625$ 260,260$

2016 171,176$ 117,786$ 23,777$ 265,185$

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NOTE 10 – SELF-INSURED CLAIMS

As discussed in Note 1, the District is self-insured for medical malpractice and general comprehensive liability, medical benefits, and workers’ compensation, and discounts the medical malpractice and general comprehensive and workers’ compensation liabilities using a 3.0% and 2.3% discount rate, respectively. The following is a summary of the changes in the self-insured plan liabilities for the years ended June 30 (in thousands):

Beginning EndingBalance Additions Payments Balance

2017 29,599$ 29,101$ 29,411$ 29,289$

2016 26,530$ 28,052$ 24,983$ 29,599$

NOTE 11 – EMPLOYEES’ RETIREMENT PLANS

The Kaweah Delta Health Care District’s Employees’ Retirement Plan (the “Retirement Plan”), is a single-employer defined benefit pension plan established to provide retirement benefits for District employees based on length of service and the average of the highest consecutive three years of earnings. The Retirement Plan is administered by a retirement plan committee appointed by the Board of Directors of the District. The Retirement Plan issues a separate financial report that includes financial statements and required supplemental information. Employees were eligible to participate on the first day of a pay period following six months of service if hired prior to January 1, 2003, and elected not to participate in the salary deferral plan’s matching contribution component. Employees hired on or after January 1, 2003 were not eligible to participate in the Retirement Plan. Employees’ retirement benefits vest 100% after five years of completed service. Effective June 30, 2011, the Retirement Plan was amended to suspend all accruals and otherwise freeze benefits under the plan. The Retirement Plan complies with the Internal Revenue Code and ERISA as they apply to governmental plans. As a government plan, the Retirement Plan is exempt from the annual minimum funding requirements of ERISA. The Retirement Plan’s funding policy provides for periodic employer contributions at actuarially determined rates that, expressed as a percentage of annual covered payroll, are sufficient to accumulate assets to pay benefits when due. The District contributed $9,000,000 and $5,000,000 to the plan in 2017 and 2016, respectively. The District uses a measurement date of June 30 for each year presented. The actuarial valuation for fiscal year 2017 and 2016 is based on participant data as of June 30, 2016 and June 30, 2015, respectively. Update procedures were used to roll forward the total pension liability to the measurement date, including the mortality assumption change described below.

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NOTE 11 – EMPLOYEES’ RETIREMENT PLANS (CONTINUED)

Components of pension cost and deferred outflows of resources under the requirements of GASB No. 68 are as follows:

Pension cost 2017 2016

Service cost 83,419$ 83,419$ Administrative expense 242,282 745,337 Interest 19,281,685 17,727,522 Expected return on assets, net of investment expenses (14,851,428) (15,653,631) Recognition of deferred amounts 8,695,102 9,654,088

Total pension cost 13,451,060$ 12,556,735$

Deferred outflows of resources

Established July 1Difference between expected and actual experience 5,776,828$ 445,293$ Change in assumptions 4,280,597 12,045,745 Net difference in expected and actual earnings 7,678,194 21,728,572

Deferred outflows of resources at thebeginning of the year 17,735,619 34,219,610

Amount recognized in current year pension cost

Established July 1Difference between expected and actual experience 2,252,527 231,466 Change in assumptions 3,714,132 4,807,191 Net difference in expected and actual earnings 2,728,443 4,615,431

Amount recognized in current year 8,695,102 9,654,088

Contributions between the measurement date and fiscal year end recognized as deferred

outflow of resources - -

Deferred outflows of resources at end of the year 9,040,517$ 24,565,522$

Years Ended June 30,

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Amounts reported as deferred outflows of resources to be recognized in pension cost for future years:

2018 6,123,529$ 2019 3,424,120 2020 1,379,856 2021 (1,886,988)

9,040,517$

Participant data for the plan is as follows:

2017 2016

Active employees 834 880 Terminated vested 993 996 Retirees receiving benefits 715 672

Total participants 2,542 2,548

June 30,

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The following table summarizes changes in net pension liability for the years ended June 30:

2017 2016Total pension liability

Service cost 90,092$ 90,092$ Interest 19,275,012 17,720,849 Differences between expected and actual experience 5,563,001 - Changes in assumptions (2,957,958) 11,817,557 Benefit payments (11,333,243) (10,577,037)

Net change in total pension liability 10,636,904 19,051,461 Total pension liability, beginning of the year 246,604,259 227,552,798

Total pension liability, end of the year 257,241,163 246,604,259

Plan fiduciary net positionEmployer contributions 9,000,000 5,000,001 Net investment income 24,286,375 (680,601) Benefit payments (11,333,243) (10,577,037) Administrative expenses (242,282) (745,337)

Net change in plan fiduciary net position 21,710,850 (7,002,974) Plan fiduciary net position, beginning of the year 183,780,944 190,783,918

Plan fiduciary net position, end of the year 205,491,794 183,780,944

Net pension liability, end of the year 51,749,369$ 62,823,315$

Plan fiduciary net position as percentage of total pension liability 79.88% 74.52%

Covered employee payroll N/A N/ANet pension liability as percent of covered payroll N/A N/A

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The following table summarizes the actuarial assumptions used to determine net pension liability and plan fiduciary net position as of June 30, 2017:

Valuation date June 30, 2016Actuarial cost method Entry Age NormalAmortization method Level DollarAsset valuation method Fair Value

Actuarial assumptions (including 2% inflation)Discount Rate 8.0%Mortality RP-2014 table, projected using

MP-2016Projected Salary Increases N/A

Sensitivity of Net Pension Liability at June 30, 2017 to changes in the Discount Rate1% Decrease (7.0%) 82,557,071$ Current Discount Rate (8.0%) 51,749,369$ 1% Increase (9.0%) 26,168,246$

The mortality assumption was updated in 2017 from the most recent tables published by the Society of Actuaries.

