i eee ae eer Cas » | RAMANA Ramaiah Medical College Hospital 74 Nella GREEN BOOK An overview to clinical policiesNursing Vision To empower nursing staff to practice innovatively, lear continuously, and to create a positive work environment Nursing Mission To deliver quality nursing care based on the individualized needs of the patient and their families. Nursing Departmental Values * Human Dignity © Integrity * Honesty * Social Justice = Compassion ‘© Team Spirit Patient rights ‘* Right to confidentiality of patient information Right to refusal of treatment Right to seek an additional opinion regarding clinical care Right to give informed consent * Right to personal dignity and privacy * Right to access his/her medical records ‘¢ Right to receive information on expected cost of the treatment _ Patient responsibility 0 observe facility policies and procedures .including those regarding smoking.noise and of visitors@ Contribution towards PE, ESI, Professional tax, IT. Gratuity, Death Relief, Welfare Amenities, anc Health Insurance for Self and Family. To know the protocols of the institution Service Rules Disciplinary procedure Hospital Policies and Guidelines ifection control, Biomedical waste management(BMW).HR policy ete nursing policies and protocols, standard operating fem) -where in hands on training by the IT department© In-Service Education © Central training- CNE- monthly onee © Unit specific training * Unit specific training ~ weekly once on Thursdays © ONTs as per the requirement * External training according to availability * BLS-renewed every year * ACLS (Advance Cardiac Life support/Paediatric advanced Life supporUNRP (Ni | resuscitation programme ‘Competency and Privileging * Competency is ability ofthe staff 10 work on the target privileges skillfully and efficiently. | * Competency check will be in the following order | > Initial self-assessment (after deployment and before going to unit) | > month (after the preceptorship programme) | > 4 month > year Privileges are rights and duties entitled and granted for each nursing staff. * Privilege depends upon their qualification, experience and competency * Privileging is done once during the first month and then if needed will be revised on 4" month and 1 year ‘+ The privileges of staff nurses are as follows 1_| Admission of patients 16 _| Nebulization 2 | Preparation of patient for procedures and diagnostic | 17 m inhalation studies | 3 | Doctorsrounds x = 18 __| Random blood sugar Check : 4 | Sample collection & dispatch _ 19 | Blood & Blood products V i | transfusion 5_| Pre-operative preparation & Care 20 [ECG | | [6 | Administration of medicines 21 _ | Foleys catheterisation forfemale | | 7_| Post-operative care i 22__| Catheter care eral '['8) | Assist doctors for all diagnostic & therapeutic studies | 23 Tracheostomy care al 19 | Comprehensive nursing care 24 | Colostomy care/ileostomy care Handling of MLC patients 25 _| Tejunostomy care iL | Aransfer in & transfer out 26 _| Care of unconscious patients Discharge/LAMA = 27 | Care of invasive & non-invasive | Es [ines | it & family education 28 | Care of patient with traction & cast_| ulation [29 | Care of patient with BIPAP. iministration 30__| Care of patient with inig ationjursing assessment Will be done at the time of admission and to be initiated within 30 minutes in Wards & immediately within 5-10 minutes in A&E and ICU ® Includes ¥ Vital signs Y Braden pressure ulcer risk assessment ¥ Fall risk assessment Pain assessment—- — an i ae cay | -omplaints raised by the employees are considered as grievance Include the matters related to leave, increment, promotion, Seniority, non-extension of benefits under rules, working conditions, compensation etc., of an individual nature, © Complaints ean be raised to HOD in writing or can put in employee feedback box j If not satisfied with decision of HOD, can submit complaint to Grievance handling committee | chairperson Dr.Anuradha (HOD, Pharmacology) & Convenor Ms.Kalpana (HR Manager) | © If no resolution within 15 days, can give appeal to DEAN a Sexual Harassement Prevention Committee/ Internal complaints committee * Any complaints which are sexual in nature includes messages, touch, sending images which are sexual in nature Written complaint to be raised to the committee chairperson ~ Dr Janaki(Radiotherapy) Various committees in our hospital © Core committee/Quality Assurance Committee Hospital infection control committee Grievance handling committee Prevention of sexual harassement committee ‘Nursing management committee Credentialing and privileging committee Hospital safety committee Medical audit committee eee eee International patient safety goals Identify patients correctly. Improve effective communication. Improve the safety of high alert medication Ensure safe surgery Prevent health care associated infection © Reduce the risk of patient harm resulting from fall cee Patient identification .