Limitless Nexus
Search site

exhibition Info
Annual Regulatory Requirements, Current Practice

Type: Literature (txt)

Submitter: [anonymous]

Category: Guides / Tutorials - Health / Medical

Exhibition Date: 2017-02-26 07:34:31 MST

Views: 901

Score: 5.00 / 5.00
(Based on 1 votes.)

Rate this exhibition

Actions

Sponsor
 


Exhibition
View in new window

Annual Regulatory Requirements, Current Practice

Purpose/Goals
Objectives
Introduction
Patient's Rights
Confidentiality of Health Information and HIPAA
Access to Emergency Services
Information Disclosure
Participation in Treatment Decisions Training
Informed Consent
Advanced Directives
Research Participation
Organ Donation
Respect and Nondiscrimination
Cultural and Spiritual Needs
Complaints, Grievances, and Appeals
Bills and Bill Examination
Workplace Safety
National Patient Safety Goals
Recognizing and Reporting Abuse
Use of Restraints
Case Study
Fall Reduction
Violence Preparation
Sexual Harassment
Radiation Safety
Environment Safety
Injury Prevention
Ergonomics
Chemical Hazards
Fire Drill
Emergency Management Disaster Preparedness
Alarm System
Infection Control
Hand Washing Guidelines
Standard Precautions
Personal Protective Equipment (PPE)
Needlestick Prevention
Transmission Based Precautions (Isolation)
Contact Precautions
Airborne Precautions
Droplet Precautions
Neutropenic Precautions
Central Line and Surgical Infections
Waste Management
Case Study
Recommended Healthcare Worker Immunization
Exposure to Bloodborne Pathogens
Hepatitis B
Hepatitis C (HCV)
Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (HIV, AIDS)
Tuberculosis
Pain Management
The 5th Vital Sign
Pain Assessment
Pharmacological Management of Pain
Common Side Effects with Long-term Opioid Treatment
Nonpharmacologic Techniques of Pain Management
Non-invasive Mechanical Interventions for Pain
Invasive Therapies for Pain
Latex Sensitivity
Hazardous Flammable Combustible - Liquids, Vapors, and Gases
Antineoplastic Drugs, Hazardous Drugs, Toxic Substances
Anticoagulants
Electrical Safety
Waived Testing
Conclusion
References:

A score of 80% correct answers on a test is required to successfully complete any course and attain a certificate of completion.
Authors: David Tilton (RN, BSN) , Julia Tortorice (RN, MBA, MSN, NEA-BC, CPHQ)
Purpose/Goals

This course updates and reviews annual training topics required for the Healthcare Insurance Portability and Accountability Act (HIPAA), the Joint Commission on Accreditation of Healthcare Organizations (TJC), and Occupational Safety and Health Administration (OSHA). It also includes medical device reporting, patient�s rights, Medical Safety Data Sheets (MSDS) and workplace safety. This course does not address facility specific information.
Objectives

After completing this course, the learner will be able to:

Identify patient�s rights
Discuss TJC national patient safety goals
Discuss HIPAA regulations
Identify components of a safe workplace
Consider the importance of infection prevention focus
Discuss environment of care safety

Introduction

Quality healthcare includes responsibility to many masters, of which the client is number one. Have you ever wondered though, who looks out for the patient? Who makes sure everything is up to date, running smoothly, and for goodness sake how do they accomplish the massive undertaking of making sure the best possible care is given?

The answer is, we all work toward the goal of quality care, and to help us on this mission we look to outside regulatory agencies and accreditation organizations who can lend an impartial eye toward how well we are doing, and the degree to which we are accomplishing the goal we all desire. One of the most important tools provided to each of us by these regulatory partners during this age of rapid change and information overload are lists of topics for which annual training is required.

Please be mindful that regulatory agencies are not the enemy, nor are they choosing to unduly burden you with repetitive classwork through which you can snooze. The viewpoint across the horizon of healthcare, on a regional, national, and even international level, shows vulnerabilities and the need for improvements that we may not be aware of. That broader view also can identify real-to-us skills that need honing or information deficits we are unaware of.

Annual training is an opportunity to be current with topics of import, and polish skills we may not have had a call to use recently. So take the opportunity to benefit from the work put in by regulatory agencies identifying key areas of focus, and let�s look at the annual review topics that help us provide the quality of care we crave.
Agency Regulation Ongoing Required Training
TJC HR.01.05.03 EP.1 Ongoing education and training for competency with documentation of training and competency.
TJC HR.01.05.03 EP.4 Ongoing education and training related to responsibilities and any change in responsibilities, with documentation.
TJC HR.01.05.03 EP.5 Ongoing education, specific for patient population needs, with documentation of training.
TJC HR.01.05.03 EP.6 Ongoing education and training on teamwork, including communication, collaboration, and coordination of care. (All of which needs documented, so just mentally add that phrase after each regulatory mandate, Okay?)
Patient's Rights

It is all about the patient, the client. It should be no surprise then that several regulatory agencies bring client�s rights to the forefront of annual required training for healthcare professionals. Definitions and concepts of the rights of a client, and even the very idea that a client might possess any rights at all, have dramatically changed over the last few decades. Be warned that patient's rights, privileges, and duties remain in a state of societal flux and the anticipation is that changing perspectives will continue for some time, making this a smart topic to require regular updates on.

In its broadest sense, client rights define the basic rules of conduct between healthcare personnel and their patients. This includes institutions and health systems, as well as those employed in any capacity to serve them. Details concerning patient's rights can be found anchored in federal regulatory documents such as the Emergency Medical Treatment and Active Labor Act (EMTALA), as well as in every health profession�s defining articles, such as the American Medical Association (AMA) Code of Medical Ethics. Concepts and details concerning patient's rights abound in state and federal legal statutes and if broken may result in professional suspension, fines, or even prison. (Davis, 2015).

When discussing aspects of patient's rights training it is perhaps easier to say, who does not require healthcare professionals to update their knowledge on this topic. Two of the major regulatory and accreditation organizations that require patient rights training is;

CMS (Center for Medicare Medicaid Services)
TJC (The Joint Commission)

Each accrediting organization or regulatory agency will have their own sphere of vision as to what a specific topic must include. As a general guide, concerning the broad topic of patient rights, the following key areas taken from the Advisory Commission on Protection and Quality in the Health Care Industry � The Consumer Bill of Rights developed by the federal Department of Health and Human Services provides a strong guiding framework (Medline Consumer Rights, 2013):

Information Disclosure

You have the right to receive accurate information that you can understand about your health, treatments, health plan, health care providers, and health care facilities. If you speak another language, have a physical or mental disability, or just don't understand something, you will be helped so you can make informed health care decisions.

Choice of Providers and Plans

You have the right to choose your health care provider, within your health plan.

Access to Emergency Services

If you have severe pain, an injury, or sudden illness and you are concerned that you could be seriously ill, hurt, or could die, you have the right to get emergency services whenever and wherever needed, to be seen by a doctor and get services, even if you do not ask your health plan first, and you will not be charged a penalty.

Participation in Treatment Decisions

You have the right to know all your treatment options, even if they are not covered by your health plan, and make decisions about your care. Parents, guardians, family members, or others that you choose can represent you if you cannot make your own decisions.

Respect and Nondiscrimination

You have the right to considerate, respectful care, and not to be discriminated against, by your doctors, other health care providers, or health plan representatives.

Confidentiality of Health Information

You have the right to talk in private with health care providers and to have your health care information protected. You also have the right to review and copy your own medical records and ask your doctor to make corrections your record if it is not accurate, complete, or has information that does not relate to your health care.

Complaints and Appeals

You have the right to a fair, fast and objective review of any complaint you have against your health plan, doctors, hospitals or other health care personnel. This includes complaints about waiting times, hours available, health care facilities, and the conduct of health care personnel

Consumer Responsibilities

Do your best to get well and stay healthy, with healthy habits, such as exercising, not smoking, and eating a healthy diet.
It�s very important to give your health care provider, and clearly communicate what you want and need
Be involved with your health care providers when making your health care decisions�Work with health care providers in developing and carrying out treatment plans you all agree upon
Use the health plan's internal complaint and appeal process to address concerns that may arise
Avoid knowingly spreading disease.
Recognition of risks and limits of the science of medical care and that health care providers are human and can make mistakes.
Be aware of a health care provider's need to fairly provide care to other patients and the community.
Learn about your health plan coverage and health plan options (when available) including all covered benefits, the limits, what isn�t covered, the rules regarding use of information, and how to appeal coverage decisions.
Show respect for other patients and health care workers.
Make a good-faith effort to pay your health care bills.
Follow procedures of the health plans and health care providers.
Report wrongdoing and fraud to the right resources or legal authorities

Rights and responsibilities are both components of patient rights, and frankly our patients are as oblivious to their duties as some of our colleagues may be to theirs - or at least would be without annual training to keep them sharp. This means we need to be on our toes and remind our patients about what they are responsible for, and what we in turn will be doing. Let�s take a look at some of the subtopics within patient rights for which annual trainings are required. These secondary, though still important, subjects may show up included in a comprehensive patient rights training, or might be presented as stand-alone topics. They do however require consistent and clear documentation of completion in order to satisfy the auditing eyes of regulatory and accrediting entities.
Confidentiality of Health Information and HIPAA
Agency Regulation Ongoing Required Training
TJC IM.01.01.03 EP.3 Education and ongoing training on managing interruptions in the information process, with a focus on when electronic systems are unavailable.
TJC IM.03.01.01 EP.1 Education and ongoing training on providing access to information resources, 24/7.

Information about both clients and staff must be kept secure and confidential. Specific staff should be designated to ensure this and any staff member working in the presence of client information must know how to maintain and secure protected information. This is not the job of medical records staff, it is everyone�s duty.
Agency Regulation Annual Required Training
OSHA 29.CFR.1910.1020(g) Annual Exposure and Medical Records Training

Let�s face it, you simply cannot talk about patient rights without serving up a side of HIPAA. The Joint Commission, CMS, and a plethora of state and federal agencies require all healthcare staff from pathologist to plumber be constantly versed on relevant aspects of the Health Insurance Portability and Accountability Act (HIPAA).

The HIPAA privacy rule is a federal regulation that was designed to address public concerns about managed care, insurance availability, and insurance affordability. However, this course only addresses the privacy, confidentiality, and security aspects of the legislation.

The rule sets standards for patient privacy and confidentiality. It also sets severe civil and criminal penalties for people who violate a patient�s privacy. To comply with HIPAA protected patient information must only be shared with people who are directly involved in that patient�s care. This is especially important when talking in public areas (elevators, restrooms, hallways, or cafeteria etc.). Charts or documents should not be left out where they might be seen by unauthorized persons, computer screens should not be angled in such a way as to allow the screen to allow unwanted viewing. It is vitally important to observe surroundings when discussing patient care.

The privacy rule standards address the use and disclosure of individuals� health information called �protected health information�. All facilities must limit access to protected health information only to those who have a need to know. A nurse who seeks information about a patient not under his/her care is violating the HIPAA rules. Protected health information can only be used for health purposes. Employers cannot use the health history information to screen candidates for hire or promotion. Financial institutions may not use it to determine lending practice. Only the patient can explicitly authorize employers, banks, and individuals to have access to his/her medical information.
Protected Health Information

The HIPAA Privacy Rule protects individually identifiable health information, called PHI, held or transmitted by a covered entity or its business associate, in any form, whether electronic, paper, or verbal. PHI includes information that relates to the following:

The individual�s past, present, or future physical or mental health or condition;
The provision of health care to the individual; or
The past, present, or future payment for the provision of health care to the individual.

PHI includes many common identifiers, such as name, address, birth date, and Social Security Number.

(MLN, 2015)

HIPAA also established the �minimum necessary rule� which stipulates that only the minimum necessary information may be shared, even with the patient authorization. A classic example would involve treatment for a case of child of domestic abuse; the professional would, rather than providing an entire medical record, share the pertinent data furnished in the form of an abstract, outlining the information that is necessary to provide treatment and protect the victim. The abstracted information could be provided to legal and law enforcement entities.

Health professionals who are directly involved in the treatment of patients are not subject to the minimum necessary rule and can have full access to all information that is needed to provide care. Health information that has implications for the public health and safety can be shared without consent. There are several situations where medical information can be shared:

Emergency 911 situations,

When communicable diseases are involved,

When law enforcement agencies participate,

If national defense or security is a factor.