The District also administers a salary deferral plan (the “Salary Plan”) available to substantially all full-time employees meeting certain service requirements. The Salary Plan qualifies under the Internal Revenue Code Section 401(k) and was established to provide supplemental retirement income for employees of the District. Under the Salary Plan, the District makes matching contributions to participants in accordance with an established schedule based upon each participant’s years of service with the District. The District made matching contributions of approximately $6,485,000 and $10,355,000 to participants for 2017 and 2016, respectively. The District recognized pension expense of $6,764,000 and $6,235,000 related to the Salary Plan in 2017 and 2016, respectively. The liability related to the Salary Plan was $3,424,000 and $3,167,000 at June 30, 2017 and 2016, respectively. Employees are immediately vested in their own contributions and earnings on those contributions. Employees become vested in the District contributions and earnings on District contributions after completion of five years of service. Non-vested contributions are forfeited upon termination of employment and such forfeitures are used to offset future District contributions. For the years ended June 30, 2017 and 2016, forfeitures reduced the District’s pension expense by $294,000 and $206,000, respectively.

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In addition, the District offers its employees a deferred compensation plan (the “457 Plan”) created in accordance with Internal Revenue Code Section 457. The 457 Plan, available to all District employees with at least one year of service, permits them to defer a portion of their salary until future years. The deferred compensation is not available to employees until termination, retirement, death, or certain emergency situations.

NOTE 12 – COMMITMENTS

At June 30, 2017, the District has projects in progress to construct, improve, and equip various routine, ancillary, and support services. Projects in progress include the expansion of the ambulatory surgery center; an expansion of the emergency department; the improvement of the second, fifth, and sixth floors of the Acequia Wing; an expansion of the Exeter rural health clinic; the implementation of a new information technology platform and the construction of a new urgent care center. Total costs expended as of June 30, 2017 related to these projects and others are approximately $43,722,000. The total estimated cost of these projects at completion is approximately $146,740,000 of which approximately $61,119,000 has been expended or contractually obligated. The estimated final date of completion for the projects is June 2019. Funding for the projects is expected to include a combination of revenue bond funds, operating cash flows, community donations, and funded reserves. The District has entered into various physician income guarantees whereby, pursuant to the terms in the agreement, the District has extended income guarantees to certain doctors in exchange for the doctors maintaining a medical practice in the District’s service area. Payments under the guarantees are expected to be forgiven over a two- to three-year period should the physician remain in practice in the community. If a doctor terminates his medical practice in the community prior to the completion of the term, the remaining balance under the guarantee is immediately due and payable. The District records expenses under these guarantees as payments are made to physicians. Accounts receivable are recorded when defaults under the agreements occur and are evaluated for collectability.

NOTE 13 – CONTINGENCIES

Malpractice, workers’ compensation, and comprehensive general liability claims have been asserted against the District by various claimants. The claims are in various stages of processing and some may ultimately be brought to trial. There are also known incidents that have occurred through June 30, 2017, that may result in the assertion of additional claims. District management has accrued their best estimate of these contingent losses. D

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NOTE 13 – CONTINGENCIES (CONTINUED)

The health care industry is subject to numerous laws and regulations of federal, state, and local governments. Compliance with these laws and regulations can be subject to government review and interpretation, as well as regulatory actions unknown and unasserted at this time. Over the last several years, government activity has increased with respect to investigations and allegations concerning possible violations of regulations by health care providers, which could result in the imposition of significant fines and penalties as well as significant repayment of previously billed and collected revenue for patient services. Management believes that the District is in substantial compliance with current laws and regulations and that any potential liability arising from compliance issues have been properly reflected in the District’s consolidated financial statements or are not considered to be material to the District’s financial position and results of operations as of and for the year ended June 30, 2017. As disclosed in Note 1, the Medicare and Medi-Cal government reimbursement programs account for a substantial amount of the District’s net patient services revenue. Expenditure reduction efforts and budget concerns within the United States and California legislature continue to create uncertainty over the volume of future health care funding. It is at least reasonably possible that future reimbursements for patient services under these programs could be negatively impacted. The Recovery Audit Contractor (“RAC”) program detects and corrects past improper payments so that the Centers for Medicare and Medicaid Services (“CMS”), claims processing contractors, and providers can implement actions that will prevent future improper payments. The RAC operates to identify overpayments and underpayments made to providers. RACs may review the last three years of provider claims. With respect to audits performed by Health Data Insights (“HDI”), a RAC contractor operating as an agent of the Medicare Program, the District has received and responded to hundreds of medical record requests since February 2010. The primary audit focus has been on the appropriateness of billing certain services as an inpatient verses outpatient level of care and on coding accuracy, which drives the Diagnosis Related Group assignments and resulting payment. The District has vigorously appealed any disputed adverse findings it has received and in May 2017 entered into an Administrative Agreement with CMS to resolve the majority of the disputed RAC claims outstanding at that time. As of June 30, 2017 and 2016, the District has recorded accounts receivable of $6,392,000 and $5,900,000, respectively, representing management’s estimate of amounts ultimately expected to be recovered through the settlement and appeal processes. The $5,773,000 estimated to be settled with CMS is classified in current assets as other accounts receivable at June 30, 2017, while remaining amounts to be appealed as of June 30, 2017 and all RAC amounts receivable as of June 30,2016 are classified as other long-term assets in the consolidated statement of net position.