- any transfer in and out Ete Uupon selecting a patient in HIS for ordering procedures, lab orders, radiology orders, medications ete = while filing any patient reports or forms A ~ while handing over discharge summary and prescription paper to patient. E = before documenting any information in the patient file +. © Vulnerable patient are identified with orange colour identification tag. Ldentification, S-Situation, B-Background, ‘A-Assessment R-Recommendation munication about patient should be in written. hand over with head to toe inspection especially skin inspection of patient to be done-Musele relaxant -lonotropes -Vasodilators -Psychotropies -AIL LASA (Look Alike and Sound Alike) * Double check the medication rights before administering high alert medication and countersign in Medication administration chart. ‘© Monitor patient closely after administration of high risk medication, Narcotic policy © Narcotic drugs are stored only in critical area- ICU, A and E, OT and LR. Drugs are kept under double lock and the key to be with two staff(in charge and a senior nurse) © While opening narcotic cupboard, there should be presence of these two staff who are handling the key. “© There should be a written order for the drug. Double check for medication rights before administering narcotics and countersign the administration. ient to be monitored closely for any complications after administration. ¢ balance unused medicine to be discarded under running water in the presence of 2 witness.Dispensing Enror-While receiving medicines to unit check for right patient.right drug, right dose and quantity with expiry check. ® Administration Error. Three Check for 7 medication rights before administration. -right patient tight drug -tight time a tight dose 5 right route -right frequency tight to know the effect and side effect. it to be monitored for any adverse event after medication administration.Fal IV fluid, IV set ete for further evaluation. * Keep the balance medicine, medication vial, IV fluid, IV set ete for: further eval © In case of blood transfusion reaction, keep the blood bag, blood set and send it to blood bank along with an EDTA blood sample taken from the other extremity with cross matching slip. Drug Allergy * Every patients to be assessed for preexisting allergy status upon admission and before drug administration * Ifatall any allergy related symptoms occur, stop the drug., inform doctor and carry out as per doctors order * Continue observe the patient. Surgical Safety * Patient to be prepared as per the preoperative checklist before the day and to be counterchecked before sending the patient to OT © Prophylactic antibiotic to be administered 1 hr before incision and to be repeated if the surgery exceeds 4 hrs * Sign in, time out and sign out to be performed in OT: ie Sign In: check before inducing anesthesia E ‘Time out: check before putting skin incision b Sign out: check before closing the skin incision * Ensure consent is taken by the surgeon or his team. Ensure Surgical site marking is done ( upward arrow towards site)for the surgeries involving Bilateral organs -Laterality "Various levelsMoments of hand hygiene © Before touching the patient ® Before clean or aseptic procedure * After touching the patient * After touching the patient surrounding * After risk or exposure to blood and body fluid Steps of hand hygiene * Rub hands palm to palm _¢ Right palm over left dorsum with interlaced fingers and vice versa; _ * Injerlacing of fingers :Palm to palm with fingers interlaced: locking of fingers : Backs of fingers to opposing palms with fingers interlocked; nt rotation : ‘otational rubbing of left thumb clasped in right palm and vice versa; ibbing, backwards and forwards with clasped fingers of right hand in left palm and vice nagement. a WHITE * Tubing, Broken or discarded an | Needles, | © Plastic bottles, | 4 contaminated glass i © Syringes with fixe ® Intravenous tube } eluding medicine vial dneedles, sand sets, sand ampoules except © Scalpels, | Bi cetheters, those contaminated wit | 5 Blades, | ees any other contami nated sharp object that may eause p uneture and cuts | | ia Metallic Body Implant | ' s e Pulmonary TB, Chicken pox, Measles jental contact and glove removal slosed ctSARS, whooping cough. HIN1 Droplet precautions ~For Diphtheria, Mumps . pertussis, Hand hygiene alter all patient /environmental