The public health department is deemed a legitimate recipient of certain personal health information and professionals may, in fact, in some instances, must report certain findings to the proper public health agency. Included are: cause of death even when the patient dies at home, reportable communicable diseases, child abuse, reporting an adverse drug reaction to the Federal Drug Administration, occurrence of cancer in a state with a cancer registry, meningitis, and immunizations for children.

HIPAA privacy regulations also mandate specific patient rights that include the following;

Right to privacy notice requires disclosure and reasonable effort to ensure that the patient understands the agency�s policy concerning privacy of information.

Right to request restrictions - patients may specify health information that cannot be released and/or, they may restrict to whom information can be released.

Right to access of personal health information - patients must be allowed to inspect and copy information contained in the agency�s record.

Right to know what disclosures have been made - the agency must track all information released and be able to provide documentation to the patient.

Right to amend the personal health information - while patients may request amendments and the agency must allow amendments, the agency may deny some requests.

Electronically generated, stored, or transferred information also falls firmly under HIPAA privacy rules. Both individuals and facilities are responsible for defending electronic protected health information (ePHI).
HIPAA Security Rule The Security Rule specifies safeguards that covered entities and their business associates must implement to protect the confidentiality, integrity, and availability of ePHI. Covered entities and business associates must develop and implement policies and procedures to protect the security of ePHI that they create, receive, maintain, or transmit. Each entity must analyze the risks to the ePHI in its environment and create solutions appropriate for its own situation.

(MLN, 2015)

Protected information that does get shared, either by accident or with purpose, must immediately be reported using the facilities established procedures. Depending on the extent of the information breach, the federal agency overseeing HIPAA accountability and/or local media may need notified.
HIPAA Breach Notification Rule

The Privacy Breach Notification Rule requires covered entities to notify affected individuals, the Department of Health and Human Services (HHS), and in some cases, the media of a breach of unsecured PHI. Most notifications must be provided without unreasonable delay and no later than 60 days following the discovery of a breach. Notifications of smaller breaches affecting fewer than 500 individuals may be submitted to HHS in a log or other documentation annually. The Rule also requires business associates of covered entities to notify the covered entity of breaches at or by the business associate.

The HHS Office for Civil Rights enforces the HIPAA Privacy, Security, and Breach Notification Rules. For more information on the enforcement process, visit http://www.hhs.gov/ocr/privacy/hipaa/enforcement on the HHS website. Violations may result in the imposition of civil monetary penalties. In some cases, criminal penalties may apply, enforced by the Department of Justice.

(MLN, 2015)
Access to Emergency Services

Several regulatory agencies require annual training regarding the ability of patients to access emergency care, this is especially important to CMS. Right to care is reflected in the 1986 Emergency Medical Treatment and Labor Act (EMTALA) and ensures the public has access to emergency services regardless of lack of insurance or ability to pay.
Emergency Medical Treatment & Labor Act of 1986 (EMTALA)

Section 1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor, regardless of an individual's ability to pay. Hospitals are then required to provide stabilizing treatment for patients with EMCs. If a hospital is unable to stabilize a patient within its capability, or if the patient requests, an appropriate transfer should be implemented.

(CMS EMTALA, 2012)

EMTALA is often called the anti-dumping law and was passed as part of the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA). Insurance companies are now obligated to use a standard definition for the need of emergency room (ER) services. This definition uses the concept of a prudent layperson. Under this definition, a person has need for ER services if he or she has signs or symptoms that a reasonable non-medical person would consider an emergency.

If the patient has severe pain, an injury, or a sudden illness that convinces him/her that their health is in serious jeopardy, they have the right to receive screening and stabilization emergency services whenever and wherever needed without prior authorization or financial penalty. The patient has the right to request transfer to another institution providing it is medically permissible and the other facility will accept the transfer.

Under EMTALA, a hospital must screen all incoming patients. The screening must be complete enough to find out whether that person has an emergency medical condition. The medical screening exam must be performed by a physician or qualified individual who is designated by the facility to provide the medical screening exam.
Agency Regulation Ongoing Required Training
TJC HR.01.05.03 EP.13 Education and training on how to identify and respond to changes in a patient�s condition.

Please note all trainings involving EMTALA must clearly state that a triage exam does not constitute a medical screening exam.

If the patient does not have an emergency condition, the hospital has no further obligation under EMTALA. If the patient does have an emergency condition, the hospital must provide stabilizing treatment. This treatment must be provided without considering the patient�s ability to pay. Before the patient is stabilized, the hospital may transfer the patient out only if another facility is better equipped to treat the patient and their condition. The hospital may not transfer an unstable patient for purely economic reasons.
Information Disclosure

Patients in healthcare facilities have the right to accurate and easily understand information about their health plan, healthcare professionals, and the facility itself. Should English not be their primary language, or they have physical or mental disabilities, then appropriate information must be provided to allow them to make informed healthcare decisions.

Patients have the right to know about the facility itself. This information can cover a wide range like;

How to file a complaint.

The facility�s position on withholding and withdrawing life-sustaining care and treatment.

Experience with specific procedures and services.

Accreditation status, quality and consumer satisfaction ratings � Note: this information is already available through the internet.

Their healthcare team � who is responsible for their care � names and professional status, team members education and board certification status, years of practice, experience, quality and consumer satisfaction ratings.
Their rights and responsibilities as patients. Remember they must understand the information they are given about their rights.

While auditing agencies understand that each facility will have its own methods for making sure patients know and understand their rights, regulatory agencies require proof that facilities are providing this information to patients. Inspection of expectations come both by undertaking direct observation and examination of facility policies or records.

Most facilities display information on patient rights at intake points in the facility. Many also provide patients with a written form of rights at intake during the admission process in patient handbooks. Rights and responsibilities may also be posted in waiting areas; be aware however, a written list of rights is not enough. The facility must make sure that all patients understand their rights well enough to exercise them. In fact, this is true of all information. All information must be presented so that the person can understand it. This means that patients may need special help if they do not speak English, cannot hear well, or have other mental or physical barriers to understanding. Examples of special help include:

Sign-language interpreters

Social workers or case managers

Large print or Braille materials

Magnifying glass or large print documents

Participation in Treatment Decisions Training

Patients have the right to participate in decisions about their care and to set the course of their treatment. This means that they must be given accurate information. They have the right to know their diagnosis, prognosis and treatment options. Healthcare providers must discuss all treatment options with their patients, which includes the option of no treatment. Further, they need to know the risks, benefits and potential medical consequences for each treatment option.
Informed Consent

Discussing clinical information with a patient is part of informed consent. Informed consent is an ongoing process of communication between a healthcare provider and the patient. It allows the person to make intelligent decisions about a proposed course of treatment. Remember, information is useful to a patient only if he or she can understand it. When discussing diagnosis and treatment options with the patient avoid the use of medical jargon and terminology; seek the services of a translator or interpreter if necessary, and assist the patient in obtaining a second opinion if requested.

After receiving all pertinent information, a patient may give informed consent for treatment or refuse treatment. Signing as a witness on the informed consent document is witnessing that the patient themselves signed the document. It does not mean that the witness participated in providing informed consent.

Except in an emergency, a patient must give his or her informed consent prior to the start of any procedure or treatment. Informed consent or the reason for a patient�s inability to provide informed consent must be documented in the medical record. The informed consent document must:

Be clearly worded in simple terms without abbreviations.

Indicate the specific procedure to be performed.

Include a list of possible complications.

Be written as stated in physician orders.

Be signed by the patient before receiving pre-op meds that induce sedation or amnesia or reduces anxiety.

Contain the patient�s dated signature, if the patient is of age and competent.

Contain the signature of the physician performing the procedure.

Ensure that the consent has date and time.

Include a witness� signature affirming the patient signed.

Please note that two witnesses are required for;

Person signing for incompetent patient.

Telephone consent.

Signature of �X� if patient cannot write.
When there is a clause for photographs and blood transfusion if applicable.

If the patient cannot give consent, laws vary from state to state and policy varies from facility to facility. The following are generally accepted practices. If the patient is a minor, the legal guardian must sign the consent. An emancipated minor can sign consent. An emancipated minor is usually recognized as one who is not subject to parental control, as in the following situations:

Married minor.

In military service.

College student under legal age but living away from home.

Minor who has a child.
Court ordered emancipated minor.

If the patient is incompetent or incapacitated, permission can be sought from a patient representative who is usually a family member or Power of Attorney. An incompetent patient is any patient who is mentally or physically incapacitated, as determined by physicians, such that the patient cannot communicate treatment preferences. The patient does not have to be adjudicated incompetent by a court of law for the purposes of consenting for a procedure. Facility policy usually dictates the process and how many physicians must be involved in the decision.

In an emergency, where the physician feels that delaying a procedure would be an immediate threat to the patient�s life or limb, and the patient cannot give consent, the physician may proceed with the procedure without consent. This process requires extensive documentation and often a consultation with other physicians. Check your facilities policy.

Patients have the right to refuse treatment. Even after giving informed consent, patients may change their mind at any time. If the patient decides to withdraw consent, the treatment must be stopped. When a patient refuses treatment, he or she has the right to know what will happen. They should receive information on the possible medical and other consequences of refusing treatment. Parents, guardians, family members, or other individuals that are designated as the representative of the patient if he cannot make his/her own decisions must be provided the same information.
Advanced Directives

The Patient Self Determination Act became effective December 1991. This federal law requires that all hospitals receiving Medicare or Medicaid funding provide information to all adult patients upon admission about advanced directives and to ask whether they have an advanced directive. In accordance with Federal and State regulations, patients should receive information regarding advanced directives if they do not present with this information at admission. Advanced directives can be used from admission to admission, however, they should be reviewed with the patient at each admission to verify accuracy.

If the patient is incompetent at the time of admission, the information should be provided to the surrogate or proxy. If the patient is temporarily incapacitated, the information should be provided when decisional capacity returns. A patient�s right to make decisions about his/her care is true even after they are no longer able to communicate those decisions directly. Advance directives can protect people who may be unable to communicate due to a condition such as irreversible brain damage or brain disease that affects the ability to think as well as communicate.

Advanced directives can limit life-prolonging measures when there is little or no chance of recovery. For example, advanced directives may enable patients to make their feelings known about cardiopulmonary resuscitation (CPR), intravenous (IV) therapy, feeding tubes, ventilators respirators and dialysis. Advanced directives can address pain relief, either requesting or refusing it.
Agency Regulation Ongoing Required Training
TJC PC.02.01.11 EP.4 Education and training on resuscitation equipment and techniques, as well as proper need and use for.
TJC PC.02.02.01 EP.2 Education and training on the needs of dying patients and their families.

An advanced directive is a legal document that allows a patient to participate in future healthcare decisions. There are two forms of advanced directives:

Living Will: a patient documents his/her wishes for future treatment in the event of terminal illness.A living will goes into effect when a patient develops a terminal condition that makes it impossible to communicate healthcare decisions directly.They are called living wills because they take effect while a patient is still alive.
Durable Power of Attorney for Healthcare: in this document, the patient appoints a representative to make healthcare decisions.The power of attorney goes into effect when the patient loses the ability to communicate his/her own decisions.The patient names a person called a surrogate or proxy to make decisions.

An additional tool for participating in future healthcare decisions is the do-not-resuscitate (DNR) order. A DNR order states that a patient does not want CPR if he/she goes into cardiac or respiratory arrest. A patient may request a DNR order; however, only a physician can approve and give the order.

To be clear, an advanced directive takes effect only after the patient is no longer able to communicate directly. Until that time, the patient�s direct communication is the only thing that matters. A competent patient may change his/her advanced directive at any time. If a patient wishes to change a directive, the healthcare professional must make it possible. Care must never be based on whether or not the patient has an advanced directive and the decisions in the directive. All patients must be treated fairly and equally, regardless of advanced directives.

Power of attorney, drafted by a licensed attorney, is when one person authorizes another person to act on one�s behalf. Some important points regarding a power of attorney include signatures of the principal party, two adult witnesses, and the notary public. It may be used immediately. A power of attorney does not need to be filed in court except for real estate transactions. The power of attorney is in effect until revoked by the principal, participant�s death, or revoked by the court. A power of attorney may have more than one agent. If so, all agents must concur when making decisions. There are several types of power of attorney.

General: an agent acts on behalf of the person in a variety of situations.

Limited: limited to a specific transaction.