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NOTE 14 – INTERGOVERNMENTAL AND DIRECT GRANT SUPPLEMENTAL PAYMENT PROGRAMS

The District participates in various supplemental payment programs administered by the State of California including intergovernmental transfer and direct grant funding mechanisms. A summary of these programs is as follows. The District receives payments under the Quality Assurance Fee (“QAF”) Managed Care Medi-Cal payment program. The California Hospital Fee Program (the “Program”) was signed into law by the Governor of California and became effective on April 1, 2009. The Program is ongoing but requires an extension or revision of the methodology approved by CMS periodically. The Program required a “hospital fee” or “Quality Assurance Fee” (“QA Fee”) to be paid by certain hospitals to a state fund established to accumulate the assessed QA Fees and receive matching federal funds. QA Fees and corresponding matching federal funds are then paid to participating hospitals in two supplemental payment methodologies: a fee-for-service methodology and a managed care plan methodology. In the 2009-10 Program, the District, as a non-designated public hospital (“NDPH”) in California, was not subject to the QA Fee assessment according to the legislation, but rather received net supplemental payments. The Program evolved in 2010 through 2014 with District hospitals participating in a variety of ways. Currently, legislation for the Program that ran from January 1, 2014 through December 31, 2016 allows for direct grant funding for rural District hospitals and additional funding available in the form of Intergovernmental Transfer (“IGT”) payments offered for a match of funding. A new program is in the process of being outlined with the State that will provide for direct grants for all District hospitals as well as the IGT-generated funding. This new QAF program is expected to run from January 1, 2017 through June 30, 2019, once approvals are obtained from the State and federal regulatory agencies. In fiscal years 2017 and 2016, the District recognized QAF program related net patient services revenue of $14.8 million and $12.6 million, respectively. The District also receives AB113 IGT FFS Medi-Cal Inpatient payments. Legislation in March 2011 (“SB 90”) extended the QAF Program for the period from January 1, 2011 through June 30, 2011; however, the extension under SB 90 included only private hospitals and thus excluded the District related to the FFS portion of the QAF Program. As an alternative, the NDPG IGT Program was established under AB 113 in 2011 to allow NDPH facilities to access additional federal funds. Under this legislation, the District recognized net patient services revenue of $4.3 million and $6.7 million related to this program for the years ended June 30, 2017 and 2016, respectively. Additionally, the District receives “Rate Range” IGT Managed Medi-Cal payments. Federal rules allow that NDPH facilities may access managed care rate range room as determined by negotiations with Medi-Cal managed care plans. As defined by law, rate range room is the difference between the amount that the State pays the managed care plans, referred to as a “lower bound” rate, and the maximum allowed, or the “upper bound” rate. This difference, or rate range, is then available through supplemental IGT payments to public entities that participate in the program in each county. The District recognized net patient services revenue of $4.3 million and $6.7 million related to this program in fiscal years 2017 and 2016, respectively.

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NOTE 14 – INTERGOVERNMENTAL AND DIRECT GRANT SUPPLEMENTAL PAYMENT PROGRAMS (CONTINUED)

The Public Hospital Redesign and Incentives in Medi-Cal (“PRIME”) program was approved as a part of the Medi-Cal 2020 Section 1115 demonstration waiver. The program participants include both designated public hospitals and district and municipal public hospitals. PRIME supported activities encourage participants to improve the manner in which care is delivered in order to maximize health care value and also to position participants to successfully transition managed care payments to alternative payment methodologies. The District’s participation in the program in 2016, its initial year of participation, and 2017 included creating the five-year implementation plan, completing related process measures and developing PRIME project infrastructure. Future years’ participation includes submission of baseline data and the measurement and achievement of quality improvement metrics. The State’s share of the Medi-Cal funding for the PRIME program is furnished by IGT’s from the participants. The District recognized other operating revenue of $15.6 million and $3.9 million related to the PRIME program in fiscal years 2017 and 2016, respectively.

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SUPPLEMENTAL PENSION INFORMATION

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The following table summarizes the number of total plan participants:

2017 2016

Active employees 834 880 Terminated vested 993 996 Retirees receiving benefits 715 672

Total participants 2,542 2,548

June 30,

The following table summarizes changes in net pension liability from July 1, 2016 to June 30, 2017:

2017 2016Total pension liability

Service cost 90,092$ 90,092$ Interest 19,275,012 17,720,849 Differences between expected and actual experience 5,563,001 - Changes in assumptions (2,957,958) 11,817,557 Benefit payments (11,333,243) (10,577,037)

Net change in total pension liability 10,636,904 19,051,461 Total pension liability, beginning of the year 246,604,259 227,552,798

Total pension liability, end of the year 257,241,163 246,604,259

Plan fiduciary net positionEmployer contributions 9,000,000 5,000,001 Net investment income 24,286,375 (680,601) Benefit payments (11,333,243) (10,577,037) Administrative expenses (242,282) (745,337)

Net change in plan fiduciary net position 21,710,850 (7,002,974) Plan fiduciary net position, beginning of the year 183,780,944 190,783,918

Plan fiduciary net position, end of the year 205,491,794 183,780,944

Net pension liability, end of the year 51,749,369$ 62,823,315$

Plan fiduciary net position as percentage of total pension liability 79.88% 74.52%

Covered employee payroll N/A N/ANet pension liability as percent of covered payroll N/A N/A

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The District’s actuarially determined contribution and actual contributions, since 2008 are presented in the following table:

ActualContribution

Actuarially Contribution as a PercentageDetermined Actual Excess Covered of CoveredContribution Contribution (Deficiency) Payroll Payroll

Fiscal Year Ended2008 8,612,952$ 9,341,143$ 728,191$ 72,727,071$ 12.8%2009 10,089,712 10,091,082 1,370 70,003,288 14.4%2010 12,909,875 12,911,247 1,372 66,642,031 19.4%2011 11,324,298 11,325,664 1,366 N/A N/A2012 2,233,412 2,234,786 1,374 N/A N/A2013 4,093,248 4,094,618 1,370 N/A N/A2014 3,971,905 4,058,364 86,459 N/A N/A2015 2,672,587 3,720,167 1,047,580 N/A N/A2016 3,223,884 5,000,001 1,776,117 N/A N/A2017 6,879,390 9,000,000 2,120,610 N/A N/A