contact and glove removal Wear mask if within 3 feet distance with patient ‘Three layered Mask for entry to room. Gloves for all patient (environmental contact Contact precautions-For MDR (multi drug resistance) eases, MRSA (methicillin-resistant Staphylococcus | aureus), VRE (Vancomyein-resistant enterococci) , scabies, herpes zoster , clostridium difficle etc... * Hand hygiene after all patient /environmental contact and glove removal * Gloves for all patient /environmental contact * Gowns for all patient /environmental contact, Reverse isolation /protective isolation precaution. ‘* To protect immuno suppressed / immuno-compromised hosts from infection * Single rooms for physical isolation * Avoid unnecessary contact * Wear mask, sterile gloves and gowns Safe injection practices a. ‘Medication vials are pricked with a new needle and a new syringe, even when obtaining additional doses for the same patient Single dose medication vials, ampules and bags or bottles of intravenous solution are used for only one patient Medications administration tubing and connectors are used for only one patient rub hub rule and patency check before administration of mediation through IV access the VIP score for the carly identification of IV related complication Vials are dedicated to individual patients whenever possible to recap the needles are to be discarded only to puncture proof containers wear PPE(mask,gloves,goggles,apron) ‘putting a newspaper on it lorite on the newspaper.( 200ml of 3% hypochlorite in $00 ml of water) and discard into yellow cover ab cloth and discard into yellow coveriat 4) —__ Mop the area with lyzol (disinfectant solution) Chemical spill management a. Wear apron and Nitrile gloves b. Place the caution board & Sprinkle the granular powder and place the absorbent pads over the spill Dispose absorbent pad in disposable bag = (Clean area with water and Dry thoroughly from outside to inner. Wash hands with soap and water and dry thoroughly. Report the incident to the respective department Incharge and document the same. Chemical Spill kit to be available and Housekeeping must be aware of the spill management process. spill management zr > 96. Pourdeactivating agent (1% hypochlorite for platinum : minutes. Retrieve the absorbent pad with drug and discard in C-type cover gnalogues) on top of the pad and leave for 2 utes. Retrieve 1 Ph the cloth and discard in C-type cover. a mop cloth on the area of spillage and pour Lysol solution and leave for 8. Tie the C-type cover and discard into the second C-type cover & Remove PPE 9. Document the spillage of incident Hazardous Chemicals Hazardous chemicals include : 1. Tincture Benzoin 2. Betadine 3. Ethyl ether 4. Isopropyl alcohol 5. Magnesium sulphate anhydrous 6 Mercurochrome 7. Sodium HypoChlorite & Surgical spirit items are stored in HAZMAT cupboard. ‘Data Sheet) are there for all hazardous chemicals and are kept inside HAZMAT cupboard S refers to : th effects and first aid measures ng and transportation ‘or indirectly exposed to blood and body fluid are infected linen en is taken to dedicated washing area g water, soak in 1% hypochlorite solution (200 ml of 5% hypochlorite solution in ater)for 30 min , wash and send to laundry in yellow cover,- (2) meeting and based on the find f The reported case is analyzed in the RCA Committe CAPA will be taken a eS vo vil be presented in the HICC Meeting fextubation yinage system (Once in 3-4 hrs & as and when required) n-Care Bundlenn Frequency of cleaning Skno | Areas Departments Edu eae | 1 High Risk Areas TCUS(OTILRIA and E/ medical | 4 Times Day ° | Oncology/lab / blood bank . biomedical | waste sub centre | 2 Moderate Risk Areas | All wards 3 Times (Day | | | 3 Low Risk Areas Reception, MRD, radiology. | Once ina day | administrative offices | J Enyironment cleaning Areas | Disinfectant Dilution Floor’mursing station , wall ea Gumi of lysol in One litre of water Toilet floor Action plus 100ml in one litre of water Isolation ward ,OT Isolation ICU- furniture and floor ‘Bacillocid solution 200ml in 10 litre water-0.2% uipment and general items cleaning and disinfection method Disinfection method / disinfectant Dilution ~Extemal Surface: Lysol with water Circuits: Single use -Soreen- Use glass cleaner Extemal Surface : Lysol with water -Screen- use glass cleaner -Lysol Lysol External surface -Glass Cleaner -Internal Surface- Lysol 4ml of lysol in One litre of water -Screen- use gla ~Body-damp dusting with Lysol solution. -Screen-Glass Cleaner -Keyboard-70% isopropyl alcohol -Lysol “Extemal Surface: 70" isopropyl alcohol Circuits: Single use al— : [Thermometer /Stethoscope {| /Glucometer/Infusion