Healthcare: to make decisions when incapacitated.

Springing: in effect at some future time � illness, disability of principal.

Durable: all of the above can be made �durable� by adding text � enables agent to act when the principle is incompetent and physically unable to make decisions.

A healthcare surrogate is any competent adult expressly designated in writing by a patient to make healthcare decisions on his or her behalf when incapacitated. This surrogate has no authority to act until the primary care physician determines that the principal lacks capacity to make informed healthcare decisions. A proxy is a competent adult, who has not been expressly designated to make healthcare decisions for a particular incapacitated individual but who nevertheless is authorized to make healthcare decisions. A healthcare proxy is appointed by the hospital when there is no power of attorney or surrogate and healthcare decisions need to be made. Potential representatives for an incapacitated patient may include:

Guardian

Adult child

Domestic partner

Brother or sister
Close friend

When a patient loses the ability to communicate directly often he/she does not have an advanced directive. The hierarchy of healthcare decision makers for a patient without an advance directive depends upon state law.
Research Participation

Patients have the right to be part of research studies or educational activities. If a patient refuses experimental treatment, this should not have any effect on his/her regular care. If the patient wants to be part of a research study, he/she must sign a written consent which explains that the proposed treatment is experimental. The consent form for participation in experimental treatment must include the nature of experimental treatment, procedures involved, risks and benefits, other available options, and confirmation of any interruption in patient care.
Organ Donation
Agency Regulation Annual Required Training
CMS 482.45(a)(5) Organ and Tissue Donation Training

Patients have the right to choose about organ donation. They must give informed consent if they want to donate their organs. Notify the organ procurement agency affiliated with the facility as described in the facilities policy. The organ procurement agency will determine if the potential donor is medically suitably.
Agency Regulation Ongoing Required Training
TJC TS.01.01.01 EP.4,5 Education and training on organ donation issues such as organ procurement organizations (OPO), the need for discretion and sensitivity to beliefs and circumstances in regard to the family of potential organ donors.
Respect and Nondiscrimination

Patients have the right to considerate, respectful, nondiscriminatory, and compassionate care from doctors, health plan representatives, and other healthcare professionals. Respect means valuing the patients� needs, desires, feelings, and ideas. Treat patients with common courtesy. For example: knock and wait before entering a patient�s room; respond politely to patients; listen to patients; and remain compassionate. Patients have the right to fair and equal healthcare services regardless of:

National origin

Political affiliation

Level of education

Place of residence or business

Marital status

Personal appearance

Mental or physical disability

Sexual orientation

Genetic information

Source of payment

Cultural and Spiritual Needs

Culture is the way of life of a population, including shared knowledge, beliefs, values, attitudes, rules of behavior, language, skills, and world view among members of a given societal group. Culture shapes human behavior because it is the foundation of conscious and unconscious beliefs about "the proper" way to live. Cultures change constantly. Different members of a society internalize and express different parts of their shared culture. Subcultures are also always present and can reflect differences by geographic region or other subgroups within a larger shared society.

Religion, faith, and spirituality have significant cultural and spiritual roles in end of life customs. When discussing advanced directives or hospice, ethnic and cultural beliefs greatly influence the conversation as well the decision.

It is important to remember that simply because a person is identified as a member of a particular ethnic group or religion does not necessarily mean that the person or their family have the standard set of beliefs that may be associated with that ethnicity or religion. Within ethnic groups are characteristics that define the use of language, the role of family, religion, spirituality, the definitions of illness, the use of healing practices in healthcare, and health-seeking behaviors. For every case, an assessment must be made of how acculturated a person and their family are, their language skills, and whether an interpreter is needed. An assessment requires both the knowledge and the skills of the clinician. (OMH National CLAS Standards, 2015).

Patient perception of their condition is sometime referred to as �acceptance�. Rather than asking the patient if they accept their diagnosis, a better format can be asking open ended questions that elicit a cultural response. A patient may be taking herbal remedies, employing traditional healing methods, or believe their illness is in direct response to past behaviors, a punishment of some sort. The following questions should be considered.

Do you think that there are ways to get better that your physician may not be aware of?

What do you think is wrong or causing your health problem?
Is there anyone else helping you get better?

This approach is likely to provide a truer response to the patient�s acceptance of illness. The healthcare professional must also take into consideration cultural beliefs on terminal diseases and death and dying practices. Be aware, there are cultures that believe it is better to withhold terminal news. (Searight, 2005).

Each facility should have a standardized assessment form that will include cultural, religious, and spiritual assessments. Communication is probably the most important aspect of the assessment. The patient may have limited English proficiency (LEP) that creates a language barrier. A family member may not be the best interpreter.

Remember that inadequate interpretation is a form of discrimination. Also, cultural beliefs held by the person interpreting may result in misinformation. For instance, a Hispanic woman may not want her son interpreting in discussion of gynecological issues and may give false information to avoid that situation. An unbiased interpreter should be used for discussions of informed consent and dying.

Cultural competence is the ability to give healthcare in ways that are acceptable and useful to patients because it is congruent with their cultural background and expectations. National cultural competence standards for healthcare professionals include: (OMH National CLAS Standards, 2015).

The Principal Standard

Provide effective, equitable, understandable and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs.

Governance, Leadership and Workforce

Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices and allocated resources.
Recruit, promote and support a culturally and linguistically diverse governance, leadership and workforce that are responsive to the population in the service area.
Educate and train governance, leadership and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis.

Communication and Language Assistance

Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services.
Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing.
Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided.
Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area.

Engagement, Continuous Improvement and Accountability

Establish culturally and linguistically appropriate goals, policies and management accountability, and infuse them throughout the organizations� planning and operations.
Conduct ongoing assessments of the organization�s CLAS-related activities and integrate CLAS-related measures into assessment measurement and continuous quality improvement activities.
Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery.
Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area.
Partner with the community to design, implement and evaluate policies, practices and services to ensure cultural and linguistic appropriateness.
Create conflict- and grievance-resolution processes that are culturally and linguistically appropriate to identify, prevent and resolve conflicts or complaints.
Communicate the organization�s progress in implementing and sustaining CLAS to all stakeholders, constituents and the general public.

Complaints, Grievances, and Appeals
Agency Regulation Ongoing Required Training
TJC PC.01.02.09 EP.3 Education and training on recognizing signs of abuse or neglect and staff roles in follow-up.

Consumers of health services have the right to question, complain about, file grievances, or appeal decisions made concerning their health care. CMS, TJC, and many state and federal agencies request and require healthcare professionals to be trained on this subject annually.

Every patient has the right to a fair, fast, and objective review of any complaint that they have concerning the health plan, doctors, hospital, or other healthcare personnel. This includes complaints about waiting times, operating hours, the conduct of healthcare personnel and the adequacy of healthcare facilities. Many facilities have a patient care representative to deal specifically with complaints or grievances. Many patient complaints can be addressed quickly. For example, if a patient complains about getting the wrong items on her lunch tray, make sure she gets the right items next time. The sooner the issue is resolved at the lowest level possible the better patient compliance and satisfaction with the healthcare provided. The patient may need to have access to the ethics committee for issues regarding his/her care. They should expect that issues related to end-of-life care be treated with respect and sensitivity. The patient should be able to examine and receive an explanation of his/her bill regardless of source of payment.

More than 50% of the patients who sue do so because of miscommunications, anger, and lack of information between physicians, hospital staff, and patients/families. Grievance management is everyone�s responsibility. Handling grievances effectively from the start benefits everyone involved, helps keep small grievances from becoming big ones and reduces the risk of liability. When complaints cannot be resolved quickly and easily, patients have the right to file a grievance. A grievance is a formal written or verbal complaint. If a patient wants to file a grievance, the healthcare professional must:

Explain the grievance process at the facility. This includes the name of the staff person the patient should contact for assistance of with resolution of their grievance.

Explain that grievances may be filed with state agencies.This is true whether or not the patient has already used the facility�s internal grievance process.

Give the patient the phone number and address for filing a grievance with the state.

Healthcare facilities must review, investigate, and resolve all grievances within a reasonable period. If the grievance has to do with the patient�s safety it should be reviewed immediately. Examples include grievances about abuse or neglect. To complete the grievance process, the facility must give the patient a written report. This report should explain: how the facility investigated the grievance and the facility�s decision about the grievance.
Bills and Bill Examination

Patients possess the right to question their bills. They have the right to request and receive a detailed explanation of every item on a bill, and training on this subject is expected either separately or as a component of patient rights training.
Workplace Safety

It�s about the patient and also about us as healthcare providers. We all want to return home safely at the end of the day.
National Patient Safety Goals
Agency Regulation Ongoing Required Training
TJC APR.09.02.01 EP.1,2 Staff concerns about safety and quality of care reporting ongoing training.

The Joint Commission is one of five hospital and health services accrediting agencies accepted by CMS in the United States; The Joint Commission (TJC), Healthcare Facilities Accreditation Program (HFAP), Accreditation Association for Hospitals Health Systems Inc. (AAHHS), the Center for Improvement in Healthcare Quality (CIHQ) and Det Norske Veritas Healthcare Inc. (DNV). TJC is the big dog, providing oversight for more than 5000 hospitals and 10,000 other types of healthcare facilities. All accreditors serve the same function of inspection and accreditation of quality in health facilities so as to assure CMS that the health care provided meets or exceeds conditions of payment for services participation set by the federal government. This allows the approved health provider to receive payments and other monies from Medicare and Medicaid.

Please remember that although accrediting organizations serve a vital link between tax dollars and health care, these organizations are not part of the federal government. They are independent contractors serving the function of assuring federal and state, and in turn private insurers and citizens, that each healthcare facility they accredit provides a high level of quality care. The process of approval is often referred to as the health services provider gaining a �deemed� status, as in deemed worthy to receive payments. For the purpose of this course we will focus on The Joint Commission annual training requirements due to TJC�s size, standing, close working relationship with CMS and the history of comprehensive observation and inspection of its expectations. (Headley, 2015).
TJC 2015 Hospital National Patient Safety Goals Goal 1 Identify Patients Correctly
NPSG.01.01.01 Use at least two ways to identify patients. For example, use the patient�s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment.
NPSG.01.03.01 Make sure that the correct patient gets the correct blood when they get a blood transfusion.
Goal 2 Improve staff communication
NPSG.03.04.01 Before a procedure, label medicines that are not labeled, e.g. medicines in syringes, cups and basins. Do this in the area where the medicines and supplies are set up.
NPSG.03.05.01 Take extra care with patients who take medicines to thin their blood.
NPSG.03.06.01 Record and pass along correct information about a patient�s medicines. What they are prescribed, what they are actually taking. Often referred to as medication reconciliation.
Goal 3 Use medicines safely
NPSG.03.04.01 Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups and basins. Do this in the area where medicines and supplies are set up.
NPSG.03.05.01 Take extra care with patients who take medicines to thin their blood.
NPSG.03.06.01 Record and pass along correct information about a patient�s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines being given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor.

Goal 4 Use Alarms Safely
NPSG.06.01.01 Make improvements to ensure that alarms on medical equipment are heard and responded to on time.
Goal 5 Prevent Infection
NPSG.07.01.01 >Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning.
NPSG.07.03.01 Use proven guidelines to prevent infections that are difficult to treat.
NPSG.07.04.01 Use proven guidelines to prevent infection of the blood from central lines.
NPSG.07.05.01 Use proven guidelines to prevent infection after surgery.
NPSG.07.06.01 Use proven guidelines to prevent infections of the urinary tract that are caused by catheters.
Goal 6 Identify Patient Safety Risks
NPSG.15.01.01 Find out which patients are most likely to try to commit suicide.
Goal 7 Prevent Mistakes in Surgery
UP.01.01.01 Make sure that the correct surgery is done on the correct patient and at the correct place on the patient�s body.
UP.01.02.01 Mark the correct place on the patient�s body where the surgery is to be done.
UP.01.03.01 Pause before the surgery to make sure that a mistake is not being made.

(TJC Topic Library, 2014)

The Joint Commission national patient safety goals provide a clear map of which areas will be the target of interest and inspection during accreditation surveys or inquiries. Be certain to address the topics found in the TJC safety goals in your annual trainings.