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Acronyms in this Presentation • LOS- Length of Stay • CHF- Congestive Heart Failure • WBC- White Blood Cells • UTI- Urinary Tract Infection • Acute ABD – Acute Abdomen • SBP- Spontaneous Bacterial

Peritonitis • INR- International Normalized

Ratio • PTT- Partial Thromboplastin

Time • SIRS- Systemic Inflammatory

Response Syndrome • EHR- Electronic Health Record

• AHRQ- Agency for Healthcare Research and Quality

• ABX- Antibiotics • BP- Blood Pressure • MAP- Mean Arterial Pressure • CVP- Central Venous

Pressure • US - ultrasound • VS- Vital Signs • LA- lactic acid • RRT- Rapid Response Team • SOV- Signs of Vitality • VBG- Venous Blood Gases

Why Focus on SEPSIS?

• Mortality up to 40% • 6% of hospital admissions

• 10% of hospital readmissions • 20% of hospital mortality • 50% longer LOS than CHF

• Delay in care increases mortality by 8% / hour delay

Cost of Sepsis

• $24 billion annually (AHRQ 2016) • Most expensive condition in U.S. healthcare • KDMC: Avg LOS 7.7 days 1056 cases in 2016 Direct Cost/Case $12,258 Direct Cost/Day $1667 $1.76 million – saved by 1 day ↓LOS

Sepsis Quality Focus Team Restructure – February 2016

Team Purpose Achieve early detection and treatment of severe sepsis and septic shock as outlined in sepsis core measure bundle as well as decrease LOS and mortality Team Goals Achieve 80% compliance of SEP 1 – Early Management Bundle in 12 months.

Team Members Dr. Gray, Dr. J. Javed, Dr. Malli, Dr. Said, Residents, Emergency Department, Pharmacy, Clinical Documentation Improvement, Advance Practice Nurses, ICU Department, Clinical Educators, Quality & Patient Safety, Rapid Response Team

SIRS Infection Organ Dysfunction

Severe Sepsis

Severe Sepsis

Systemic Inflammatory Response Syndrome

• 2 Or More • Temp >101 or <96.8 • Heart Rate >90 bpm • Resp Rate >20 • Altered Level of

Consciousness • WBC > 12,000/mm3

or < 4,000/mm3 or >10% bands

Infection Examples

UTI Pneumonia Cellulitis Appendicitis Meningitis Acute Abd Osteomyelitis C-Diff

Organ Dysfunction •Systolic blood pressure <90, or MAP <65, or SBP decrease of more than 40 mmHg from baseline •Acute respiratory failure as evidenced by increase oxygen needs such as BiPAP or mechanical ventilation. •Creatinine >2.0, or urine output <0.5mL/kg/hour for 2 hours •Bilirubin >2mg/dl (34.2mmol/L) •Platelet count <100,000 •INR >1.5 or aPTT >60 sec •Lactate >2mmol/L

Severe Sepsis

Refractory SBP <90 despite

fluid resuscitation

&/or LA>4

Septic Shock

Septic Shock

Sep-1 Early Management Bundle

Three Hours

• Blood Culture prior to ABX • Lactic Acid & REPEAT in 6 hours if

elevated (>2) • Broad Spectrum Antibiotics • Septic Shock – 30ml/kg crystalloid

fluids (MUST DOCUMENT WEIGHT THAT YOU USED TO CALULATE FLUIDS – IT CAN BE AN ESTIMATED WEIGHT)

Six Hours • If hypotension persists after fluid

administration • (Hypotension defined as two

consecutive BP of SBP< 90, Map < 65, or change by 40 from baseline)

• Vasopressors • Reassessment (any two)

– CVP – SvO2 – Bedside Cardiovascular US – Passive Leg Raise

• OR – Focus Exam – by physician

• VS, Cardiopulmonary, Cap refill, skin, & peripheral pulse

KDHCD vs Midas Benchmark

Severe Sepsis Bundle Measures Sepsis Core Measure Performance Report CY 2017

January February March April May June July Goal

Total Severe Sepsis Cases 11 15 14 15 14 13 13

Severe Sepsis

Core Management Bundle 55% 60% 64% 57% 54% 69% 46% 80% 3 Hour Bundle 91% 87% 100% 79% 100% 92% 85% 80% 1. Lactate Management 3 Hours 100% 100% 100% 93% 100% 100% 92% 2. Blood Cultures 3 Hours 100% 87% 100% 93% 100% 93% 92% 3. ABX 3 Hours 91% 100% 100% 93% 100% 100% 100% 4. Repeat Lactic 6 Hours if First LA> 2 88% 73% 57% 91% 50% 100% 78% 80%

Septic Shock

Total Severe + Septic Shock cases 3 2 3 2 3 6 3 5. Fluid Resuscitation (30ml/kg) 3 Hours 100% 100% 100% 100% 100% 91% 33% 80% 6. Vasopressors 6 Hours 100% NA 0% NA NA 100% NA 80% 7. Reassessment 6 Hours 50% 50% NA 0% 0% 60% 100% 80%

Total Mortality 1 0 1 3 0 1 0

Achievements of Sepsis QFT

• Monthly review of data and case reviews • Fallout letters • Sepsis hero letters • Test piloted sepsis screening tool • Nursing and physician education • Developed current physician order sets

