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UPPER CHESAPEAKE HEALTH SELF-LEARNING PROGRAM ANNUAL SAFETY EDUCATION PROGRAM December 2011 Fire, Safety, Infection Control, TB, Legal Compliance, HIPAA ... – PowerPoint PPT presentation

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  • December 2011
  • Fire, Safety, Infection Control, TB, Legal
    Compliance, HIPAA, Communication Assistance, Risk
    Management, Occupational Health Team Member
    Injury Reporting, Patient Safety, and other
    important information including the Management of
    Unsafe Behavior Supplement for those requiring
    this update/review.

  • UCH is accredited by The Joint Commission
  • The Joint Commission standards deal with quality
    of care issues and the safety of the environment
    in which the care is provided.
  • When an individual has concerns about patient
    care and safety in the hospital, that the
    hospital has not addressed, he or she is
    encouraged to contact the hospitals management.
  • If the concerns cannot be resolved through the
    hospital, the individual is encouraged to contact
    The Joint Commission
  • You may address your concerns to
  • Division of Accreditation Operations
  • Office of Quality Monitoring
  • The Joint Commission
  • One Renaissance Boulevard
  • Oakbrook Terrace, IL 60181
  • You may also send the concerns by
  • Fax 630.792.5636
  • Telephone 1.800.994.6610
  • Email complaint_at_jointcommission.org
  • Medical staff and team members reporting safety
    or quality of care concerns to The Joint
    Commission are immune from any disciplinary or
    punitive action taken by UCH.

PURPOSE To provide a review of pertinent Fire,
Safety, and Infection Control policies, patient
safety, and other information. The supplement
provides an annual review for those trained in
Management of Unsafe Behavior. To fulfill
regulatory and The Joint Commission requirements
for annual fire, safety, electrical safety and
infection control review, including AIDS,
Hepatitis and TB. OBJECTIVES After Reviewing
this Self-Learning Program or after attending an
appointment with the Education Resource
Development Department, the participant will be
able to Define the priority actions to take in
fire and exposure to hazardous substance and
chemical emergencies. State the purpose of MSDSs
in their work area. State the number one method
used to prevent the spread of infection. Verbalize
role in providing a safe environment for
patients, visitors, team members, and
self. Discuss the prevention and spread of AIDS,
Hepatitis B C, and TB. Discuss your role in
communication assistance and legal
compliance. For management of unsafe behavior,
discuss the alternatives to restraints.
  • Lynne Adams, Director, UCMC QHIM Privacy
  • Amy Myers, Safety Manager
  • Todd Dousa, Safety Coordinator
  • Debbie Bittle, Director of Risk Management
  • Ron Green, Director, Clinical Engineering
  • Colleen Clay, Director, Healthcare Epidemiology
    Infection Control
  • Barbara Finch, Director, Service Excellence and
    Resource Development
  • Thomas French, Director, Security Services
  • Jane Gordon, Director, HMH QHIM Privacy Officer
  • Diane Campbell, Education Specialist
  • Lisa Karmel, Director, Guest Services
  • Karen Linderborn, Education Specialist, Course
  • Mark Moody, Director, Occupational Health
  • Carolyn Phillips, Accreditation Coordinator
  • Cindy Triplett, Education Specialist

  • Emergency Information
  • Fire Plan Review
  • Hazard Communication
  • Infection Control Overview
  • Occupational Health Injury Reporting
  • Abuse Reporting
  • Legal Compliance Communication Assistance
  • HIPAA Privacy Security
  • Body Mechanics
  • Supplement Management of Unsafe Behavior
  • REFERENCES Available on UCH Intranet Reference
    Library/ Policy Libraries

Revised 6.01, 12.01, 12.02, 12/03, 11/04, 11/05,
11/06, 10.07, 10/08 , 12/09, 12/10
  • Review the 2011 SLP packet of information.
  • If you prefer to review the information with a
    member of the Education Resource Development
    Department team, please call for an appointment.
    (UCMC - 2900 or HMH - 5344)
  • Complete the Post-Test on-line or as a hard copy.
    You may use the SLP or any of the references as
    resources. If you need assistance, contact the
    Education Resource Development Department.
  • The ON-LINE post test is automatically graded and
    sent to the ERDD. If you did a hard copy of the
    post test you MUST RETURN the Post-Test answer
    sheet to the Education Resource Development
    Department office at UCMC or HMH immediately.
  • If you don't pass with an 80 your incorrect
    responses to the questions will be reviewed with
    you in writing/e-mail or in person by a member of
    the Education Resource Development Department.
  • Upon successful completion of the Post-Test you
    will receive 2 contact hours of education credit
    AND fulfill your requirement for ANNUAL MANDATORY

Dial 3333
Code Phone
  • THE NUMBER TO CALL on any Hospital Telephone to
  • GIVE the operator your name location and tell
    the nature of the emergency you are reporting!

  • CODE RED Fire, Smoke, or Excessive Heat -
  • Get fellow Team Members to help, pull the fire
    alarm AND dial 3333.
  • RACE and PASS help you remember what to do.
  • CODE BLUE A Cardiopulmonary Arrest, Adult
  • CODE BLUE C Cardiopulmonary Arrest, Child 8
    years old or younger
  • CODE PINK Attempted or Actual Infant/Child
  • CODE GREEN Disruptive or Combative Person
  • Requires response by team members and security
    to protect the person from harming self or others
  • Armed. Threatening person inside building
  • Called if someone threatens another person
    with a deadly weapon or shots are fired inside
    the building
  • CODE PURPLE Security Response Urgent
  • A security matter that requires only Security
    Officers to response. The matter is urgent, but
    not critical in nature

How do I access the Emergency Plans?
  • The Emergency Operations Plan is located in UCH
    Intranet from the UCH Intranet site home page,
    go to Resources at the top of the page and
    select Emergency Management (Code Yellow), 2010
    Emergency Operations Plan. This plan covers
    many internal and external events.
  • Some emergency situations are covered by separate
    plans. These include Bomb Threat, Fire (Code
    Red), Evacuation, Hazardous Materials Spill
    Infant/Child Abduction (Code Pink). These are
    found on the Intranet in the Reference Library
    under Policies Procedures in the Environment of
    Care Manual.
  • Know your role in a Disaster! REPORT to your
    department and follow the UCH and department
    Emergency Operations Plan.