pumps /Sytinge pump Pulse Oxymeter | | ‘Defibrillators/ECG machine (Torch/Scissors/Telephones propyl alcohol | | Nebulizer Machine and | [Tubing’s -70% isopropyl alcohol -Tubings and mask for single patient Ambu Bag =Wash with water and dry it. Send for ETO sterilisation. -Mask: wipe it with Isopropyl aleohol Laryngoscope “Blade: wash and dry, wipe with 70% isopropyl alcohol 2 -Handle: wipe with 70% isopropyl alcohol G2 Humidifier Reuse only for Single patient -Daily wash with soap and water Fill with sterile water and label | with date of change of water After patient use: through cleaning with soap and water, dry it, “Reuse only for Single patient | -Wash with soap and water after every suctioning | “Send for ETO after 5 days of use of single patient and after each | patient use | -Suction catheter single use | -Aseptik solution to be poured in sputum cup before use | -Afier use , discard and clean with soap and water “Soap &Water after each use =Wash in Soap &Water weekly , | -For isolation patient — single patient use, wash and dry before using | for next patient “High risk areas = once in a week and whenever required -Medium and low risk: once ina month and whenever required Tupon completion of each task of floor cleaning, disinfect with Lysol ‘and hang to dry -Change mops once in a monthDressing sets and other sets , clressing bins, cheatle forceps 10 days-sets Cheatle forceps zonce it is, opened can use only for 24 hrs. instruments used for laparoscopy Suction jar, bain circuit, amb) ETO 6 month Dag. corrugated tubes , guide Wires Adapters, Flow sensors, NIV Mask Camera, light source, cables, | Plasma Sterilization 6 month | Antiseptic solutions used Solutions, | Use Purellium Gel AS handrub |_| Povidone iodine Serub(7.5%) As ahandserub before surgery / procedure |_| Povidone iodine Sotution(5%) Skin disinfectant before any invasive procedures Indwelling days of catheters and tubes ‘72hrs and on clinical indication ] | 24s Discard after each transfusion | | 30 days and on clinical indications het 14 days and on clinical indication 30 days and on clinical indication 1 48 hs 7 days 1 72 hrs as and when required | Tidays ith Soap and running waier.(Do not suck or do not squeezejew or used needle, blade or any sharp instruments | Identify whether itis Determine the status of the patient, ifit was used for the patient The floor Supervisor should inform the Infection Control Nurse The ICN will informs the Nodal Officer HealthCare Action Worker status | | Susceptible (no Give HBIG and start immunization or primary immunization infection ie. HBsAg within 2-3 days Neg/HbsAb Neg.) Immunized, but not Test for antibody if tested for antibody negative.give immunoglobulin within 2-3days and Immunised,antibody Immunized, antibody > No further action 101U/ml Give booster in 1 Susceplible (no HB immunization or for infection) HBsAg future prophylaxis Neg/HBsAg Negi Immunized, but Retest for HbsAg. if unknown antibody negative or<10 1U/mt | status ive booster. | ‘ action, > | | HBsAgnegative Tmmunized, antibody No further | 10 1U/ml | within past 1 year Occupational HIV Postexposure Prophylaxis * Postexposure prophylaxis (PEP) is recommended for health-care personnel who have Cccupational exposure to blood or other body fluids that may contain human immunodeficiency virus (HIV). The HIV status of the exposure source patient should be determined, if possible, to guide the need for HIV PEP, PEP medication regimens should be started as soon as possible afteroccupational exposure to HIV, and they should be continued for a 4-week duration, PEP medication regimens should contain 3 (or more) antiretroviral drugs for all occupational exposures to HIV. Drugs Related to Antiretroviral Therapy for HIV Infection © lamivudine/zidovudine/abacavir © bictegravir/emtricitabine/tenofovir AE © cfavirenz/lamivudine/tenofovir DF * lamivudine/abacavir Vulnerable patients * Senior citizens * Babies and children * Mentally challenged patients * Sedated patients Unconscious patients Physically challenged patients Notable to ADL Immuno compromised© Reassessment done daily , whenever there is a change in patient condition, after sation procedure and as and when required ® Morse fall risk assessment is used for adults and Humpty dumpty for Paediatric * Morse Fall Scale assessment includes ~History of falling: immediate or within 3 months ~Secondary diagnosis 5 — Ambulatory aid i ~1V/Heparin Lock Bes —Gait/Transferring . Mental status ‘© Ifthe score is more than 2, perform fall prevention measures jure ulcer risk assessment and prevention » Assessment done at the time of admission Reassessment done daily, whenever there