Next Steps - Cerner

• Screening of all patients with St Johns Sepsis Early Alert System

• Automatic computer alerts to bedside RN’s when patient meets severe sepsis

• Real time severe sepsis alerts via smartphone to Quality Department

• Automatic tracking of compliance with sepsis bundle

• Refining physician order sets

Next Steps - Other

• Structured admission criteria and management of severe sepsis patients

• Establish Sepsis Coordinator

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KAWEAH DELTA HEALTH CARE DISTRICT (the “District”) FINANCE DIVISION MEMORANDUM TO: Finance Committee, Board of Directors, Chief Executive Officer and Executive Team FROM: Malinda Tupper, Interim Chief Financial Officer Jennifer Stockton, Director of Finance DATE: October 12, 2017 SUBJECT: 2017C Refunding Revenue Bonds Preliminary Resolution On October 23, 2017, the District’s Board of Directors (the “Board”) will be asked to approve Resolution No. 1970 authorizing certain officers of the District to take steps necessary for the issuance of refunding revenue bonds (the “2017C Refunding Bonds”) in an amount necessary to provide for the refunding of a portion of the District’s outstanding 2012 Bonds and all of the outstanding Siemens Lease obligation (the “Debt to be Refunded”). Adoption of this resolution does not give management the authority to issue the 2017C Refunding Bonds as final authority for issuance of the 2017C Refunding Bonds is expected to be sought at the Board’s meeting on November_29, 2017, and will be contingent upon the facts, circumstances and conditions that exist at that time. Information regarding the Debt to be Refunded is provided below as background information: 2012 Siemens Bonds Lease Proposed Refunding Amount $46,010,000 $12,033,000 Interest Rates 3.60%-4.65% 4.15% Final Bond Maturity 2042 2021 Use of Funds Refi & Const. Refi Refunding Type Current Current Call Premium 102% 101.5% Management believes that favorable tax-exempt interest rates currently available offer the District an opportunity to generate significant debt service savings relative to the Debt to be Refunded. While interest rates for underwritten bonds are not determined until the bonds are actually sold, the current interest rate environment suggests a possible weighted-average interest rate of approximately 2.65% for a private placement for a 15-year maturity tax-exempt bonds based upon discussions with selected trading desks and prospective bank purchasers. We will work with the District to secure a commitment from one or more bank purchaser(s) or an acceptable underwriter to purchase the 2017C Refunding Bonds that would also provide an interest rate lock for up to 30 days prior to closing of the proposed refinancing if from a bank purchaser. Without increasing the average weighted maturity of the Debt to be Refunded, we estimate that total debt service savings over the remaining life of the Debt to be Refunded to be approximately $8.9 million (approximately $6.2 million on a present-value basis), or 10.4% of the par amount of debt being refunded, based on current market conditions. This estimated savings, if achieved, will also reduce the District’s maximum annual debt service by approximately $351,000 annually and will resolve the balloon payment coming due on the Siemens Lease well in advance of its maturity date of April 1, 2021. We have evaluated both a public offering

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and a private placement of the 2017C Refunding Bonds and have concluded that a private placement would be more advantageous for the District. The following summarizes the purpose and general content of the preliminary resolution to be reviewed by the Board on October 23, 2017. Resolution No. 1970. The preliminary resolution allows management of the District to proceed forward with the proposed refinancing and is preliminary to the final resolution planned to be considered for approval by the Board at its meeting in November 29, 2017, subject to the facts, circumstances and conditions that exist at that time. The preliminary resolution describes the use of proceeds of the 2017C Refunding Bonds, establishes a limit as to the principal amount of bonds authorized to be issued and establishes a not-to-exceed final maturity for the 2017C Refunding Bonds. The preliminary resolution authorizes the President of the Board, the District’s Chief Executive Officer, its Chief Financial Officer, and/or its Director of Finance to take any and all necessary action needed to carry out the intended purposes of this preliminary resolution but not to commit the District to sell bonds. For any questions regarding the documents, please contact Malinda Tupper at 624-4065 or Jennifer Stockton at 624-5536.

Aug 15, 2017 11:58 am Page 1

SOURCES AND USES OF FUNDS

Kaweah Delta Health Care District(Tulare County, California)

Revenue Refunding Bonds, Series 2017APRELIMINARY - Assumes Private Placement

Dated Date 12/05/2017Delivery Date 12/05/2017

Siemens Lease Series 2012Sources: Refunding Refunding Total

Bond Proceeds:Par Amount 12,285,000.00 47,205,000.00 59,490,000.00

12,285,000.00 47,205,000.00 59,490,000.00

Siemens Lease Series 2012Uses: Refunding Refunding Total

Refunding Escrow Deposits:Cash Deposit 12,218,265.20 46,951,148.36 59,169,413.56

Cost of Issuance:Total Cost of Issuance 51,626.32 198,373.68 250,000.00Placement Agent 14,455.37 55,544.63 70,000.00

66,081.69 253,918.31 320,000.00

Other Uses of Funds:Additional Proceeds 653.11 (66.67) 586.44

12,285,000.00 47,205,000.00 59,490,000.00

Aug 15, 2017 11:58 am Page 2

BOND DEBT SERVICE



PeriodEnding Principal Coupon Interest Debt Service

06/01/2018 166,000 2.650% 770,726.00 936,726.0006/01/2019 650,000 2.650% 1,572,086.00 2,222,086.0006/01/2020 660,000 2.650% 1,554,861.00 2,214,861.0006/01/2021 1,127,000 2.650% 1,537,371.00 2,664,371.0006/01/2022 3,547,000 2.650% 1,507,505.50 5,054,505.5006/01/2023 7,786,000 2.650% 1,413,510.00 9,199,510.0006/01/2024 7,983,000 2.650% 1,207,181.00 9,190,181.0006/01/2025 5,255,000 2.650% 995,631.50 6,250,631.5006/01/2026 4,803,000 2.650% 856,374.00 5,659,374.0006/01/2027 4,921,000 2.650% 729,094.50 5,650,094.5006/01/2028 5,045,000 2.650% 598,688.00 5,643,688.0006/01/2029 5,175,000 2.650% 464,995.50 5,639,995.5006/01/2030 791,000 2.650% 327,858.00 1,118,858.0006/01/2031 811,000 2.650% 306,896.50 1,117,896.5006/01/2032 10,770,000 2.650% 285,405.00 11,055,405.00