What is Emergency Management?
  • POLICIES PROCEDURES are designed to do four
  • 1) MITIGATION actions to reduce the chance of
    or lessen the impact from a disaster event.
  • 2) PREPAREDNESS equipment, policies training
    to enable quick and effective response
  • 3) RESPONSE implementing plan in reaction to an
    unplanned event or drill in a coordinated,
    successful manner.
  • 4) RECOVERY getting back to normal business
    after a major disaster event.

Types of Emergencies / Disasters
1)EXTERNAL - The facility is not damaged, but it
requires the hospital to prepare for potential
impacts, including loss of power, reduction of
external services or the potential to receive any
casualties. Examples are hurricanes, floods,
tornadoes, radiation releases, civil disturbance,
building collapse or transportation
disasters. 2) INTERNAL - The facility has a
failure of a critical system that could
potentially affect patient care or normal
operations. Examples are fire, water shortages,
power loses, explosions, or acts of violence.
What is our PLAN?Written policies and procedures
assist us in responding to an emergency.
Drills are held at least twice a year to practice
a quick and appropriate response.
  • The GOALS
  • Prepare through training drills and awareness of
    the plan. KNOW your role as part of both the
    hospital plan and your departmental plan.
  • Manage resources and make decisions based on the
    needs of the community and our patients, working
    closely with local emergency agencies.
  • Give the best care to the greatest number of
    patients with a coordinated effort by all.

  • The BOMB THREAT PLAN advises team members in the
    steps to take in the event of a bomb threat. As
    a review, these are the steps you would take if
    you receive a BOMB Threat over the telephone
  • Try to keep the caller on the phone as long as
    possible, and
  • Ask questions to gather information, such as
    where exactly is the bomb located (questions to
    ask can be found in the yellow Environment of
    Care Quick Reference Chart).
  • Write down as much information as you can
    remember about the caller as well as specific
    information regarding the bomb.
  • Dial, or have a co-worker dial, 3333 immediately
    to report the situation.

Code Green Shelter in Place
  • Designates a Hostile Person and/or Possible
  • In the event of any dangerous criminal activity
    within our facilities, there may be an immediate
    need to communicate hospital-wide that everyone
    should seek shelter and avoid public areas.
  • Situations may include a hostile person, use of a
    deadly weapon, a shooting, a serious assault, an
    escaped forensic patient and/or a hostage
  • Team Members should find the closest lockable
    room and barricade inside far from the door.
    Cell phones should be set to vibrate or silent.

Code Green Shelter in Place
  • Take immediate action
  • Inform people in your immediate surroundings to
    follow you to a secure area, such as an office or
    the closest area that can be locked.
  • Team members that are not responsible for direct
    patient care should try to exit the building if
    not in the affected area. Clear clear public
    waiting rooms and hallways if in the immediate
  • DO NOT attempt to shut patient room doors as in a
    Code Red protect YOURSELF.
  • The cafeterias will be secured.
  • The gift shop and conference rooms in use should
    be secured by those inside these areas.
  • When hospital security has been advised by law
    enforcement and administration, an ALL CLEAR
    announcement will be made using overhead paging
    and text pagers. Once the incident is over,
    return to your workplace and report to your

  • Code PINK is an actual or attempted infant or
    child abduction.
  • All UCH team members will need to be watchful for
    ANYONE attempting to leave the unit/facility with
    an infant or child in any fashion.
  • ALL TEAM MEMBERS are to respond immediately to
    the nearest exit or hallway. BE ALERT for any
    suspicious person(s) carrying any package not
    just an infant or child!

  • To help all team members be more alert to the
    size of the child involved in the situation,
    the following is included when a CODE PINK is
    called . . .
  • If the child is less than one, state to the
    operator when calling the CODE PINK to announce
    Code Pink - Infant.
  • If the child is over the age of one, state to the
    operator when calling the CODE PINK to announce
    Code Pink Age ____ (state approximate age of

CODE PINK . . . Team Members should pay attention
to anyone
  • Physically carrying an infant instead of using a
  • Attempting to leave the facility with an infant
    on foot, rather than by wheelchair.
  • Carrying large packages (i.e. gym bag),
    particularly if they are "cradling" or "talking"
    to it.
  • Notify Security Services IMMEDIATELY, if you
    observe any such behavior. If the person is
    attempting to leave the building, try to prevent
    them from leaving.
  • Security Services phone numbers
  • HMH 5314 UCMC - 2444

If a CODE PINK is in effectExplain to all
visitors who are unable to exit the facility that
a security incident has taken place. Reassure
them they will be allowed to leave as soon as
possible and thank them for their cooperation.
Rapid Response Team (RRT)
  • The RRT is a team of clinicians assist with
    assessment and treatment of a patient that has
    had an acute change in his/her condition. The
    RRT can be called ANYTIME. An ICU Nurse, a
    Respiratory Therapist, and the Intensivist/PA/NP,
    if needed, after the ICU Nurse asses the patient,
    will respond. The Primary Nurse is always a part
    of the team. The Stroke Facilitator will also be
    contacted if a stroke is suspected.
  • Purpose The RRT is a patient safety strategy
    that can rescue patients when their conditions
    decline. It can reduce the number of code blues
    and the inpatient mortality rate.
  • To ACTIVATE the RRT dial ext 3333 and
  • request the Operator page the RRT.