By the way, communication between health professionals and accrediting bodies is meant to flow both ways. Should you have concerns about patient safety or quality of care both CMS and Joint Commission have avenues of communication open to hear your concerns.
Recognizing and Reporting Abuse

All patients should be screened for abuse. Facilities must have procedures for identifying, reporting, and treating victims of abuse. Patients have the right to expect access to protective services in the case of abuse.
Agency Regulation Ongoing Required Training
CMS 482.13(c)(3) Education and ongoing training regarding abuse and neglect for all employees.

Abuse can take many forms. It may include emotional abuse, economic abuse, sexual abuse, threats, using the threat of removing children, using privilege, intimidation, isolation, and other behaviors used to maintain fear, intimidation, and power. There are many theories as to why some people are abusers. However, the reason abusers use this behavior is because violence is an effective method for gaining and keeping control over another person.

Sexual abuse is unwanted sexual activity with perpetrators using force, making threats or taking advantage of victims not able to give consent. Most victims and perpetrators know each other. Immediate reactions to sexual abuse include shock, fear or disbelief. Long-term symptoms include anxiety, fear or post-traumatic stress disorder. While efforts to treat sex offenders remain unpromising, psychological interventions for survivors, especially group therapy, appears effective. (APA Topics, 2015).

Psychological abuse occurs when a person tries to control information available to another person with intent to manipulate that person�s sense of reality or their view of what is acceptable and unacceptable. Psychological abuse often contains strong emotionally manipulative content and threats designed to force the victim to comply with the abuser�s wishes and can include constant verbal abuse, harassment, excessive possessiveness, isolating the person from friends and family, deprivation of physical and economic resources, and destruction of personal property. (Psych Central, 2014).

Physical abuse is physical force or violence that results in bodily injury, pain, or impairment. It includes assault, battery, and inappropriate restraint. It often begins with what is excused as trivial contact that escalates into more frequent and serious attacks.

Child abuse and neglect is at a minimum any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; and an act or failure to act which presents an imminent risk of serious harm. Physical abuse is the use of physical force that may result in bodily injury, physical pain, or impairment. Physical abuse may include acts of violence like striking, hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, and burning. This abuse may not have been intended to hurt the child; but an injury may have resulted from over-discipline or physical punishment. Neglect is the failure to provide for the child�s basic needs.

Child abuse or neglect is defined by the child welfare branch of the U.S. Department of Health and Human Services (DHHS) as:

Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or
An act or failure to act which presents an imminent risk of serious harm.

Mandatory Reporters of Child Abuse and Neglect

All States, the District of Columbia, American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands have statutes identifying persons who are required to report suspected child maltreatment to an appropriate agency, such as child protective services, a law enforcement agency, or a State�s toll-free child abuse reporting hotline.

To access the statutes for a specific State or territory, click here to visit the State Statutes Search.

(Child Welfare Information Gateway, 2014)

Any suspicion of abuse involving minors requires consideration of cultural values and standards of care as well as recognition that the failure to provide the necessities of life may be related to poverty.

Elder abuse can take many forms. It too may include physical, emotional, psychological, sexual abuse, neglect, abandonment, or financial and material exploitation. With the frail elderly, neglect is a major problem. Neglect is the refusal or failure to fulfill any part of a person's obligations or duties to an elderly person. Most laws concerning elder abuse are state laws, and can be found in a variety of state legal codes such as criminal, probate, welfare, business, and professional codes. Please be aware of your own states regulations and guidelines.

Many victims of abuse are seen in healthcare settings. Healthcare professionals often fail to identify victims, because there is a lack of training on what to look for and how to ask about abuse. Opportunities for intervention are missed and victims continue to suffer the adverse health consequences of physical and emotional abuse. For example, physically battered victims seek assistance in healthcare settings, often repeatedly.

Staff should question whether abuse might have occurred if a patient�s explanation of the injury does not match the actual injury. For example, a child�s x-rays may show an unexplained broken bone.

Screening for abuse must be done. The healthcare professional should document abuse in the medical record; safeguard evidence; provide medical advice, referrals, and safety planning; and show empathy with compassion. Each facility must maintain a list of private and public community agencies that provide help for abuse victims. Staff should make appropriate referrals for victims.

Screening questions should always be asked in a private room, away from the suspected batterer, and preceded by assurances of all the confidentiality allowed by law. Healthcare professionals should find ways to separate the patient from the possible abuser should the latter demand to accompany the potential abuse victim into the examining room.
Use of Restraints

Sometimes patients need to be kept safe from their own actions. While we always encourage individuals to exercise internal control, at times there may be need for external measures of restraint. The decision to use physical or chemical restraints is a medical decision. Restraints must never be used for the purpose of discipline or convenience. When a patient requires external restraint, it is important to protect that person�s safety, rights, comfort, and dignity.
Agency Regulation Ongoing Required Training
TJC PC.03.03.01 EP.2 Education and training on the use of restraint and seclusion.
TJC PC.03.03.07 EP.1,3 Education and training on minimizing the use of restraint and seclusion for behavioral purposes.
TJC PC.03.03.07 EP.4 Education and training on safe use of physical holding techniques, procedures for �take-downs�, and the application and removal of mechanical restraints.
CMS 482.13(f)

CMS 483.13(e)(11)
Periodic ongoing restraint and seclusion policy training.
Agency Regulation Ongoing Required Training
TJC PC.03.03.07 EP.5,6

TJC PC 03.05.17 EP.2,4,5
Qualifications, education and training of staff allowed to initiate restraint or seclusion, and perform 15-minute assessments of patients in restraint or seclusion. Demonstration of staff competence to perform these duties.

Review the equipment, policies, and documentation tools for each facility where you practice, as there may be some variation in both practice and definition of restraints. Restraint standards for medical/surgical purposes apply when the primary reason for use directly supports medical healing. Different standards are used for behavioral management, such as in a psychiatric setting. The use of restraints for behavioral reasons in a non-behavioral healthcare setting is differentiated by the reason the restraints are being used. Different standards are used for long term care. (TJC E-dition PC, 2015).
Medical vs. Behavioral Restraint Use

According to The Joint Commission:

�The decision to use restraints for medical/surgical reasons or for behavioral health care reasons is not based on the treatment setting but on the situation the restraint is being used to address���The simplest way to determine what is a behavioral health reason is first to determine what it is not. When restraints must be applied to directly support medical healing - this is not a behavioral health reason�.

(TJC Standards FAQ, 2009)

Behavioral use of restraints are the last option, and used only when a patient is imminently at risk of harming themselves or others with their behaviors. Less intrusive methods of regaining safety must be attempted before restraint is applied.

Medication to control behavior should be used only as part of a therapeutic plan, after appropriate assessment by professionals. Chemical restraint is a term used to describe the use of medications for purposes unrelated to the patient�s medical condition. An example is the use of a sedating psychotropic drug to manage or control behavior.

It is the intended use of a device or method that classifies the device or method as a restraint. For instance IV armboards, postural support devices, orthopedic appliances, protective devices like helmets, are not restraints when used to promote healing or protect an easily injured tissue or surgical site.
Restraint vs. No Restraint

According to The Joint Commission:

�Technically, a bed enclosure or side rails are neither purely a restraint nor a form of seclusion, based on the definitions that accompany the Joint Commission standards. However, a bed enclosure (e.g., net bed) and likewise a side rail could potentially restrict a patient's freedom to leave the bed and as such, would be restraint. If for example a bed rail is used to facilitate mobility in and out of bed, it is not a restraint. If the patient/patient can release or remove the device, it would not be a restraint.�

(TJC Standards FAQ, 2009)

Restraints or seclusion are to be used as a last resort after alternatives have proven to be unsuccessful. Restraints should not cause harm or be used as a form of punishment. Examples of alternatives to restraints include, but are not limited to:

Interaction on 1:1 basis with staff,

Redirection,

PRN medication with patient consent,

Staff or patient initiated time out in a quiet room with door unlocked. It should be presented as a way for patient to regain control, not as a threat.

Staff presentation of limits where consequences are presented for patient to choose,

Removal of stimuli from the patient or vice versa. Keep in mind that moving a patient close to a busy nurses' station so you can keep a close eye on him/her could over stimulate and worsen symptoms.

Relaxation exercises,

Calming music,

Distraction tactics.

If lesser interventions are not successful and you need to apply a physical restraint as a last resort, use the least-restrictive device possible. For example, a lap buddy is a soft vinyl device that attaches to the wheelchair rather than the patient. Although the patient can remove it when they are oriented, it serves as a reminder that he/she should not get up without assistance and protects in the event that he/she becomes confused again. Another alternative is a geriatric chair set in a reclining position or with a lapboard. This is less restrictive than a safety belt or roll belt. And a roll belt, in turn, is less restrictive than a vest restraint. Mitts are generally more suitable than wrist restraints because they are less restrictive and allow the patient to move their arms freely. Another option is elbow restraints that keep the arm straight but allow free arm movement.

A licensed, independent practitioner must order the restraint or seclusion; however, the facility may authorize qualified staff members, usually registered nurses, to initiate the use of restraints when needed before an order is obtained. The independent practitioner must evaluate the need for restraint or seclusion and assess the patient within 1 hour.

The authorized staff member can discontinue restraints or seclusion as soon as assessment reveals that restraints or seclusion is no longer necessary. The use of restraints for acute medical or surgical purposes must be reviewed and renewed if needed by the licensed, independent practitioner at least every 24 hours. The use of restraints for behavioral healthcare purposes in long term care must be reviewed and renewed if needed by the licensed, independent practitioner at least every 30 days.

Procedures for checking and documenting while a patient is in restraints are rigorous. Each facility will have a restraint or seclusion documentation tool that must be completed which must include the following.

Assessment of patients in restraints in acute care setting or long term care setting:

Patient to be checked at least hourly.

Restraints removed to allow movement at least every 2 hours.

Assess, turn, reposition, range of motion exercises, offer nourishment and fluids, and toilet the patient at least every 2 hours.

Psychiatric setting assessment of patients in restraints or seclusion:

Continuous observation is required.

Vital Signs every hour.

Ongoing assessment of airway and respiratory status.

Assess hydration and offer fluids at least every two hours.

Toileting offered every two hours.

Nutrition at mealtimes as safety permits.

Assess circulation and range of motion every fifteen minutes.

Check for injury associated with the application of restraint or seclusion.

Assess psychological status including readiness for discontinuation of restraint or seclusion.
Documentation of all activities.

Agency Regulation Ongoing Required Training
TJC PC.03.05.13 EP.1 Education and training on the need for continuous monitoring when a patient is both restrained and secluded.

The written order in the chart must include the justification for restraint or seclusion, type of restraint used, and the time limit for use. Some facilities will have a template for the physician�s order. The documentation of restraints and seclusion needs to include; the circumstances that led to seclusion or restraint, consideration or failure of non-physical interventions, rational for intervention used, notification of family if appropriate, criteria for discontinuation as well as informing the patient of the behavior criteria, each evaluation, any assistance provided to the patient, continuous monitoring, debriefing of patient with staff and any injuries that are sustained and treatment received.

Physical restraints should always be fastened for easy release in an emergent situation. The restraint should be attached on a fixed part of the furniture, like the bed frame. Fixing it to a movable part, like a side rail, could inadvertently tighten the restraint causing patient injury, or loosen the restraint causing it to be ineffective.
Case Study

A Joint Commission surveyor comes to the ward where a patient is in behavioral restraint due to assaultive behavior, and secluded in a corner room due to loud cursing and continuous verbal threats upsetting other patients. The primary physician is awaiting drug toxicology results before beginning a medication process to calm the patient, and a staff member is setting at the foot of the patient�s bed observing their vital signs and respirations.

The surveyor asks the observing staff if she can speak to them at the nurse�s station away from the anxious, animated patient.

The observing staff refuses, stating this patient must have continuous direct attendance at all times.

What reaction do you anticipate from survey personnel spurned?

This is a WIN! No person in seclusion AND restraint can be left alone at any time, for any reason. The possibilities of things going wrong while in restraints and isolated are mind boggling, here are a few:

Sudden unattended emesis and aspiration,

Medical emergencies due to heightened adrenal functions and agitation, e.g., stroke, cardiac arrest, panic attack, etc.

Self-injury from throwing oneself against restraining devices,

Another patient or person entering the room where the first is tied down and unattended and causing injury.

NOTE: Surveyors do not utilize trick questions, they are however willing to observe if staff are familiar with their own institutional procedures and policy.
Fall Reduction
Agency Regulation Ongoing Required Training
TJC HR.01.05.03 EP. Ongoing education and training on fall reduction.