59,490,000 14,128,183.50 73,618,183.50

Aug 15, 2017 11:58 am Page 3

BOND SUMMARY STATISTICS



Dated Date 12/05/2017Delivery Date 12/05/2017Last Maturity 06/01/2032

Arbitrage Yield 2.650024%True Interest Cost (TIC) 2.650024%Net Interest Cost (NIC) 2.650000%All-In TIC 2.719198%Average Coupon 2.650000%

Average Life (years) 8.962Duration of Issue (years) 7.907

Par Amount 59,490,000.00Bond Proceeds 59,490,000.00Total Interest 14,128,183.50Net Interest 14,128,183.50Total Debt Service 73,618,183.50Maximum Annual Debt Service 11,055,405.00Average Annual Debt Service 5,081,009.60

Underwriter's Fees (per $1000) Average Takedown Other Fee

Total Underwriter's Discount

Bid Price 100.000000

Par Average AverageBond Component Value Price Coupon Life

Term Bond 59,490,000.00 100.000 2.650% 8.962

59,490,000.00 8.962

All-In ArbitrageTIC TIC Yield

Par Value 59,490,000.00 59,490,000.00 59,490,000.00 + Accrued Interest + Premium (Discount) - Underwriter's Discount - Cost of Issuance Expense (320,000.00) - Other Amounts

Target Value 59,490,000.00 59,170,000.00 59,490,000.00

Target Date 12/05/2017 12/05/2017 12/05/2017Yield 2.650024% 2.719198% 2.650024%

Aug 15, 2017 11:58 am Page 4

SAVINGS



Present ValuePrior Refunding to 12/05/2017

Date Debt Service Debt Service Savings @ 2.6500240%

06/01/2018 1,291,480.54 936,726.00 354,754.54 352,116.3106/01/2019 2,576,736.06 2,222,086.00 354,650.06 351,120.6406/01/2020 2,568,436.06 2,214,861.00 353,575.06 341,003.0406/01/2021 13,813,815.22 2,664,371.00 11,149,444.22 10,226,089.2906/01/2022 1,885,352.50 5,054,505.50 (3,169,153.00) (2,813,695.47)06/01/2023 6,030,352.50 9,199,510.00 (3,169,157.50) (2,740,053.03)06/01/2024 6,021,132.50 9,190,181.00 (3,169,048.50) (2,668,448.24)06/01/2025 6,017,587.50 6,250,631.50 (233,044.00) (188,178.46)06/01/2026 6,013,867.50 5,659,374.00 354,493.50 286,426.5806/01/2027 6,004,272.50 5,650,094.50 354,178.00 278,468.7106/01/2028 5,998,272.50 5,643,688.00 354,584.50 271,237.1806/01/2029 5,994,912.50 5,639,995.50 354,917.00 264,094.3406/01/2030 1,473,192.50 1,118,858.00 354,334.50 256,433.6706/01/2031 1,471,855.00 1,117,896.50 353,958.50 249,435.8006/01/2032 1,473,585.00 11,055,405.00 (9,581,820.00) (6,542,056.02)06/01/2033 1,468,130.00 1,468,130.00 978,723.2006/01/2034 1,385,670.00 1,385,670.00 899,689.0506/01/2035 1,384,507.50 1,384,507.50 875,407.0606/01/2036 1,386,082.50 1,386,082.50 853,452.8306/01/2037 1,384,622.50 1,384,622.50 830,219.5206/01/2038 1,381,092.50 1,381,092.50 806,402.3606/01/2039 1,384,942.50 1,384,942.50 787,444.0006/01/2040 1,381,235.00 1,381,235.00 764,736.2806/01/2041 1,385,202.50 1,385,202.50 746,804.1206/01/2042 1,381,380.00 1,381,380.00 725,189.48

82,557,715.38 73,618,183.50 8,939,531.88 6,192,062.21

Savings Summary

PV of savings from cash flow 6,192,062.21Plus: Refunding funds on hand 586.44

Net PV Savings 6,192,648.65

Aug 15, 2017 11:58 am Page 5

SUMMARY OF REFUNDING RESULTS



Siemens Lease Series 2012Refunding Refunding Total

Dated Date 12/05/2017 12/05/2017 12/05/2017Delivery Date 12/05/2017 12/05/2017 12/05/2017Arbitrage Yield 2.650024% 2.650024% 2.650024%Escrow YieldValue of Negative Arbitrage

Bond Par Amount 12,285,000.00 47,205,000.00 59,490,000.00True Interest Cost 2.650044% 2.650021% 2.650024%Net Interest Cost 2.650000% 2.650000% 2.650000%All-In TIC 2.776568% 2.711885% 2.719198%Average Coupon 2.650000% 2.650000% 2.650000%Average Life 4.576 10.103 8.962

Par amount of refunded bonds 12,032,233.50 46,010,000.00 58,042,233.50Average coupon of refunded bonds 4.150000% 4.248084% 4.241478%Average life of refunded bonds 3.232 11.704 9.947

PV of prior debt 12,601,359.87 53,080,702.35 65,682,062.21Net PV Savings 317,002.54 5,875,646.12 6,192,648.66Percentage savings of refunded bonds 2.634611% 12.770368% 10.669212%Percentage savings of refunding bonds 2.580403% 12.447084% 10.409562%

Aug 15, 2017 11:58 am Page 6

SUMMARY OF BONDS REFUNDED



Maturity Interest Par Call CallBond Date Rate Amount Date Price

$75,800,000 Revenue and Refunding Bonds, Series 2012:SERIAL 06/01/2023 3.600% 4,145,000.00 12/05/2017 102.000