Rapid Response Team (RRT)
  • The RRT will respond to a Rapid Response Team
    CALL in any location with the hospitals, and at
    UCMC on the ground floor of the ACC.
  • The RRT will assume responsibility for the
    treatment of the patient if he/she is an
  • The ED will also respond to RRT calls in
    ancillary departments as well as the UCMC ground
    floor the ED will assume responsibility for
    treatment of the patient is not an inpatient.
  • Patients and family members can call the RRT
    directly by dialing ext. 3339 from any hospital
    phone and asking the Operator to call the RRT to
    the patients room. Encourage patients and
    family members to call whenever the patient is in
    an emergency medical situation and is unable to
    get the attention of the nurse if there is a
    sudden worsening in the patients condition and
    the healthcare team is not present or if there
    is a breakdown in communication over what needs
    to be done to treat them.

Rapid Response Team (RRT)
  • There are additional Rapid Response Team
  • A Pediatric Rapid Response Team (PRRT) can be
    called when there is a need to assess a pediatric
    patient in any area of the hospital. A PRRT if
    for children and adolescents up to the age of 18.
    A PALS nurse and a Respiratory Therapist with
    ACLS responds. At UCMC a pediatric hospitalist,
    a pediatric nurse and the 1 West charge nurse
  • The STEMI RRT includes the Primary Nurse, ICU
    Nurse, RT, EKG Tech, IV Team Nurse, and the
    Intensivist as first responders. The ICU nurse
    is to take the STEMI medication box to the
  • The OB STAT Team can be called to respond to OB
    emergencies . The team is consists of designated
    Family BirthPlace team members as well as
    pediatric hospitalist, anesthesiologist,
    respiratory therapist and other clinical team
    members as needed.

RESPONDING to Emergencies for all other areas on
  • For All Other Areas on Campus Upper Chesapeake
    Health will provide immediate medical support and
    evaluation to those individuals requiring medical
    attention while on Upper Chesapeake facility
    grounds. The on-campus emergency response is
    intended to determine the need for medical
    treatment and provide for safe transport to an
    appropriate treatment area in a safe and timely
  • Notification This notification can come from
    hospital personnel, visitors, physicians, law
    enforcement agencies and guests passing through
    the campus.
  • Once a team member is notified of an emergent
    situation, they will contact the Switchboard by
    dialing extension 3333.
  • The Switchboard will call a Rapid Response to the
    location of the emergent event.
  • The Switchboard will then contact the Emergency
    Department and the Security Department (each will
    immediately respond to investigate the
    situation). The Switchboard will notify the
    Administrative Coordinator if on duty.
  • The Emergency Department and Security Department
    team members will respond to the area according
    to policy.
  • On campus emergency policy and procedure is being
    moved to the Rapid Response Policy and will soon
    be updated on the UCH Intranet Reference Library
  • If a UCH team member is either on or off duty,
    and encounters an emergency situation on the
    hospital premises, UCH requires the individual to
    assist in the emergency until relieved by the RRT
    or EMS.

FYI AEDs (Automatic External Defibrillators)
are now located in the ACC and the Physician
  • Every TEAM MEMBER MUST know and understand WHAT
    to do when a Code Red is called!
  • Every TEAM MEMBER MUST know and understand WHAT
    to do if they discover a Fire or Smoke!
  • Every TEAM MEMBER MUST know and understand WHAT
    to do if they smell or see smoke, or feel
    excessive heat in an area that should not be HOT!

There are 4 steps that are CRITICAL and can be
remembered by the word
R Rescue anyone in immediate danger A Alarm
Sound the ALARM Get fellow Team
Members to help! Pull the Fire Alarm and Dial
3333 Tell the operator the exact location of
the fire. Get fellow Team members involved to
help respond. (Note Pull stations are at doors
to stairs or outside, and
nursing stations) C Contain the fire - Close
Doors Windows E Extinguish the Fire if it is no
larger than a waste basket AND you can
do so without endangering yourself, OR
Evacuate if there is an overhead
announcement to do so from your area or a
supervisor tells you to.
reporting SMOKE
  • SEE FIRE --- INITIATE Code Red
  • Attempt to locate the origin of the smell.
  • If you investigate and think the smoke is from a
    fire activate the pull alarm and CALL 3333.
  • NOTIFY your supervisor or Facilities Services if
    you cant locate the smell or dont think it is
    related to a fire.

By knowing what to do and responding effectively,
you enhance our Fire Protection Plan and provide
a safe environment for our patients and fellow
team members
fire if it is larger than the size of waste
basket OR if there is excessive heat or
smoke. KNOW the Class of Fire you have- Class A
Common combustibles (paper, wood, cloththings
that leave an ash) Class B Flammable liquids or
gases Class C Electrical (energized electrical
equipment) TYPES of Extinguishers
Class B C ONLY
Class ABC
Another 4-Step Word for Using an Extinguisher
  • Pull the pin
  • (before you approach the fire)
  • Aim the nozzle
  • (at the base of fire)
  • Squeeze the handle
  • (start about 6-10 from the fire)
  • Sweep side to side

What to do if an Inpatient Unit Patient Room
Smoke Detector Alarms UCMC ONLY
  • All UCMC Inpatient Room smoke detectors are
    connected to the Nurse Call system. If activated
    the following will occur
  • Individual smoke detector will alarm inside
    patient room.
  • A critical alarm will ring through the nurse
    call system to all nursing CISCO phones and to
    the console at the nurses station on the unit
    with the fire/smoke.
  • The Switchboard Operator will receive
    notification of the specific room number with

If an inpatient unit smoke detector alarms inside
a patients room, go to the patient room where
the alarm is sounding. Follow RACE
acronym. Rescue anyone in immediate danger Alarm
Activate manual pull station, Call 3333, Notify
Team Members in area of fire. (even if you do not
see or smell smoke) Contain Close and latch all
doors. Extinguish Extinguish small trash can
size fires. Evacuate If there is an overhead
announcement to do so from your area or a
supervisor informs you to.  
  • Fire Exits Smoke Doors must NEVER be blocked
    and must remain closed during a fire/smoke event
  • Keep stairs and corridors clear at all times
    NEVER store objects in halls, even if objects are
    on wheels.
  • Reassure patients and visitors that Code Red is
    in effect and we are taking appropriate action.
  • You may need to explain what a Code Red is We
    are taking precautions as there may be a fire or
    smoke in the hospital we will keep you
  • Team Members assigned to non-patient care areas
    should remain in their department, if not the
    fire zone.
  • Team Members assigned to patient care areas
    should return to their unit. Be prepared to
    evacuate patients and visitors to another smoke
    compartment on the same floor if the fire is