A high falls risk is not a reason to use restraints. The following are suggestions to reduce falls risk:

Check the patient at least every hour.

Remind the patient to call for assistance if he/she wants to visit the bathroom.

Use low beds or put the mattress on the floor for patients who will not call for assistance to get up.

Arrange furniture so that it does not block the walkways.

Use a nightlight and keep debris and liquids off the floor.

Keep the patient's personal items, water pitcher, and call light within reach at all times.

Make sure the patient wears his/her eyeglasses, hearing aid, or other devices.

Ask family or friends to stay with him/her at night or other times when he/she tries to climb out of bed.

Violence Preparation

CDC reports identify the risk of violence to healthcare workers being much higher than for all other private sector industries. The circumstances of hospital violence differs from workplace violence in other settings such as banks, convenience stores or taxicabs where violence most often relates to robbery. Violence in hospitals is usually an outpouring of emotion rather than an attempt at material gain. With the violence toward others resulting from patients or their family members who feel frustrated, vulnerable, and out of control. Common risk factors for hospital violence include the following. (CDC Violence, 2014).

Working directly with volatile people, especially if they are under the influence of drugs or alcohol or have a history of violence or certain psychotic diagnoses.

Working when understaffed-especially during meal times and visiting hours.

Transporting patients.

Long waits for service.

Overcrowded, uncomfortable waiting rooms.

Working alone.

Poor environmental design.

Inadequate security.

Lack of staff training and policies for preventing and managing crises with potentially volatile patients.

Drug and alcohol abuse.

Access to firearms.

Unrestricted movement of the public.

Poorly lit corridors, rooms, parking lots, and other areas.

Violence may occur anywhere in a hospital, but it is most frequent in psychiatric wards, emergency rooms, waiting rooms, and geriatric units. Studies indicate that violence often takes place during times of high activity, and during interaction with patients. Assaults may occur when service is denied, when a patient is involuntarily admitted, or when a healthcare worker attempts to set limits on eating, drinking, tobacco or alcohol use. Patients with a condition that causes confusion and impaired judgment are more likely to become violent than a patient with normal mentation. Confusion and impaired judgment may be caused by neurologic conditions, seizures, hypoglycemia, or dementia. Watch for signals that may be associated with impending violence:

Verbally expressed anger and frustration.

Body language such as threatening gestures.

Signs of drug or alcohol use.

Also, it is important to note how your co-workers behave. If a colleague�s demeanor or behavior has changed for the worse, notify your manager. For example, slamming equipment around is red-flag behavior.

Learn from history. If a patient has a history of violent behavior (such as acting combative in the ambulance or waiting room), prepare yourself for potentially violent behavior and warn others who are caring for him/her. Let security know if you feel threatened or if you find or suspect that he�s carrying a weapon. Notify the supervisor if you suspect a patient is going to be violent. Help relieve the patient�s tension and anxiety by keeping him informed about when he�ll be examined or treated and what�s going on.

Be alert to your environment: (CDC Violence, 2014)

Evaluate each situation for potential violence when you enter a room or begin to relate to a patient or visitor.

Be vigilant throughout the encounter.

Do not isolate yourself with a potentially violent person.

Plan your exit. Always keep an open path for exiting. Do not let the potentially violent person stand between you and the door.

When you�re with an upset patient or co-worker, avoid areas of the room that lacks an accessible exit.

If you�re going to an isolated part of your facility, let others know where you�re going and when you expect to return.

Consider asking for an escort.

Note anyone who�s not wearing staff ID and is lingering where he/she shouldn�t. Ask politely if you can help them and notify security if you aren�t satisfied with the answer. If you�d rather not approach someone, call security and provide a full description.

Evaluate the way you wear equipment to be sure it cannot be used as a weapon against you. For example, consider that a stethoscope or ID badge without a breakaway necklace can be used to choke you. Carry your stethoscope in a pocket and use an ID badge necklace that has a breakaway feature.

If you wear a necktie, opt for a clip-on style.

If your hair is long, wear it in a way that�s not easy to pull, and do not wear dangling jewelry

In the presence of a potentially violent person:

Do

Plan a clear exit route.

Keep 5 to 7 feet between you and him. Never turn your back on him or let him get between you and the exit.

Keep your voice calm and quiet.

Acknowledge that he has a right to his feelings.

Assume that he has a valid concern and address it.

Try to meet reasonable demands.

Offer alternatives when possible. For example, tell an angry patient that although he cannot order take-out pizza, you�ll see if you can get him an early dinner. Tell an angry colleague that you see that she�s angry and that you�d like to work with her and your manager to resolve the situation.

Call for backup or security if a situation grows increasingly tense.

Ensure access to bathrooms, a phone, TV, and something to read.

Track equipment. Return it to its rightful place. When you take an item into a patient�s room, dispose of it properly or take it with you when you leave.

Take these steps if you cannot defuse the situation quickly:

Remove yourself from the situation.

Call security for help.

Report any violent incidents to your management.

Do not

Do not ignore the agitated person or avoid him.

Do not threaten or demand obedience.

Do not argue or become defensive or judgmental.

Do not laugh, move suddenly, make threatening gestures, or invade his personal space.

Do not try to handle a dangerous situation alone. Call security or initiate your facility�s violence prevention protocol.

In the presence of a weapon, maintain behavior that helps diffuse anger:

Present a calm, caring attitude.

Do not match the threats.

Do not give orders.

Acknowledge the person�s feelings (for example, �I know you are frustrated�).

Avoid any behavior that may be interpreted as aggressive (for example, moving rapidly, getting too close, touching, or speaking loudly).

Sexual Harassment

Let�s face it, something about the healthcare environment brings out the best, and the worst in people and their behaviors. Sexual harassment is not acceptable and can lead to civil prosecution and/or disciplinary action up to termination. Sexual harassment includes unwelcome:

Sexual advances

Request for sexual favors
Verbal, visual, or physical behavior of a sexual nature

Sexual harassment becomes unlawful when it becomes a condition of employment, advancement, unreasonably interferes with work performance, or creates an intimidating, hostile, or offensive work environment.

Work environments vary and people have varying levels of sensitivity. The worker has a responsibility to inform the people involved that they must stop because he/she is offended or feels sexually harassed. If the behavior continues report it to your supervisor or the human resources department. Do not mistakenly think it will go away on its own. Like a lingering foul stench harassment requires positive action in order to have it cease.
Radiation Safety

The main sources of radiation exposure in a healthcare facility are x-rays and radionuclides used in diagnostic tests and therapy. Areas where radiation is used are marked with the international tri-foil symbol.
GHS Chemical Hazard Symbol

Radiation

Danger Radiation Risk
4

Ionizing Radiation

Information on radiation and its hazards can be obtained from OSHA here: https://www.osha.gov/SLTC/radiation

Remember, portable x-ray machines may be found tucked in closets, storage rooms, at the side hall of emergency or critical care units, or many other unmarked areas.
Agency Regulation Annual Required Training
OSHA 29.CFR.1910.1096(f) and (i) Annual Ionizing Radiation Worker Training

During exposure to radiation, you should limit your time as much as possible, Move at least six to ten feet from the source, and wear leaded shields. If your job requires routine exposure, you should wear a monitoring device to measure your exposure. When working with radioactive material, wash your hands well and dispose of trash in the appropriate manner. Do not eat, drink, smoke, or apply products to your skin in an area where radioactive material is being used.
Environment Safety

For most health professionals and virtually every organization in the health industry the major regulatory authorities expecting targeted annual trainings are TJC, CMS, and OSHA. Let�s take a look at training topics that focus on safety in the workplace from the perspective of those organizations expectations.
Agency Regulation Ongoing Required Training
TJC EC.03.01.01 EP.1 Ongoing training so staff know how to identify physical risks in the environment of care, and demonstrate how to eliminate them.
TJC EC.03.01.01 EP.2 Ongoing training so staff can demonstrate the ability to handle an environment of care incident.
TCJ EC.03.01.01 EP.3 Ongoing training so staff can demonstrate the ability to report an environment of care risk.
Injury Prevention

If you are injured or exposed to a dangerous substance on the job, stop what you are doing; report the injury or exposure to your supervisor; seek medical attention if needed; and complete an employee accident report.

Accident hazards such as wet floors, stairway obstructions, and faulty ladders make the environment of care dangerous, eliminate them. Wet-floor hazards can be reduced by proper housekeeping procedures such as marking wet areas, cleaning up spills immediately, cleaning only one side of a passageway at a time, keeping halls and stairways clear, and providing good lighting for all halls and stairwells. Stairway hazards can be minimized by use of the handrail on stairs, avoiding undue speed, and maintaining an unobstructed view of the stairs ahead, even if that means requesting help to manage a bulky load.
Ergonomics

Back injury prevention, safe lifting, and safe movements all fall under the heading of ergonomics. Ergonomics is a science that designs equipment and work tasks to fit the worker. The goal is to prevent worker injury. If you have pain, tingling, or numbness associated with a specific activity, reevaluate how you are performing the task to assure you are doing it correctly. Consult your supervisor or employee health provider to have an ergonomic evaluation of your work. There may be equipment and methods available to reduce the risk of injury.

Injuries and illness that affects muscles, nerves, tendons, ligaments, joints, or spinal discs are known as musculoskeletal disorders (MSD). Injuries can result from cumulative trauma and repetitive strain, where small injuries over time build up until one more injury triggers a debilitating MSD. The following tasks have a high risk of cumulative trauma and repetitive strain:

Repetitive activity (typing)

Contact stress (hammering)

Twisting while lifting or carrying

Pulling or dragging

Sitting or standing in one position for a long time

Reaching above your shoulder

While stooping low

Heavy objects

Unwieldy objects

An object that is positioned far from your body
Frequent lifting without rest between lifts

The primary approach to preventing back injury involves reducing manual lifting and other load-handling tasks that are biomechanically stressful. The secondary approach is to train workers how to perform stressful tasks while minimizing the biomechanical forces on their backs, and how to maintain flexibility and strengthen the back and abdominal muscles. To prevent back injury, workers should: (WebMD Back Pain, 2014).

Use tools to avoid lifting when possible

Lifting devices

Slide boards

Shower chairs

Gait belts

Use proper lifting techniques

Keep your back in its normal upright position when lifting

Keep your head and shoulders up, and tighten your abdominal muscles when lifting

Bend at the knees, not at the waist

Get a good grip and slightly bend your elbows

Lift with your legs in a smooth even motion, not with your back

Bear the weight with your arms and legs, not your back

Bear the weight as close to your body as possible

Pivot on your feet to change direction, do not twist

Lower an object by widening your stance and bending your knees

Don�t reach higher than your shoulders to lift

Limit the number of lifts per day

Request help. When in doubt about whether a task may strain the back, a worker should request help rather than taking a chance.

Back exercises can be used to strengthen the back muscles and help prevent back injuries. A physician or physical therapist should be consulted.
The benefit of using back belts is undetermined. The belt may lead to a false sense of security and a failure to use proper lifting techniques. This can lead to injuries

Patient transfers are particularly hazardous for healthcare professionals. The following special points should be emphasized to prevent back injuries during transfers. (Perry, 2013).

Obtain lifting equipment as applicable

Do not do a manual transfer alone

Position equipment and furniture effectively (for example, move a wheelchair next to the bed) and remove obstacles

Communicate the plan of action to the patient and other workers to ensure that the transfer will be smooth and without sudden, unexpected moves

Use a wide balanced stance

Ensure good footing for the patient if applicable (patients should wear slippers that provide good traction)

Maintain eye contact and communication with patient. Be alert for trouble signs

Record any problems on the patient�s chart so that other workers will know how to cope with difficult transfers. Note the need for any special equipment, such as a lift.

Chemical Hazards

All healthcare facilities are required to have detailed information about the chemicals that are at the worksite. This information is in a standard format called a Safety Data Sheet (SDS). A Safety Data Sheet (SDS) is basically an updated format for material safety data sheet (MSDS). Manufacturers� transition from MSDS to SDS must be complete by December 2015. The reason for this transition is the mishmash of different MSDS styles and formats in use in the United States, which is simply bad news for all of us end users. The new rules require a standardized format of 16 sections in a strict ordering.