06/01/2024 3.700% 4,285,000.00 12/05/2017 102.00006/01/2025 3.800% 4,440,000.00 12/05/2017 102.00006/01/2026 3.900% 4,605,000.00 12/05/2017 102.00006/01/2027 4.000% 4,775,000.00 12/05/2017 102.00006/01/2028 4.100% 4,960,000.00 12/05/2017 102.00006/01/2029 4.200% 5,160,000.00 12/05/2017 102.00006/01/2030 4.250% 855,000.00 12/05/2017 102.00006/01/2031 4.300% 890,000.00 12/05/2017 102.00006/01/2032 4.350% 930,000.00 12/05/2017 102.00006/01/2033 4.400% 965,000.00 12/05/2017 102.00006/01/2034 4.450% 925,000.00 12/05/2017 102.00006/01/2035 4.500% 965,000.00 12/05/2017 102.000

2037TERM 06/01/2037 4.600% 2,065,000.00 12/05/2017 102.0002042TERM 06/01/2042 4.650% 6,045,000.00 12/05/2017 102.000

46,010,000.00

$12,300,000 2011 Siemens Lease:TERM 04/01/2021 4.150% 12,032,233.50 12/05/2017 101.500

58,042,233.50

Aug 15, 2017 11:58 am Page 7

ESCROW REQUIREMENTS



Period Principal RedemptionEnding Interest Redeemed Premium Total

12/05/2017 26,496.56 58,042,233.50 1,100,683.50 59,169,413.56

26,496.56 58,042,233.50 1,100,683.50 59,169,413.56

Aug 15, 2017 11:58 am Page 8

DISCLAIMER



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The information contained herein may include hypothetical interest rates or interest rate savings for a potential refunding. Interest rates used herein take into consideration conditions in today's market and other factual information such as credit rating, geographic location and market sector. Interest rates described herein should not be viewed as rates that Piper Jaffray expects to achieve for you should we be selected to act as your underwriter or placement agent. Information about interest rates and terms for SLGs is based on current publically available information and treasury or agency rates for open-market escrows are based on current market interest rates for these types of credits and should not be seen as costs or rates that Piper Jaffray could achieve for you should we be selected to act as your underwriter or placement agent. More particularized information and analysis may be provided after you have engaged Piper Jaffray as an underwriter or placement agent or under certain other exceptions as described in Section 15B of the Exchange Act.

FiscalYear RBS Siemens KDMF Cisco 2006 2011B 2012 2015A 2015B 2017 Total

2017 2,327,329 503,488 267,988 272,101 651,920 100,885 6,048,853 1,459,954 4,140,563 267,584 16,040,664 2018 2,327,329 699,684 267,988 272,101 6,038,353 1,144,681 4,140,563 1,149,927 16,040,625 2019 2,327,329 691,384 267,988 272,101 6,035,603 1,165,485 4,140,563 1,139,918 16,040,371 2020 1,745,495 683,084 264,835 6,034,853 1,641,200 4,140,563 1,530,169 16,040,197 2021 11,928,463 130,669 6,025,603 1,876,079 4,140,563 2,734,718 26,836,094 2022 47,645 6,032,853 628,468 4,140,563 1,667,772 12,517,300 2023 6,030,353 626,592 4,140,563 1,719,648 12,517,155 2024 6,021,133 636,577 4,140,563 1,719,158 12,517,429 2025 6,017,588 2,156,086 4,140,563 3,138,922 15,453,158 2026 6,013,868 3,069,916 4,140,563 2,815,902 16,040,247 2027 6,004,273 4,297,802 4,140,563 1,598,046 16,040,682 2028 5,998,273 4,421,213 4,140,563 1,480,612 16,040,660 2029 5,994,913 4,655,563 5,390,158 16,040,633 2030 1,473,193 4,598,825 9,968,308 16,040,326 2031 1,471,855 4,618,388 9,950,271 16,040,514 2032 1,473,585 4,631,175 6,104,760 2033 1,468,130 4,647,275 6,115,405 2034 1,385,670 4,052,150 5,437,820 2035 1,384,508 10,732,150 12,116,658 2036 1,386,083 10,731,650 12,117,733 2037 1,384,623 10,734,450 12,119,073 2038 1,381,093 10,736,050 12,117,143 2039 1,384,943 10,736,050 12,120,993 2040 1,381,235 10,737,300 12,118,535 2041 1,385,203 10,733,800 12,119,003 2042 1,381,380 10,736,600 12,117,980 2043 12,120,400 12,120,400 2044 12,119,400 12,119,400 2045 12,121,200 12,121,200

Total 8,727,481 14,506,101 1,247,114 816,304 651,920 100,885 96,638,010 23,124,052 199,129,175 46,271,114 391,212,156