  • AND
  • If in the Code Red location, take charge of the
    area and provide leadership to Team Members.
  • Designated Team Members from Facilities
    Security will report to the Code Red scene. Have
    a Team Member wait in the main corridor to direct
    respondents to the Code location. Get
    Facilities to help cut power to electrical
    equipment that is on fire, if needed.
  • Oxygen, gas or other devices that could aid in
    the spread of fire should be shut off (see
    Patient Care Area slide for more on oxygen
  • Keep telephone lines open during any emergency by
    not using them unless absolutely necessary.
    Avoid calling the switchboard if you can get
    information any other way they are VERY busy
    during a code.

  • Nursing Team Members
  • Report to your nursing unit promptly
  • Account for all patients
  • CLOSE doors to patient rooms
  • Inform patients and visitors that the Fire Plan
    is in effect and to stay in their room until they
    receive further instructions
  • Be reassuring and calm
  • Clear hallways of all items
  • Be ready to implement evacuation procedures

  • Respiratory Care Team Members
  • Report to scene to assist with O2 valve shut-off
  • Nursing Team Members
  • Charge Nurse or Clinical Nurse Manager takes
    charge of O2 issues, if Respiratory TM does not
  • Oxygen shut-off priorities
  • Identify any patients with a critical need for O2
  • Assess the proximity of fire and risk to piped O2
  • Balance the two risks - do any patients need tank
    O2 prior to shutting valve AND is there time to
    do so without severe fire risk?

Remember Treat every Code Red as an
emergency, even if you think it is a drill.
Drills save lives as they help us rehearse
emergency procedures. All departments must clear
hallways and close all doors during fire drills,
even if the event is not in your department or
work area.
  • The Joint Commission tells us that when we have
    known disruptions to usual fire safety features,
    we must implement ILSMs
  • Construction activities that interfere with Life
    Safety, such as those that block hallways, change
    exit routes or interfere with fire safety
    systems, are considered such disruptions.

Examples of ILSM Actions
  • Disruption Exit paths are temporarily changed
  • ILSM Know changes to escape routes (signage
    posted), make sure they stay clear
  • Disruption Fire detection, suppression or alarm
  • systems are shut down for
  • work
  • ILSM Rounds are made every two hours to look for
    possible fire safety issues (usually Security),
    control the storage of combustibles (good
    housekeeping), ensure emergency exits are
  • Disruption The end of a hall is blocked, making
    a temporary dead-end.
  • ILSM Pay attention to signage informing
    occupants of the temporary condition and help
    remind patients and visitors in that area of that

  • Whatever the disruption may be, it is important
    that all Team Members understand the impairment
    and ILSMs. Please pay close attention to
    signage, emails from your supervisor and any
    other ILSM communications.
  • There are a variety of other actions taken by
    Contractors, Facilities and Safety to ensure the
    safety of our patients, team members visitors
    during life safety disruptions that will not
    directly involve you. If you have ANY questions,
    please contact your Safety Officer _at_ ext. 3120 or
    pager 410 588 - 0643.

The safety and well-being of our patients,
families, visitors and team members are of
paramount importance.
Help to eliminate fire hazards by keeping your
work area clean and free from non-essential
combustible materials.
Memorize the BASIC Fire Plan - RACE
KNOW the location of all fire exits and how to
get to them in the event of evacuation.
Report fire hazards
Keep hallways, stairs and exits clear at all
Report all fires or suspected fires.
KNOW where fire fighting equipment is and know
how to use a fire extinguisher PASS.
A word about Electrical Safety . . .
ALL electrical equipment brought into our
hospitals MUST be checked by Bio-Med (if clinical
equipment) or Facilities (if not clinical) BEFORE
use. A sticker will be applied when this check
is done, which will give a date for a recheck, if
needed. If you find any electrical equipment
without a sticker or with an outdated sticker,
inform your supervisor. REPORT any damaged or
malfunctioning equipment DO NOT USE the
equipment. REMOVE it from use. - Put the
the equipment so that it is not used.
Write down what is wrong, your
department, your name and the date. - Take it to
Facilities or Bio-Med or call and
arrange for pick-up to make sure it will be
III. Hazard Communication
What is Hazard Communication?
It is information and education to INCREASE your
awareness about chemical hazards in your
Right to Know LAW The Access to Information
About Hazardous and Toxic Substances Act gives
team members a way to learn about chemical
hazards in the workplace and how to work safely
with these materials.
PRODUCT HAZARDS Spills, Exposure and Poisonings
  • Be aware that many products can contain hazardous
  • Educate yourself on every product you use. Read
  • Know where to get more information about hazards
    of a product.
  • (ANSWER Material Safety Data Sheet / MSDS)
  • Know how to get an MSDS.
  • (ANSWER It is on the yellow black MSDS
    sticker on the phones. Some departments maintain
    hard copies in notebooks. Copies are maintained
    at both hospitals in Risk Management in case
    phones/faxes are not working)
  • MSDSs contain information on
  • Chemical Identification Hazardous Ingredients
  • Physical Data
  • Fire, Health Reactivity Hazards
  • Spill Procedures
  • Personal Protective Equipment
  • Medical treatment for exposure

  • Know your product.
  • Ask your supervisor if you dont know.
  • Keep your work area clean.
  • Practice safe work habits.
  • Use Personal Protective Equipment, if needed.
  • Dont eat, drink, or apply cosmetics around
    hazardous products.
  • YOU need to know what to do for a spill of any
    chemical used in your department.
  • Each department with hazardous materials is
    responsible to keep spill kits readily accessible
    and fully stocked.
  • Contact your Safety Manager at ext. 3120 if you
    need further information.