If no relevant information is found for any given subheading within one of the numbered sections, the SDS must clearly indicate that no applicable information is available. Sections 12-15 of the new SDS are not currently mandatory, while sections of the SDS 1-11 and 16 are. SDS sections contain the following:

1. Product identification

2. Hazard(s) identification

3. Composition/ information on ingredients

4. First-aid measures

5. Fire-fighting measures

6. Accidental release measures

7. Handling and storage

8. Exposure controls/personal protection

9. Physical and chemical properties

10. Stability and reactivity

11. Toxicological information

12. Ecological impact information (Non-mandatory)

13. Disposal considerations (Non-mandatory)

14. Transport information (Non-mandatory)

15. Regulatory information (Non-mandatory)

16. Other information, including date of preparation or last revision of the SDS or the last change to it.

Chemicals may exert either acute or chronic effects on workers. The effects depend on the:

Extent (concentration and duration) of exposure,

Route of exposure,

Physical and chemical properties of the substance.

Did you know that all of the hazard pictograms used in the United States have already been replaced with international symbols? Tsk, tsk. That was a nationwide training mandate for 2013 and you had better be on guard for questions related to the new SDS and hazard symbols during surveys.

The new worldwide visual warning system is part of the Globally Harmonized System of Classification and Labeling of Chemicals (GHS), and uses two sets of warning pictograms. One set is for the transporting of chemicals, and a second set for workplace use and storage.

Let�s take a look at a new pair of warning symbols that have replaced the retired poison pictogram commonly found in medical closets and work areas.
GHS Chemical Hazard Symbol

Health Hazard

Health Hazard
4

Carcinogen
Mutagenicity
Reproductive Toxicity
Respiratory Sensitizer
Target Organ Toxicity
Aspiration Toxicity



Skull and Crossbones

Acute Toxicity
4

Acute Toxicity (Fatal or Toxic)

Access the full list of new warning pictograms from OSHA here: https://www.osha.gov/dsg/hazcom/hazcom-faq.html

OSHA HCS HazCom 2012 Final Rule
https://www.osha.gov/dsg/hazcom/ghs-final-rule.html

Effects exerted by a substance may also be influenced by the presence of other chemicals and physical agents or by an individual�s use of tobacco, alcohol, or drugs. The exposure dose is the amount of a substance that actually enters the body during the period of exposure. The substance continues to be present in the body until it is metabolized or eliminated. Although some chemicals are rapidly metabolized, others are not and may be excreted unchanged or stored in the fatty tissues (solvents), lungs (dusts and fibers), bone (lead and radium), or blood (soluble gases).
Agency Regulation Annual Required Training
OSHA 29.CFR.1910.1001(j)(7) Annual Airborne Asbestos Training
OSHA 29.CFR.1910.120(e)

OSHA 29.CFR.1910.120.AppC
Annual Hazardous Waste Training

Annual Hazardous Waste Emergency Response Training
OSHA 29.CFR.1910.1045(o)(1) Annual Hazardous Substance Training � Acrylonitrile
OSHA 29.CFR.1910.1028(j)(1) Annual Hazardous Substance Training � Benzene
OSHA 29.CFR.1910.1003(e) Annual Hazardous Substance Training � Carcinogens
OSHA 29.CFR.1910.1047(j)(3) Annual Hazardous Substance Training � Ethylene Oxide
OSHA 29.CFR.1910.1048(n)(1) Annual Hazardous Substance Training � Formaldehyde

Toxic substances can enter the body through several routes, including intact skin, the respiratory system (inhalation), the mouth (inhalation and ingestion), the eyes, and by accidental needle punctures. Inhalation and skin exposure are the most likely. Some substances can also damage the skin or eyes directly without being absorbed. Not all substances can enter the body through all routes. Inorganic lead, for example, can be inhaled or swallowed, but it does not penetrate the skin. Exposure routes for antineoplastic and other hazardous drugs are inhalation, skin absorption, ingestion, and injection.

Not every toxic substance annual training requirement should be on your individual training list. You should not be handling asbestos, for instance. Someone in the hospital or at the care site does however as many of the buildings used for offices, clinics and hospitals fall into the timeframe during which asbestos was used in flooring, ceiling products, building insulation and a plethora of other practical products. Take the time to find out which specific substances are used and handled in your work setting, and whether or not you need any of the annual trainings concerning them.
Fire Drill
Agency Regulation Annual Required Training
TJC EC.02.03.03 EP2 Annual Fire Drill Training
OSHA 1910.156(c)(2) Annual Fire Brigade Training
OSHA 1910.157(g)(2,4) Annual Portable Fire Extinguisher Training
OSHA 1910.158(b)(10) Annual Fixed Fire Extinguisher Training

Training on fire safety is not only required by the major regulatory agencies, it is common sense. Any health professional who has lived through a fire in a care setting knows, and most likely has night terrors about, the complexity of moving ill patients out of harm�s way in an emergency.

In healthcare we are all expected to render assistance during situations that place our patients at risk. We therefore all require a working understanding of fire response, small fire suppression, and tactics to slow the spread of larger fires. A fire brigade designation such as found in OSHA regulations does not pertain to every health worker, but rather to those who have received additional instruction on fire suppression and rescue. If you have floor or unit staff designated as �safety officers� or �fire wardens� please review the OSHA Fire Brigade definitions to make sure they receive correct training before an inspection, or cross your fingers, before you are called on to perform in an actual emergency.
Agency Regulation Ongoing Required Training
TJC EC.02.02.03 EP.3,4 Quarterly unannounced fire drills, all shifts, varying conditions, with staff participation.

For all of us, when you enter a new work area, look around and find fire alarms, fire extinguishers, exit signs, and oxygen cut off valves. One way to remember fire safety is the acronym, RACE.

R: rescue

A: alarm

C: contain fire (if possible)
E: extinguish or evacuate

Never hesitate to sound the alarm with any suspicion of fire, yet also never �yell fire�. Yelling �fire� creates panic. Instead, call out the facilities verbal code for fire. Call the switchboard to report the fire and pull the fire alarm. When you call the switchboard, be sure to stay on the phone long enough to ensure they have received the correct information.

If a fire is small and confined, you may be able to extinguish it. If a patient�s garments are on fire, wrap them tightly in a large blanket to extinguish the flames. If a piece of equipment catches fire, pull the plug or cut the electricity as soon as possible.

OSHA is very clear, if you place hand-held portable fire extinguishers for staff to use in emergencies, you must train every staff annually how to use them. Portable fire extinguishers come in different classes for use on fires of different sources. The extinguisher has small pictures on the label that help you identify the type of fire source material they should be used on. Class A puts out fires involving ordinary combustibles. Class B extinguishers smother fires involving flammable liquids or gases. Class C extinguishers put out fires in or near electrical equipment. Type ABC extinguishers can be used to fight all three types of fires. To use an extinguisher remember PASS:

Pull the pin

Aim the nozzle at the base of the fire

Squeeze the trigger while making
Sweeping strokes with the extinguisher plume

If a fire cannot be extinguished and smoke, fumes or flames threaten patient safety, you may need to evacuate. Evacuate ambulatory patients first. Stay calm and give clear directions. Evacuate horizontally for as long as you can. Then evaluate vertically down to a lower level. Never use an elevator to escape during a fire. A sudden loss of power could leave you and your patient trapped inside the elevator.

Healthcare units are required to be separated by heavy fire doors that close automatically when the alarm is sounded, to keep the fire from spreading. To confine a fire close the doors, windows, and all vertical openings like the laundry chute. Stuff wet towels under doors to keep smoke out. Shut off oxygen supplies if directed to do so. Usually facility policy designates someone in supervision to decide when to turn of oxygen supplies.

When rescuing anyone in immediate danger, remember to stay low. Smoke rises to the ceiling and forms a heavy dense cloud that slowly descends. This cloud is deadly because it contains toxic gases.

Staff responsible to inspect, maintain, or repair fixed fire extinguishing equipment such as sprinklers or fire hose reels must be trained annually concerning these essential safety items.
Emergency Management Disaster Preparedness

Katrina, Joplin Missouri, the Twin Towers; the list of disasters effecting hospitals, all of us in the health professions are limitless due to the fact that emergencies come to us, either physically or by proxy in the form of waves of injured.
Agency Regulation Annual Required Training
TJC EM.03.01.03 EP.1,2,3,4 Annual Emergency Response Training
OSHA 29.CFR.1910.120(q) Annual Emergency Response Training
CMS 40.CFR.311 Annual Emergency Response Training

Joint Commission requests and requires annual training for emergency responses specific to healthcare facilities, including twice yearly live emergency scenarios (e.g. bomb threat, hostage situation, facility fire, plane crash into the building, etc.). At least one of these annual trainings must involve the community around the organization, such as fire department, search and rescue, police, etc. Be aware that TJC requires an assigned designee at these exercises to monitor performance and document deficiencies, with staff training following up to correct anything found lacking. Don�t be tempted to take emergency response training lightly, not only will it be �graded� by regulatory agencies, it could very well save the lives of those precious to you.
Agency Regulation Ongoing Required Training
TJC EM.03.01.03 EP.5 Evaluation of disaster exercises and scenarios specific to communications, resources, assets, security, staff, utilities, and patients.
TJC EM.03.01.03 EP.17 Evaluate disaster scenarios then change the EOP Emergency Operations Plan to include changes in further ongoing trainings.

Supervisors, you must know how to initiate the disaster plan and designate tasks to workers.

Each worker must be trained to:

Locate the disaster plan on each unit where he/she works

Know the alarm codes for each type of disaster

Know the exit routes

Know how to use any evacuation equipment

Alarm System

As of January 1, 2016 the Joint Commission will be expecting ongoing training on the purpose and correct operation of medical devise alarm systems. This will be an expectation for every health care professional who uses in any manner devices that possess alarms.
Agency Regulation Annual Required Training
TJC NPSG.06.01.01 EP.4 Purpose and Correct Operation of Alarm Systems

Nearly every medical device possesses an audible or visual alarm these days, and the wild cacophony that is heard, and often be ignored, in health settings is a cause of �alarm� to both public and regulatory agencies. Knowing when to set an alarm, how to set it, how to respond to it in a timely manner are all matters requiring proper training and accountability.

As health systems move further into the age of electronic health records and systems expect digital monitoring of essential medical equipment. In other words, should equipment alarms sound consistently without being attended to, the marvelous mechanism of the Joint Commission Tracer System is likely to tumble upon and take notice. So train appropriately, staff accordingly, work intelligently, or practice how to respond to accreditation surveyor queries.
Infection Control

Every health professional knows the drill; Infection = Bad, Prevention = Good. What a shame it�s not that easy, what with new organisms and changing drug resistances cropping up all the time. CMS, Joint Commission, OSHA, and every state have expectations concerning annual training of health workers on infection prevention, and that failing, infection control.
Agency Regulation Annual Required Training
TJC NPSG.07.03.01 EP.2 Health care�associated infections, multidrug-resistant organisms, and prevention strategies.
TJC NPSG.07.04.01 EP.1 Central line�associated bloodstream infections and the importance of their prevention.
TJC NPSG.07.05.01 EP.1 Surgical site infections and the importance of their prevention.
OSHA 29 CFR 1910.1030(g)(2)

OSHA 8 CCR 5193
Bloodborne Pathogens Annual Training.
CMS 482.42(a)(1) Ongoing infection prevention training for all staff.
Hand Washing Guidelines

Under the current Center for Disease Control (CDC) hand washing guidelines, washing hands with soap and water is to be done whenever the hands are visibly dirty. If not visibly soiled rubbing hands with an alcohol hand rub is the primary means of hand hygiene for routinely decontaminating the hands during routine patient care. Alcohol based hand rubs increase compliance with hand hygiene because hand rubbing requires less time, results in less skin irritation, and does not require proximity to a sink. Hand hygiene is indicated before:

Patient contact,

Donning gloves when inserting a central venous catheter (CVC), and

Inserting urinary catheters, peripheral vascular catheters, or other invasive devices that don�t require surgery.

Hand hygiene is also indicated after;

Contact with a patient�s intact skin,

Contact with body fluids or excretions, non-intact skin, or wound dressings, and after removing gloves.