Kaweah Delta Health Care DistrictAggregate Debt Service

Capital Leases Revenue Bonds

Current Situation

FiscalYear RBS Siemens KDMF Cisco 2006 2011B 2012 2015A 2015B 2017 2017A Total

2017 2,327,329 503,488 267,988 272,101 651,920 100,885 6,048,853 1,459,954 4,140,563 267,584 16,040,664 2018 2,327,329 350,879 267,988 272,101 5,095,676 1,144,681 4,140,563 1,149,927 936,726 15,685,871 2019 2,327,329 - 267,988 272,101 4,150,250 1,165,485 4,140,563 1,139,918 2,222,086 15,685,721 2020 1,745,495 - 264,835 4,149,500 1,641,200 4,140,563 1,530,169 2,214,861 15,686,622 2021 - 130,669 4,140,250 1,876,079 4,140,563 2,734,718 2,664,371 15,686,650 2022 47,645 4,147,500 628,468 4,140,563 1,667,772 5,054,506 15,686,453 2023 - 626,592 4,140,563 1,719,648 9,199,510 15,686,312 2024 - 636,577 4,140,563 1,719,158 9,190,181 15,686,478 2025 - 2,156,086 4,140,563 3,138,922 6,250,632 15,686,202 2026 - 3,069,916 4,140,563 2,815,902 5,659,374 15,685,754 2027 - 4,297,802 4,140,563 1,598,046 5,650,095 15,686,504 2028 - 4,421,213 4,140,563 1,480,612 5,643,688 15,686,075 2029 - 4,655,563 5,390,158 5,639,996 15,685,716 2030 - 4,598,825 9,968,308 1,118,858 15,685,991 2031 - 4,618,388 9,950,271 1,117,897 15,686,555 2032 - 4,631,175 11,055,405 15,686,580 2033 - 4,647,275 4,647,275 2034 - 4,052,150 4,052,150 2035 - 10,732,150 10,732,150 2036 - 10,731,650 10,731,650 2037 - 10,734,450 10,734,450 2038 - 10,736,050 10,736,050 2039 - 10,736,050 10,736,050 2040 - 10,737,300 10,737,300 2041 - 10,733,800 10,733,800 2042 - 10,736,600 10,736,600 2043 12,120,400 12,120,400 2044 12,119,400 12,119,400 2045 12,121,200 12,121,200

Total 8,727,481 854,367 1,247,114 816,304 651,920 100,885 27,732,029 23,124,052 199,129,175 46,271,114 73,618,184 382,272,624

Kaweah Delta Health Care DistrictAggregate Debt ServiceAfter Refunding (Private Placement - Full Refunding of Series 2012 Bonds / Full Refunding of Siemens Lease)

Capital Leases Revenue Bonds

Draft


RESOLUTION NO. ____

____________________________________________________

A RESOLUTION OF THE BOARD OF DIRECTORS OF KAWEAH DELTA HEALTH CARE DISTRICT AUTHORIZING CONSIDERATION FOR THE ISSUANCE OF REVENUE REFUNDING BONDS PURSUANT TO THE CALIFORNIA HEALTH AND SAFETY CODE AND THE CALIFORNIA GOVERNMENT CODE.

______________________________________________________

WHEREAS, the Board of Directors (the “Board”) of Kaweah Delta Health Care District

(the “District”) is authorized to issue its revenue refunding bonds pursuant to the Local Health Care District Law of the State of California, as set forth in the California Health and Safety Code, and the California Government Code to provide funds for the refunding of a portion of the outstanding principal amount of the Kaweah Delta Health Care District (Tulare County, California) Revenue and Refunding Bonds, Series 2012, issued on July 17, 2012, and the Kaweah Delta Health Care District Master Lease Purchase Agreement with Siemens Public, Inc., issued on April 20, 2011 (the “Debt to be Refunded”), and the payment of costs of issuance thereof,

NOW, THEREFORE, BE IT RESOLVED by the Board as follows:

Section 1. The District is a local health care district and a political subdivision organized and existing pursuant to the Local Health Care District Law of the State of California as set forth in Sections 32000 et. seq. of the California Health and Safety Code. The District currently owns and operates health care facilities within and outside the boundaries of the District in Tulare County, California.

Section 2. The Board has received information indicating that it may be in the best interests of the District to issue its Kaweah Delta Health Care District (Tulare County, California) Revenue Refunding Bonds, Series 2017C (the “Series 2017C Refunding Bonds”) to provide funds for the refunding of the outstanding aggregate principal amount of the Debt to be Refunded and paying the costs of issuance of the Series 2017C Refunding Bonds. The information suggests that the Series 2017C Refunding Bonds would generate both overall and present value debt service savings for the District. The Series 2017C Refunding Bonds would be issued pursuant to a Resolution of the Board Authorizing the Issuance and Sale of its Kaweah Delta Health Care District (Tulare County, California) Revenue Refunding Bonds, Series 2017C, the Execution and Delivery of a Depository Trust Agreement, and certain related matters (collectively, the “Authorization”), and would be secured by and payable from a revenue fund pledge of the District, and would have such terms, conditions and provisions, as set forth in the Authorization.

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Section 3. If authorized and issued, the Series 2017C Refunding Bonds and all obligations of the District with respect thereto would be and remain special obligations of the District payable from a revenue fund pledge of the District.

Section 4. If authorized and issued, the Series 2017C Refunding Bonds would be secured by a revenue fund pledge of the District. No recourse could be had for the payment of the principal of or interest on the Series 2017C Refunding Bonds or for any claim based thereon against any member, officer or employee of the District or any person executing the Series 2017C Refunding Bonds.

Section 5. If authorized and issued, i) the principal amount of the Series 2017C Refunding Bonds would not exceed the amount necessary to provide for the refunding of the Bonds to be Refunded and the costs of issuing the Series 2017C Refunding Bonds, and ii) the final maturity of the Series 2017 Refunding Bonds would not exceed June 1, 2037.

Section 6. The President of the Board, the Chief Executive Officer, the Chief Financial Officer and the Director of Finance for the District, and such other District personnel as may be directed by any of the foregoing are each hereby authorized, empowered and directed, for and on behalf of the District, to take any and all actions necessary or appropriate in order to further the intent of this Resolution.

Section 7. This Resolution will take effect immediately.

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THE FOREGOING RESOLUTION WAS PASSED AND ADOPTED by the Board of Directors of Kaweah Delta Health Care District on October __, 2017, by the following vote:

AYES: Directors: ____________________________________________

NOES: Directors: ___

ABSENT:

Carl Anderson President, Board of Directors Kaweah Delta Health Care District

Attest: Lynn Havard Mirviss Secretary-Treasurer, Board of Directors Kaweah Delta Health Care District