IV. Infection Control Overview
SAFETY also includes providing an environment
that minimizes the risk of infection for
patients, visitors, team members and the
Important information before you start this
Infection Control and Bloodborne Pathogen section
  • If at any time during the review of the Infection
    Control/Bloodborne Pathogen training you have any
    questions, please contact a member of the
    Healthcare Epidemiology and Infection Control
    Department. One of them is available 24 hours a
    day, seven days a week.
  • Call 3106, 3104 or 5047
  • off-hours page 410.588.0407

Lets review some very important points...
HAND HYGIENE The MOST important measure to
prevent the spread of infection!
  • Perform hand hygiene by using the waterless hand
    sanitizer .
  • when entering and exiting a patient care
    environment (cleanse in/cleanse out)
  • before and after contact with a patient or
    anything a patient has touched.
  • before donning gloves when preparing to perform
    patient care
  • before eating, drinking, smoking, applying
    makeup, or handling contact lenses.
  • before performing invasive procedures.
  • before medication preparation.
  • after removing gloves
  • Perform hand hygiene by using soap and running
    water if (scrub for 15-20 seconds)
  • Your hands are visibly soiled
  • You finished caring for a patient with
    Clostridium difficile
  • Your hands feel gritty after many consecutive
    uses of waterless hand sanitizer
  • Other aspects of hand hygiene include
  • Keep fingernails neat and clean and do not allow
    the length to exceed ¼ inch beyond the fingertip
  • Artificial nail enhancements are not permitted
    for any team member who provides direct hands-on
    patient care
  • Use the hospital approved lotion to help
    moisturize the skin

Keep yourself safe from germs - follow OSHAs
  • OSHA states that
  • eating,
  • drinking,
  • applying cosmetics or lip balm,
  • handling contact lenses
  • are prohibited in work areas where
  • there is a likelihood of exposure to
  • blood or other potentially infectious
  • materials.
  • Be sure that you are following this in clinical
    areas, patient care areas, desks/counters and
  • carts/areas - - -
  • ITS THE LAW and it is meant to
  • protect you from infection!

  • the Care of All Patients
  • Prevent spread of bloodborne pathogens through
    the use of safe work practices used in all
    patient care activities.
  • Wearing Personal Protective Equipment (PPE)
    appropriate to the task you are performing.

USE Personal Protective Equipment (PPE)
  • PPE is available in all areas of the hospital.
  • PPE includes gloves, face protection, gowns, etc.
  • Wear appropriate PPE if you WILL or MAY come in
    contact with blood or potentially infectious
  • FOLLOW established job procedures if you work in
    a job where contact with blood or potentially
    contaminated body fluids or contaminated material
    is possible.
  • Do not take shortcuts, DO NOT put yourself or our
    customers at risk.
  • For a detailed description of PPE and its use,
    please contact the Healthcare Epidemiology
    Infection Control Department, the Safety Manager
    or the Risk Management Department.

  • There are 3 categories of isolation used at UCH
  • All patients on isolation are to be placed in a
    private room
  • If a private room is not available, select an
    appropriate roommate. Refer to the Infection
    Control Policies and Procedures on the Intranet
    and review the Isolation Precautions Policy for
    guidance on roommate selection.
  • When initiating isolation be sure to complete the
  • Place an isolation sign on the patient room door
  • Place an isolation supply box on the patients
    room door
  • Place an isolation sticker on the spine of the
    patients chart
  • Enter into Meditech the category of isolation
    being used for the patient
  • Provide appropriate patient/family education and
  • Follow policy for proper use of personal
    protective equipment
  • Dedicate equipment used for isolation patient if
    possible if unable, disinfect equipment before
    use on another patient

Lets REVIEW the three (3) categories of
  • Airborne Precautions
  • Prevent the spread of infections that are
    transmitted by small particle droplets that
    remain suspended in the air
  • The patient is placed in a negative pressure room
    and keep door closed.
  • Notify Facilities when a patient is placed on
    Airborne Precautions so they can monitor the
    ventilation in the room.
  • Team members wear a PAPR for patient care
  • If patient must leave room, patient is to wear a
    surgical mask while out of room

categories continued . . .
  • Contact Precautions
  • Prevent the spread of infections that are
    transmitted from skin-to-skin contact or contact
    with a contaminated object, i.e., MRSA, VRE other
    MDRO (Multi-Drug Resistant Organisms)
  • used for known or suspected C. difficile. Be
    sure to check must wash with soap and water on
    isolation sign for C-diff.
  • Team members visitors must wear gown gloves
    if they touch anything in the patient room
  • 3. Droplet Precautions
  • Prevent the spread of infections that are
    transmitted by large-particle droplets that can
    be created by certain medical procedures or by
    coughing, talking or sneezing, i.e., influenza.
  • Team members must wear a surgical mask when
    providing patient care
  • Patient must wear a surgical mask when out of the
  • REMEMBER For all categories of isolation, read
    and follow the instructions on the isolation sign
    posted on the patient room door.

  • Dispose of needles and sharps in puncture
    resistant containers immediately after use.
  • Use needle safety devices properly engage safety
    devices immediately after use of sharp
  • NEVER re-cap a used needle by hand.
  • NEVER leave needles or sharps exposed or
  • NEVER practice hand to hand transfer of any
    sharps place sharps on a neutral field to avoid
    this type of transfer.
  • This applies primarily in areas such as the OR
    and ED.

  • KNOW the location and review the Bloodborne
  • Exposure Control Plan
  • It contains information specific to your job.
  • The plan is located in the Infection Control
    Manual on the intranet
  • Review the task list that applies to your
  • The plan is reviewed and revised annually.
  • You are responsible for knowing about any
    changes that occur.
  • HANDLE contaminated or potentially contaminated
    waste according to procedure ensuring that it is
    identified properly, i.e. RED BAG, Bio-Hazard
    Label, etc.