Efficacy of Hand Hygiene
4

Standard Precautions

Standard precautions are strategies for protecting healthcare workers from occupational transmission of organisms. The premise is that all pre-existing patient infections cannot be identified; therefore, barrier precautions should be used routinely to protect from all sources of potential infection. Standard precautions apply to blood, all body fluids, secretions, and excretions except sweat regardless of whether or not they contain visible blood, non-intact skin, and mucous membranes. Additional precautions are based on highly transmissible or epidemiologically important pathogens. Transmission Based Precautions (isolation) are airborne, droplet, and contact.
Agency Regulation Ongoing Required Training
TJC IC.01.05.01 EP.7

TJC IC.02.01.01 EP.7
Training and education on responsibilities related to preventing and controlling infections.
CMS 482.23(c)(1) Ongoing training and competency for administration of drugs and biologicals.
Personal Protective Equipment (PPE)

The appropriate use of personal protective equipment (PPE) is an important element of standard infection prevention precautions. Gloves provide a protective barrier between the patient and the healthcare worker and prevent gross contamination of the hands. Gloves do not replace the need for hand washing because gloves may have small defects, may be torn during use, and hands may become contaminated during glove removal.
Agency Regulation >Ongoing Required Training
OSHA 1910.132(f)(1)(i-v);(2),(3)(i-iii);(4) PPE training ongoing and as needed.

Masks, goggles, or face shields should be used to protect the mucous membranes of the eyes, nose, and mouth during situations where there is a likelihood of splashes or sprays. A surgical mask is worn by healthcare workers to provide protection against large-particle droplets during close patient contact. When tuberculosis is known or suspected, healthcare workers should wear a N95 respirator, a high-efficiency particulate air (HEPA) filter respirator, or a powered air-purifying respirator (PAPR).

Gowns are worn to prevent contamination of clothing and protect the healthcare worker�s skin from blood and body fluid exposure. Impermeable gowns, leg coverings, boots, or shoe covers provide more protection when large quantities of blood or body fluids may be splashed. Gowns are also worn as a part of some transmission based precautions. Mouthpieces, resuscitation bags, or other ventilation devices should be used instead of mouth-to-mouth resuscitation.
Needlestick Prevention

Needles should never be recapped, bent, broken, or removed from contaminated syringes. Sharps should be disposed of in a puncture-proof container and then transported to a reprocessing area. Improved engineering controls are among the most effective approaches to reducing occupational hazards and therefore are an important element for a needlestick prevention program. Such controls include eliminating the unnecessary use of needles and implementing devices with safety features. Almost 83% of injuries from hollowbore needles can be prevented with use of safer sharps devices, and a number of sources have identified the desirable characteristics of such safety devices. These characteristics include the following: (CDC NIOSH, 2013).

The device has no needle.

The safety feature is an integral part of the device.

The device preferably works passively (i.e., it requires no activation by the user). If user activation is necessary, the safety feature should be engaged with a single-handed technique and allows the worker's hands to remain behind the exposed sharp.

The user can easily tell whether the safety feature is activated.

The safety feature cannot be deactivated and remains protective through disposal.

The device performs reliably.

The device is easy to use and practical.

The device is safe and effective for patient care.

Although each of these characteristics is desirable, some are not feasible, applicable, or available for certain healthcare situations. For example, needles will always be necessary where alternatives for skin penetration are not available. Also, a safety feature that requires activation by the user might be preferable to one that is passive in some cases. Each device must be considered on its own merit and ultimately on its ability to reduce workplace injuries. The desirable characteristics listed here should serve only as a guide for device design and selection.
Transmission Based Precautions (Isolation)

Transmission based precautions and protective environment (PE) are terms used to describe protective measures that need to be employed for specific groups of patients. An older term for this was isolation. Patients requiring transmission based precautions require a private room. Patients infected with the same organism can share a room. This is referred to as cohorting.
Contact Precautions

Contact Precautions are used for patients with known or suspected infections, or who are colonized with epidemiologically important microorganisms that can be transmitted by direct or indirect contact. Examples include:

Presence of stool incontinence (may include norovirus, rotavirus, or Clostridium difficile), draining wounds, uncontrolled secretions, pressure ulcers, or presence of ostomy tubes and/or bags draining body fluids.

Presence of generalized rash.

Contact precaution patients should be in a private room. Standard precautions should be used, and a gown should be worn if there is likely to be contact with the patient or environmental surfaces.

Airborne Precautions

Airborne Precautions are implemented for diseases that are transmitted by microorganisms in airborne droplet nuclei. Droplet nuclei are tiny particle residues left when droplets evaporate. Droplet nuclei remain suspended in the air and can be widely dispersed by air currents. Early identification and triage of suspected cases of airborne transmitted diseases should be done and possibly infectious patients should be separated from others and asked to wear a surgical mask.

Airborne precautions require a specially ventilated room with at least 6 air changes per hour; negative air pressure relative to the hallway; and outside exhaust or HEPA-filtered recirculation. The door to the room must be kept closed. The negative air pressure should be monitored. An N-95 mask or a powered air-purifying respirator (PAPR) is used by health workers in airborne precaution settings;

These masks and respirators should be labeled and stored in a paper bag between uses.

These mask and respirators should be discarded if soiled or if it no longer maintains its structural or functional integrity.

The N-95 mask should also be discarded at the end of each work shift.
The disposable respirator should be discarded at the end of 2 weeks.

Each employee who may work in an airborne precautions setting must be fit tested to assure that the N-95 mask or PAPR fit the employee�s face so that droplet nuclei cannot get in gaps between the mask and the face. Be aware, employees with beards will not pass fit testing.

When a patient in airborne precautions needs to be moved or transported, the patient should wear a surgical mask from the time he/she leaves the isolation room, until they return.

Tuberculosis (TB) is a current high interest topic for training due to nearly 9 million new TB cases and nearly 1.5 million TB-related deaths each year. TB symptoms are cough lasting for more than 2 weeks, loss of appetite, weight loss, night sweats, hemoptysis, and fever. Patients presenting with these symptoms should be asked to put on a surgical mask until a physician can make the determination to use airborne precautions. If an acid fast bacillus (AFB) test is ordered, TB is suspected and airborne precautions should be implemented. (CDC Tuberculosis, 2015).
Droplet Precautions

Droplet Precautions are used for patients known or suspected to be infected with microorganisms transmitted by droplets generated during coughing, sneezing, talking, or performance of procedures. These microorganisms include, yet are not limited to;

Respiratory viruses (e.g., influenza, parainfluenza virus, adenovirus, respiratory syncytial virus, human metapneumovirus)

Bordetella pertussis, and

For the initial 24 hours of therapy: Neisseria meningitides, and group A streptococcus.

Droplet precautions require a private room, but no special ventilation is necessary and the door may remain open. Masks should be donned upon entering the room and especially if working within three feet of the patient. The patient should be masked if transported.

Neutropenic Precautions

Neutropenic Precautions (reverse isolation) are implemented to protect immunocompromised patients. Neutropenia is a condition that causes low neutrophils in blood. Neutrophils are a type of white blood cell made in the bone marrow that aids the body fight infection. Examples of conditions that might warrant neutropenic precautions include;

Acquired immunodeficiency syndrome

Agranulocytosis

Burns, extensive noninfected type

Dermatitis, noninfected vesicular, bullous, or eczematous disease (when severe and extensive)

Immunosuppressive therapy, until patient�s immunity is adequate
Lymphomas and leukemia, especially late stages of Hodgkin�s disease or acute leukemia

Neutropenic precautions require a private room with positive air pressure relative to the air pressure in the hall. Other precautions may range from standard precautions and limitation of traffic to extensive precautions using gloves, gowns, and masks. This varies depending on the reason for the precautions and the degree of the patient�s immunosuppression.
Central Line and Surgical Infections

Central Line Associated Bloodstream Infection (CLABSI), along with Surgical Site Infection (SSI) prevention are key areas of concern. Annual training is a focus for any health care staff whose job duties place them in contact with central venous catheters (CVCs) or surgical wounds and dressings. CVCs play an important role in support of the patient, allowing for the administration of intravenous fluids, medications, blood products, and parenteral nutrition, as well as providing hemodialysis access and hemodynamic monitoring. CVCs have also been identified as the one of the most frequent causes of heath care related bloodstream infections, with SSIs estimated to run in second place for all Hospital Acquired Infections (HAIs) at roughly 25% of all major surgeries compromised by site infection. We must say estimated, due to the lack of accurate voluntary hospital reporting on SSIs. A trend that has not gone unnoticed and will inevitably lead to more regulations and oversight should healthcare organizations not be willingly forthcoming concerning important public safety issues. (Rattue, 2012), (CDC Devise Associated BSI, 2015).
Waste Management

In healthcare it is everyone�s responsibility to properly dispose of biohazardous material. One negligent act can result in a biohazardous exposure. Biohazard materials include blood and body fluids. If you are in doubt, use a biohazard container to dispose of the material. All biohazardous containers should be red and have the following biohazard symbol.

Biohazard
4

Biohazard sharps containers are to be red and come in varied sizes. Biohazardous sharps containers are made to store small glass objects and anything capable of piercing or puncturing skin whether it is contaminated or not. This includes sharps with protective devices like retractable sheaths. Even if a sharp is not contaminated, if it is put in regular garbage someone may be stuck with that sharp and not know if it was contaminated or not. The common examples are needles, sutures, scalpels, disposable instruments, and lancets. Replace sharps containers when they are three quarters full. Failure to do so may result in someone being contaminated because sharps are close to the top, or the closure device does not swing freely.

Biohazardous bags are red, and are to be used for biohazardous material that is not sharp and may be contaminated with blood or body fluid. These bags are also used for the disposal of chemotherapy drugs and chemicals, even though they are not infectious.

Biohazardous Bags
4

Source: http://www.cdc.gov/niosh

General waste bags are used for general trash and some body fluids and equipment if there is no visible blood: urine, feces, disposable pads or chux, PPE, used gloves, respiratory care items, and suctions canisters. However, if in doubt, use a biohazardous bag.
Case Study

Earl from housekeeping is tidying the hematology section of the clinical laboratory at the end of a bustling day. He notices fragments of glass tucked under the counter edge next to the microscopy station. He carefully dons heavy gloves and disposes of the glass shards in the clearly marked sharps container.

General cleaning done, he changes to vinyl gloves for better dexterity and grabs onto a partially filled general use garbage bag. As he bends his knees to lift, he feels a sharp pain in the palm of his gloved hand supporting the bottom of the white plastic bag. Grimacing he looks at his lacerated palm and the sharp jutting dagger of broken microscope slide poking through the thin material.

All sharps, not just needles, go into the designated red sharps container. Glass shards, metal fragments, empty vials, blood tubes, microscope slides, glass pipettes, everything that is sharp or can become sharp goes into the sharps box.
Recommended Healthcare Worker Immunization

Healthcare worker vaccination is a hot button topic currently, so anticipate frequent trainings focused on this topic for years to come.
Agency Regulation Ongoing Required Training
TJC IC.02.04.01 EP.2 Education and training on influenza vaccine, non-vaccine prevention and control, diagnosis, transmission, and impact of influenza.

The CDC�s perspective is that health professionals are constantly at risk for exposure to serious, and sometimes deadly, diseases. Each of us work directly with patients or handle material that could spread infection. Due to these factors each of us should be appropriately vaccinated to reduce the chance of catching or spreading vaccine-preventable diseases. The CDC hot list of healthcare worker vaccinations include;
CDC Recommendations in Brief Hepatitis B

Absence of documented evidence of a complete hepB vaccine series, or lack of an up-to-date blood test (i.e., no serologic evidence of immunity or prior vaccination) warrants;

The 3-dose series (dose #1 now, #2 in 1 month, #3 approximately 5 months after #2).
Get anti-HBs serologic tested 1�2 months after dose #3.

Flu (Influenza) Get 1 dose of influenza vaccine annually.
MMR (Measles, Mumps, & Rubella)

If born in 1957 or later and have not had the MMR vaccine, or don't have an up-to-date blood test that shows you are immune to measles or mumps (i.e., no serologic evidence of immunity or prior vaccination), get 2 doses of MMR (1 dose now and the 2nd dose at least 28 days later). If born in 1957 or later and have not had the MMR vaccine, or don't have an up-to-date blood test that shows immunity to rubella, only 1 dose of MMR is recommended.
Varicella (Chickenpox) If you have not had chickenpox (varicella), if you haven't had varicella vaccine, or if you don't have an up-to-date blood test that shows you are immune to varicella (i.e., no serologic evidence of immunity or prior vaccination) get 2 doses of varicella vaccine, 4 weeks apart.
Tdap (Tetanus, Diphtheria, Pertussis) Get a one-time dose of Tdap as soon as possible if you have not received Tdap previously (regardless of when previous dose of Td was received).