is a change in patient condition and as and when required sk assessment done using Braden pressure ulcer risk assessment tool s include Sensory perception —Moisture Degree of activity yving-mobilisation and 2hrly position change of Incontinence-keep skin neat and dry, barrier lotion applied, change soiled diaper/under pad immediately Wy invasive procedures administration of pain medication ove yrs “Numerical pain seale’Visual Analogue Seal~29Days to 3 yrs -FLACC Seale —Below 28 days -N-PASS —For ventilator patients -CPOT © When patient reports pain, = Immediately inform doctor Administer analg as per doctor's advise DVT assessment & care * Assessment done by using WELLs Score during admission &daily © Components are: Y Clinical signs and symptoms of DVT Pulmonary embolism is most likely diagn | | ie F is (alternate diagnosis less likely) Y Tachycardia (100dpm) ma | } v v Immobilization/surgery in previous 4 weeks Prior DVT/PE Hemoptysis | Y Active malignancy with in last 6 months | _ * Those patients identified >2 score are educated as risks and DVT prophylaxis to be followed. | © DVT Prophylaxis are: | Y Bed rest | Y Elevation of legs above the level of heart | ¥ Encourage patient to perform gentle foot and leg exercise | Y Crape bandage application Y Increase fluid intake up to 2litres per day unless contraindicated ¥ Compressive stockings Management during non-availability of beds. © Initial treatment shall be given at the Emergency ICU © Later shifted to the respective beds on vacancy. * Allefforts shall be made to accommodate patient coming for admission as far as possible. © If impossible to accommodate after stabilising shift to the hospital nearby as per the referral list where service is available Transfer of unstable patient © Stabilize the unstable patient before transferring, * Ambulance with all facility can be used or outside transfers ‘A doctor shall accompany the patient while transferring ‘© A case summary to be provided mentioning the status of patient, significant findings and treatment given in the hospital Triaging process Emergeney Severity index is used for triag ing the patients in ER The colour codes are: > Green -Stable Patients* Yellow- Unstable Patients > Red- Critical Patients > Black- Deceased/Dead Code Blue management BERT Responder RI: Cardiae Compression-Nurse/Doctor ® Finds the patient Cheeks consciousness, breathing Provides oxygen (if available) — NRM-1Olpm, NP—6LPM — 3ply mask * Checks pulse(Carotid) Calls Help ~ announces Code Blue, Bed No ~ asks for foot stool/oxygenlsuction if not available Starts cardiac compression ~ 100-120, 5-6cm with recoil. Counts loud 1-1 00/charge Position: Left side of the patient’s Chest 2. BERT Responder R2: Airway/Breathing- Nurse/Doctor © Brings airway tray 9 “= * Provides airway management, opens air- head tiltchinlifvjaw thrust- clear airway © (suctioning < 15sec) * Provides Bag/Valve/Mask ventilation and Oxygen therapy Assists Anaesthetist (when they arrive) with airway management and oxygen therapy Secures ET tube, gives information to R4- revorder of actions (closed loop © communication) “Secures insertion of RylestubeOperation of Fire e —_——— ~ * Pull the pin Aim at the base of the fire © Squeeze the handle * S-Sweep from side -to -side Evacuation * Evacuation is transfer of patients/staff from the building to a safe assembly point. i. Category 1 — Patients who require stretchers / trolleys to move ii, Category 2 - Patients who are able to move with the aids of walkers, wheelchair, Category 3 — Patients that needs staffs help in moving including children less than 3years. Category 4 — Able to move on their own ry 4 will be evacuated first followed by 3,2,1 0 be gathered in assembly point near A&E It to be taken by HR Staff’ tient evacuation should be also ensured _by Chief of Nursing by taking unit counts.© Compliance to patient identification © Compliance to Clinical hand over Compliance to nursing Documentation © Compliance to Nursing care plan Accidental removal of lines and tubes Nursing staff Attrition rate Nursing Quality initiatives * VISUAL ALERT on double check of medications for preventing transcription error * CLINICAL ROUNDS CARD to prevent the patients complaints and prompt attention to Patient needs * ACUITY BASED Assignment * Position Clock Hand Hygiene Token for improving hand hygiene compliance its and Projects in Nursing department * Documentation audit Clinical audit on peripheral line care bundle maintenance Quality Improvement Project of central line audit Dose inhand x Total volume tion formula:~ Total volume to be infused(m!) *Drop factor Total time of infusion in minutes = flow rate’min