More Infection Prevention tips
  • Prevention of Central line associated bloodstream
  • Use CVC insertion checklist with each line
  • Provide patient/family education about CVC
    infection prevention and document this education
  • Avoid use of femoral site if possible
  • Be sure dressing is dry and secure
  • Scrub the hub each time accessing line
  • Assess need for line daily document remove
    when line is no longer needed

More Infection Prevention tips Prevention of
Surgical Site Infections
Before During Surgery Before During Surgery
patient pre-op bath with antiseptic solution antibiotics within 1 hour of incision
follow procedure for surgical hand scrub wear proper surgical attire
do not remove hair from operative site unless necessary if hair is removed, do in pre-op area using electric clippers
use chlorhexidine to prep surgical site allow prep to dry prior to incision
do not routinely flash sterilize instruments minimize traffic in out of the OR

After Surgery After Surgery
disinfect hands before caring for wound make sure dressing is dry intact
follow procedure for dressing changes d/c prophylaxis within 24 hours of surgery end time
MEMBERS Review of AIDS, HIV, Hepatitis B,
Hepatitis C, and TB
  • AIDS and HIV Fact Sheet
  • AIDS is caused by a virus called HIV (Human
  • AIDS stands for Acquired Immunodeficiency
  • HIV infects certain cells of the immune system
    called T-helper cells.
  • HIV can kill these cells, and then a person can
    develop other serious diseases.
  • HIV is in blood and other body fluids
  • The virus is in the blood, semen, vaginal
    secretions, cerebrospinal fluid, synovial fluid,
    pericardial fluid, peritoneal fluid, amniotic
    fluid, saliva in dental procedures, and any body
    fluid that is visibly contaminated with blood.
  • The virus can be there even if the person has no
    symptoms of AIDS or HIV infection. People who are
    infected with HIV will carry the disease for the
    rest of their lives.

  • People at highest risk of HIV infection are
  • Drug users who share needles
  • People who have received blood transfusions
    infected with HIV, including people who have
  • Anyone who has sex with a man or woman who has
    HIV or AIDS, or who is at high risk for HIV or
  • Babies born to mothers who have HIV.

HIV is spread by exposure to blood and body
fluids. HIV can be spread during sex, by sharing
dirty needles to inject drugs, from mother to
baby (before or during birth, or by breast milk),
by getting stuck by a dirty needle, or by getting
blood or other infected body fluids onto a mucous
membrane (mouth or eyes) or onto broken skin.
The virus is not spread by casual contact such as
living in the same household or working with a
person who carries HIV, shaking hands, hugging,
or sharing food or drink.
Incubation Period and Period of
Communicability Although the time from infection
to the development of detectable antibodies is
generally 1-3 months, the time from HIV infection
to diagnosis of AIDS has an observed range of
less than 1 year to 10 years after infection.
The period of communicability is unknown but is
presumed to begin early after onset of HIV
infection and extend throughout life.
  • Early Symptoms to look for
  • fever
  • weight loss
  • swollen lymph glands in the neck, under arms and
    in the groin area
  • Late Symptoms to look for
  • white patches in the mouth (thrush)
  • certain cancers (Kaposis sarcoma, certain
  • opportunistic infections (Pneumocystis pneumonia,
    certain types of meningitis toxoplasmosis,
    certain blood infections, TB, etc.

Hepatitis B Fact Sheet Hepatitis B is an
infection of the liver caused by a virus. The
virus is in blood and other body fluids. The
virus can be found in the blood, semen, vaginal
secretions, cerebrospinal fluid, synovial fluid,
pleural fluid, pericardial fluid, peritoneal
fluid, amniotic fluid, saliva in dental
procedures, and any body fluid that is visibly
contaminated with blood. Once infected the virus
can be found in the blood for several weeks
before symptoms start until several months later.
Five to ten percent of adults and up to 90 of
babies who catch Hepatitis B will go on to carry
the virus in their blood and other body fluids
for the rest of their lives -- and can continue
to pass the virus on to others. Hepatitis B virus
is spread by exposure to blood and body fluids.
The virus can be spread by sex, by sharing dirty
needles used to inject drugs, by getting stuck
with a dirty needle, or by getting blood or other
infected body fluids onto a mucous membrane
(mouth or eyes) or onto broken skin. The virus
also can be passed from mother to baby, usually
at the time of birth. The virus is not spread by
casual contact such as shaking hands or hugging.
People at higher risk of Hepatitis B infection
are - Drug users who share needles. - Anyone who
has sex with a man or woman who has Hepatitis B
or is a Hepatitis B carrier. - Anyone who has
multiple sex partners. - Babies born to
mothers who have the virus. - People who are on
kidney dialysis or are hemophiliacs. - People
born in Asia, the Caribbean, South America,
Africa, the Pacific Islands, and American Indians
and Native Alaskans (the risk extends to their
children). - Health care workers, dental care
workers, emergency workers, laboratory workers,
and others who have contact with blood and body
fluids. - People who live with a person who is a
Hepatitis B carrier.
Incubation Period and Period of
Communicability The time from infection to the
development of the appearance of the Hepatitis B
antigen is 45 to 180 days. It can be as short as
2 weeks and rarely as long as 9 months. All
persons who are HBsAG positive are potentially
infectious. About half of people who catch
Hepatitis B never feel sick. Symptoms to look
for - tiredness - loss of appetite - fever -
vomiting - yellow eyes and skin (jaundice) -
dark urine, stool light in color
Hepatitis C Fact Sheet Hepatitis C is an
infection of the liver caused by a virus. The
virus is in blood and other body fluids. The
virus is found in the blood, semen, vaginal
secretions, cerebrospinal fluid, synovial fluid,
pleural fluid, pericardial fluid, peritoneal
fluid, amniotic fluid, saliva in dental
procedures, and any body fluid that is visibly
contaminated with blood. It was formerly know as
non A, non B Hepatitis. People at higher risk of
Hepatitis C infection are - Drug users who
share needles - People who are on kidney
dialysis - Health care workers, dental care
workers, emergency workers, laboratory workers,
and others who have contact with blood.

Hepatitis C virus is spread by exposure to blood
and body fluids. The Hepatitis C Virus is spread
by exposure to blood and possibly other body
fluids. The virus can be spread by sharing dirty
needles used to inject drugs, by receiving blood
transfusions contaminated with Hepatitis C or by
getting stuck with a dirty needle.
Incubation Period and Period of
Communicability The time from infection to
development of the appearance of infection is
usually 6 to 7 weeks but can range from 2 weeks
to 6 months. The period of communicability is
from 1 to 2 or more weeks before the onset of the
first symptoms. Infectiousness may persist
indefinitely in most persons.
Hepatitis C - Symptoms to look for - Loss of
appetite - Vague abdominal
discomfort - Nausea and vomiting -
Sometimes yellow skin and eyes (jaundice)
  • The Hepatitis B vaccine is offered to team
    members who are at risk for occupational exposure
    to blood or other potentially infectious
  • It is free of charge and is administered in 3
  • The vaccine is not made from blood products you
    cannot get AIDS or Hepatitis from the vaccine.
  • Contact Occupational Health for more information
    about the vaccine.

In the event that you receive a needle stick, are
cut by contaminated glass, or are exposed to
blood or a potentially infectious body fluid,
report it immediately to the Occupational Health
Nurse and your Supervisor. A Report of
Occupational Injury or Illness MUST be filed and
designated procedures must be followed as defined
in the Exposure Control Plan.
When you are exposed, it is called an
Occupational Exposure to Blood or Body Fluids.
What is An Occupational Exposure?
  • An occupational exposure is any skin, eye, mucous
    membrane, or parental contact with blood or
    another potentially infectious materials.
  • The source patient is the individual with whom
    the team member has had an occupational exposure.
  • Most exposures do NOT result in HIV infection.
    The risk of becoming infected with HIV after a
    needlestick or cut from a HIV positive source is
    about 1 in 300.

What Should I Do If I Have An Occupational
  • An occupational exposure is considered a medical
    emergency. You must contact OCCUPATIONAL HEALTH
    immediately so that evaluations of your exposure
    can be done and medical treatment (if applicable)
    can be provided.
  • If it is after 4pm Monday Friday or on a
    weekend, contact the Administrative Coordinator
  • Wash the exposed area with soap and water and let
    it bleed freely. If you are splashed in the
    eyes, mouth or nose, rinse the area thoroughly
    with water.
  • Complete a Report of Occupational Illness or
    Injury according to the instructions later in
    this packet.

What Happens Next?
  • The Occupational Health Nurse or Administrative
    Coordinator will provide first aid and determine
    if an occupational exposure has occurred.
  • If an exposure occurred, a Rapid HIV test will be
    done on your blood sample. The source patient
    will be asked to consent to the same blood test.
    If the source patient is unable to give consent
    and no next of kin is available to consent, or
    the patient refuses to give consent, their
    previously drawn blood in the lab will be tested.
    The source patient must be told if this is done.
  • Follow-up HIV testing is recommended for a
    positive rapid HIV test. The testing is done at
    6 weeks, 3 months and 6 months after the
    exposure. This will be done in Occupational
    Health at no cost to you.

Is There Medication I Can Take?
  • If the rapid HIV test is positive, you will be
    given medication. This medication is called post
    exposure prophylaxis (PEP).
  • Studies have shown that if PEP is taken within
    the first two hours of an exposure it may reduce
    your risk of becoming infected with HIV.
  • If you take this medicine, you will be referred
    to an infectious disease specialist within five
    days of your exposure.
  • Testing, medication and physician appointments
    are provided to you at no cost.

What Can I Do to Lower my Risk of an
Occupational Exposure?
  • ALWAYS wear gloves when handling blood or body
  • Empty needle boxes when they are two thirds full
    Dont let them become full.
  • Do Not recap needles or place used needles on
    beds, overbed stands or in the mattress of a
    patients bed.
  • Use needle safety devices appropriately.
  • Take your time and always be aware of what you
    are doing! We care about you and your Safety.

REGULATION Every hospital is required by OSHA
to have a copy of the federal standard 29 CFR
1910.1035. A copy is located in the Safety
Office. The hospitals must also have a
TB Exposure Control Plan and a Respiratory
Protection Program. Please review these
procedures to follow to protect yourself from
exposure to TB.
TB is caused by bacteria named Mycobacterium
tuberculosis. This bacteria is so small that it
can float on particles of dust in the air.
Someone who has untreated TB disease can spread
this bacteria when he/she coughs, sneezes, or
talks. This provides a way for the organism to
become airborne. Someone may then inhale the
organisms into his/her lungs. Infection depends
upon the number of TB bacteria in the air. Once
the bacteria get into the lungs, it may spread
throughout the body. When you have a healthy
immune system, your body limits the spread and
inactivates the organism. This occurs 4-12
weeks after exposure. The only sign you may have
is a positive skin test (PPD). A positive PPD
test alone does not mean you have TB disease or
are contagious.
When the bodys immune system is too weak to
control the organism, TB becomes active. This is
sometimes referred to as either latent TB or TB
disease. About 10 of the population with TB
infection (PPD) go on to develop disease. TB
usually occurs in those who have HIV infection,
the elderly, and those who are receiving
chemotherapy. It usually occurs within 6-12
months after infection. At this point, the
person is infectious and the TB organism is in
the sputum.
Normally, when a person is diagnosed with TB,
he/she is admitted to the hospital, placed in
isolation, and treated with certain medications.
This person could be hospitalized 3 days to 2
weeks. Six months of therapy is required to
eradicate the disease. 50 of people with TB fail
to complete therapy which may lead to
reactivation of disease and even drug resistance
(MDRTB). This means that the organism was
partially destroyed and developed resistance to
the drugs that were used previously. The disease
can no longer be treated with the normal drugs.
  • It is important to identify the disease early -
    Be alert for the following symptoms
  • - Productive cough for greater than 3 weeks -
  • - Coughing up blood - Night sweats
  • - Weight loss - Loss of appetite
  • - Fever
  • Diagnostic test for TB should be done -- Skin
    test (PPD), and if positive, followed by a chest
    x-ray. If the chest x-ray is positive, a sputum
    test is done for TB.
  • If TB is suspected or known, isolate the
    patient. Airborne isolation is used.
  • Notify Facilities Management when placing a
    patient on airborne isolation so they can check
    the negative air pressure of the room.

to TB?
  • Anyone who enters the room must wear special
  • Only certain team members who have been fit
    tested in the last 12 months are allowed to use
    the N95 respirator. All other team members must
    use the PAPR.
  • The PAPR is a Powered Air-Purifying Personal
    Respirator a battery powered device that
    provides positive pressure filtered air through
    a protective hood.

For those team members who are trained in the use
of the PAPR, please review the following
information . . . All other team members, please
proceed to SLIDE 77.
Use of the PAPR When a patient is placed on
Airborne Precautions, all health care workers
entering the room must wear a PAPR. The team
member must have prior training on the use of the
PAPR. PAPRs are obtained from Equipment
Distribution. Perform the following outside
of the isolation room 1. Visually inspect the
PAPR unit and the breathing tube for any
damage. 2. If any damage is noted do not use the
item - return it to Equipment Distribution and
obtain another unit. 3. Visually inspect hood for
any damage. If damaged, dispose it and obtain a
new one. 4. Turn on the PAPR unit to assure that
an adequate air flow is generated at the end of
the breathing tube. THE PROTECTION AFFORDED BY
5. Connect the breathing tube to the hood. Be
sure it is seated properly. 6. Turn the PAPR unit
on, place the unit around your waist and fasten
the waist belt at a position that is comfortable,
with the motor at the small of your back. BE
7. Place the hood over your head. 8. Check the
fit of the hood by doing the following a.
Check that there is good seal to the face. b.
Air should escape through the holes at the base
of the mask and by the ears only.
c. Check that the air flows to the front of the
  • 9. The PAPR system should be removed in the
  • manner
  • a. Remove the hood.
  • b. Disconnect the breathing tube from the
  • c. Remove the PAPR filter unit from your
  • d. Turn off the PAPR filter unit.
  • 10. Inspect the entire unit for any evidence of
  • contamination or damage. Remove light
  • contamination by wiping the area with a
  • Decontaminate the hood by wiping it with an
  • antimicrobial wipe that MUST NOT contain
    alcohol. DO NOT USE ALCOHOL WIPES. A grossly
    contaminated hood is to be discarded. At the end
    of the shift, place the hood in the soiled
    utility room for cleaning (ensure that your name
    is written on the hood).
  • 12. Store the unit in the anteroom on the cart or
  • Note When isolation is discontinued, place the
    PAPR units, breathing tubes and hoods in the
    soiled utility room. return the unit, breathing
    tube, hoods and cart to the dirty utility room.
  • NOTE Each unit will be replaced every 3 days
    with a fully charged unit by Equipment

that you need to remember
1. Team Members are to have a PPD done upon
employment, but only those at risk team members
(those with patient contact) are required to have
annual PPDs. 2. If you are exposed to someone
with TB who was not properly isolated, the
Occupational Health nurse will contact you. You
may get tested depending on when your last PPD
was done. You would be tested again in 10 - 12
weeks. This is to see if you were infected. 3. If
you should develop any of the symptoms listed
above, contact Occupational Health.
If you have any questions about TB and/or need
any additional information on the content of this
section of the packet, contact the Healthcare
Epidemiology and Infection Control office at
extension 5047 or 3106.
Report of Occupational Illness or Injury
V. Occupational Health - Injury Reporting
If YOU Experience an On-The-Job INJURY or
ILLNESS, Please follow these steps IMMEDIATELY
  • If you have an On-The-Job injury or illness
  • Report to Occupational Health, your supervisor,
    or the Administrative Coordinator IMMEDIATELY.
  • They will assess your injury and may refer you
    for further treatment.
  • Complete Section I of the Report of
    Occupational Illness or Injury prior to the end
    of the shift during which the illness/injury
    occurred. If you are unable to complete the
    form, your supervisor or his/her designee will
    assist you in completing the form.
  • Have your Supervisor or the Administrative
    Coordinator review and sign the form.
  • Forward the yellow copy of the completed form to
    the Occupational Health office prior to your
    departure from UCH for the day.
  • Send any doctor's notes you may receive to the
    Occupational Health Nurse Office.
  • Send any and all medical bills/receipts that you
    receive to the Occupational Health office.

If you have any questions about reporting a team
member incident or about workers compensation,
please call the Director of Occupational Health
at 443.643.4805 or on pager 410.588.0372.
Special Tip for ALL On-The-Job Injuries and
The review of your injury to determine if you are
eligible for workers compensation cannot begin
until Occupational Health is notified or receives
your Report of Occupational Illness or Injury, so
please complete and forward the form immediately.
The FORM you will fill out is available in your
work area. It is divided into three sections.
Section I
Team member fills out the detailed information as
requested on the form
Section II
Occupational Health Nurse or Triage Nurse
completes this section covering the outcome of
the occurrence and follow-up
Section III
Supervisor Follow-up
FORM 24901
What if you may return to work, but have
  • Contact Occupational Health at ext. 4805 or by
    pager 410.588.0372 IMMEDIATELY.
  • Upper Chesapeake has a Transitional Duty Program
    that allows team members who were injured on the
    job to return to work, providing UCH can
    accommodate the restrictions.

  • ALL injuries must be reported to the Risk
    Management Office and to the Occupational Health
    Nurse. This includes
  • Team Members
  • Physicians
  • Agency Staff, and
  • Contract Staff
  • Always complete a Report of Occupational
    Illness/Injury form Its to protect your
    health! For questions, please call
  • Occupational Health Nurse at UCMC ext. 3422
  • Occupational
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