Get Td boosters every 10 years thereafter.
Pregnant HCWs need to get a dose of Tdap during each pregnancy.

Meningococcal Those who are routinely exposed to isolates of N. meningitidis should get one dose.

(CDC Vaccine Information, 2014)
Exposure to Bloodborne Pathogens

OSHA possesses a comprehensive bloodborne pathogen standard for workers in areas of risk, which of course includes healthcare, housekeeping, and emergency responders to name a few. As a healthcare professional be careful to take this topic seriously as some 295,000 hospital-based healthcare workers experience occupational percutaneous injuries annually, according to reports from the International Health Care Worker Safety Center. Infectious organisms present in the blood which can cause serious or life-threatening disease in humans include hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). (Zehnder, 2015).

The presence of an exposure control plan is essential in a healthcare setting, and as a healthcare professional you must know your facilities policies. The exposure control plan must describe how an employer will use a combination of engineering and work practice controls, ensure the use of personal protective clothing and equipment, provide training, medical surveillance, hepatitis B vaccinations, and signs/labels. Engineering controls are the primary means of eliminating or minimizing employee exposure and include the use of safer medical devices, such as needleless devices, shielded needle devices, and plastic capillary tubes.

Should a needlestick or exposure to blood occur: Provide immediate care to the exposure site.

Wash wounds and skin with soap and water.

Flush mucous membranes with water.

Irrigate eyes with clean water, saline or sterile wash.

Please note that no scientific evidence has shown that using antiseptics or squeezing the wound will reduce the risk of transmission of a bloodborne pathogen. Using a caustic agent such as bleach is not recommended.

Determine risk associated with blood exposure by: (National Guideline Clearinghouse, 2012)

Type of fluid (e.g., blood, visibly bloody fluid, other potentially infectious fluid or tissue, and concentrated virus), and

Type of exposure (i.e., percutaneous injury, mucous membrane or non-intact skin exposure, and bites resulting in blood exposure).

Evaluate exposure source.

Assess the risk of infection using available information.

Test known sources for HBsAg, anti-HCV, and HIV antibody (consider using rapid testing).

For unknown sources, assess risk of exposure to HBV, HCV, or HIV infection.

Do not test discarded needles or syringes for virus contamination.

Evaluate the exposed person.

Assess immune status for HBV infection (i.e., by history of hepatitis B vaccination and vaccine response).

A comprehensive exposure prevention plan and strategies play significant roles in decreasing the risk of infection from bloodborne pathogens. The risks of exposure with appropriate precautions are low, yet they are real. Understanding how an exposure occurs and the risks of exposure is imperative for both the occupational health clinician and the healthcare worker. After an occupational exposure to a bloodborne pathogen, the risk of infection depends on a number of factors including:

Type of body substance involved,

Route of exposure,

Volume of blood or body fluid involved,

Severity of exposure,

Pathogen suspected,

Degree of viremia (e.g., quantity of virus present in the blood),

Immune status of the healthcare worker at the time of exposure,

Whether appropriate post-exposure prophylaxis (PEP) was used.

Hepatitis B

Hepatitis B is one of the chief pathogens of concern. Healthcare workers who have received hepatitis B vaccine (HBV) and have developed immunity to the virus are at virtually no risk for infection. The risk of HBV infection is primarily related to the degree of contact with blood in the workplace and also the hepatitis antigen (HBeAg) status of the source person. Individuals who are both hepatitis B surface antigen (HBsAg) positive and HBeAg positive have more virus in their blood and are more likely to transmit HBV. The rough risk for a non-vaccinated healthcare worker with an exposure incident is between 6% to 30%. When given within one week of injury, post exposure prophylaxis (PEP) with multiple doses of hepatitis B immune globulin (HBIG) provides an estimated 75% protection from transmission. (Zehnder, 2015).

Although percutaneous injuries are among the most efficient modes of HBV transmission, these exposures probably account for only a minority of HBV infections among healthcare workers. In several investigations of nosocomial hepatitis B outbreaks, most infected healthcare workers could not recall an overt percutaneous injury, although in some studies, up to one third of infected recalled caring for a patient who was HBsAg-positive. Additionally, HBV has been demonstrated to survive in dried blood at room temperature on environmental surfaces for at least 1 week. (CDC Viral Hepatitis B, 2015).
Hepatitis C (HCV)

Hepatitis C (HCV) has no vaccine. Fortunately it is not transmitted efficiently through occupational exposures to blood, with a needlestick or sharps exposure to HCV-positive blood showing a risk for contracting HCV infection at approximately 1.8%. There have been a few instances of HCV transmission from blood splash to the eye, however the risk of such is thankfully low. Do always be sure to utilize standard precautions to minimize the risk of exposure. (CDC Viral Hepatitis C, 2015).

The CDC makes no recommendations on restriction of healthcare workers positive for HCV, as the risk of reverse transmission, staff to patient has been shown to be negligible.
Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (HIV, AIDS)

Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (HIV, AIDS) is a highly visible source of concern. HIV is the pathologic organism and AIDS is the final terminal stage of HIV infection. No vaccine is available for HIV, so prevention is key to halting its spread. Be very aware that an HIV infected person who has no signs of an infection or illness can still infect others. There are four ways HIV is transmitted:

Sexual intercourse,

Sharing of needles and syringes,

Body fluids (blood, semen, vaginal fluid, and breast milk), and
Babies born of infected mothers and drinking breast milk of infected mothers.

HIV infection is most often spread through sexual activities or exposure to infectious blood. Male to male sexual contact, aka �men who have sex with men� or MSM, when combined with injection drug use account for around half of new HIV cases in the United States. In contrast case numbers from developing countries and resource limited areas show almost 80% of new HIV infections arise from vaginal intercourse. (Bartlett, 2015).

Transmission of the HIV virus is significantly affected by the type of sexual exposure. Receptive anal intercourse has a much greater risk of viral transmission as compared to receptive vaginal intercourse. The use of condoms does not preclude transmission, due to many factors such as holes, tears, improper fitting, etc., however condom use lowers the chance of transmission as compared to intercourse sans protection. The presence of other sexually transmitted diseases, such as the ulcerations of genital herpes, can increase the risk of transmission as much as four times.

Incorrect rumors about ease of viral spread have led the CDC to provide a list of ways HIV cannot be spread; (CDC HIV/AIDS Prevention, 2015).

HIV cannot be spread in air or water.

HIV cannot be spread by insects, including bed bugs, ticks, or mosquitoes.

HIV cannot be spread in saliva, sweat, or tears and no documented case exists of HIV being transmitted by spitting.

HIV cannot be spread by casual contact such as sharing dishes or shaking hands.

HIV cannot be spread by closed mouth or social kissing.

HIV cannot be spread from toilet seats.

The average risk of HIV transmission after a percutaneous exposure to HIV-infected blood has been estimated to be approximately 0.3%. The risk after a mucous membrane exposure is approximately 0.09%. Although episodes of HIV transmission after non-intact skin exposure have been documented, the average risk for transmission by this route has not been precisely quantified but is estimated to be less than the risk for mucous membrane exposures. The risk for transmission after exposure to fluids or tissues other than HIV-infected blood is considerably lower than for blood exposures (CDC Division of Oral Health, 2013).
Tuberculosis

Tuberculosis (TB) infects one third of the world�s population, according to the World Health Organization (WHO). Active TB infections are very contagious, and several treatment resistant strands of the bacteria are actively circulating globally. To avoid acquiring TB; (WebMD TB, 2014).

Avoid spending long periods in stuffy, enclosed rooms with anyone who has active TB until that person has been on an effective course of medication for at least two weeks.

Utilize protective masks when working with patients with active TB.

The CDC identifies three levels of TB infection control in health-care settings. The first level, administrative controls, should focus on minimizing the number of areas where exposure to Mycobacterium tuberculosis may occur. The second level, environmental controls, focuses on reducing the concentration of airborne TB particles. Because persons entering areas where infected patients may go, the third level of the hierarchy is the use of respiratory protective equipment in situations that pose a high risk for exposure.
Agency Regulation Annual Required Training
TJC MS.03.01.03 EP.2 Ongoing education and training on the assessment and management of pain.
Pain Management

The right to be heard when suffering from pain, to be assessed seriously, to not have their pain minimized, and to have appropriate treatment options presented is an essential right for all humans. Some healthcare organizations, and health providers forget this foundational ideal in the search for convenience and profit. Not to worry, your eagle eyed regulatory agency soars ready to swoop should any of us misplace our first loves.
Agency Regulation Ongoing Required Training
TJC MS.03.01.03 EP.2 Ongoing education and training on the assessment and management of pain.

Pain may be defined as an unpleasant sensory and emotional experience that is associated with actual or potential tissue damage. Pain is always subjective. Pain is whatever the person experiencing it says it is, and it exists whenever he/she says it does. Patients may experience acute, chronic, or cancer (e.g. malignant) pain.

Acute pain follows injury to the body and generally disappears as healing takes place. Typically this is not greater than 6 months. There is identifiable pathology that accounts for the pain. It may arise from operative procedures or from tissue trauma associated with an inflammatory process, for example. It is often associated with objective physical signs such as increased heart rate, hypertension, and pallor (autonomic nervous system activity), giving patients a visual appearance we associate with being in pain.

Chronic nonmalignant pain is pain that lasts for an extended period of time, usually greater than 6 months. There may or may not be known active pathology to account for the suffering that the individual is experiencing. Chronic pain, in contrast to acute pain, is rarely accompanied by signs of autonomic nervous system activity, leading to many of us doubting the existence of legitimate pain.

Cancer pain may be acute, chronic, or intermittent. It usually has a definable cause, which is usually related to tumor recurrence or treatment.

Pain may be defined as an unpleasant sensory and emotional experience that is associated with actual or potential tissue damage. Pain is always subjective. Pain is whatever the person experiencing it says it is, and it exists whenever he/she says it does. Patients may experience acute, chronic, or cancer (e.g. malignant) pain.

Acute pain follows injury to the body and generally disappears as healing takes place. Typically this is not greater than 6 months. There is identifiable pathology that accounts for the pain. It may arise from operative procedures or from tissue trauma associated with an inflammatory process, for example. It is often associated with objective physical signs such as increased heart rate, hypertension, and pallor (autonomic nervous system activity), giving patients a visual appearance we associate with being in pain.

Chronic nonmalignant pain is pain that lasts for an extended period of time, usually greater than 6 months. There may or may not be known active pathology to account for the suffering that the individual is experiencing. Chronic pain, in contrast to acute pain, is rarely accompanied by signs of autonomic nervous system activity, leading to many of us doubting the existence of legitimate pain.

Cancer pain may be acute, chronic, or intermittent. It usually has a definable cause, which is usually related to tumor recurrence or treatment.
The 5th Vital Sign

The failure to routinely assess and document pain impedes change. The American Pain Society promotes the phrase, pain is the 5th vital sign, to increase the visibility of pain among healthcare professionals. Vital signs are taken seriously. For example, practitioners rarely fail to recognize and take action on an elevated blood pressure. Blood pressure is routinely measured and recorded in the patient�s chart and standard practice holds that elevated blood pressure requires assessment and action. If pain intensity is assessed routinely with the same zeal as the traditional four vital signs (temperature, heart rate, respiratory rate, and blood pressure) and then documented, pain management would improve. As the 5th vital sign, pain intensity becomes visible and can be used to guide treatment.
Pain Assessment

Basic pain assessment is simple, must be performed regularly, and action is planned on the basis of patient reports. It makes no difference whether the patient is in the hospital, a long-term care facility, a behavioral health facility, an outpatient clinic or being cared for by a home care agency. No matter where the patient is, the intensity of pain should be assessed and documented (1) during the initial evaluation of the patient, (2) after any known pain-producing procedure, (3) with each new report of pain, (4) at regular intervals when vital signs are taken, and (5) at suitable intervals after pharmacologic intervention (60 minutes after oral; 30 minutes after parenteral), or nonpharmacologic intervention to evaluate the current pain treatment plan.

The most widely used measure to assess intensity is the Numerical Rating Scale (NRS), where the patient is asked to rate their pain from 0-to-10, with 0 equaling no pain and 10 equaling the worst possible pain they can imagine. Since we have no instrument to objectively measure pain intensity in the same way that blood pressure is measured by a sphygmomanometer, the only valid measure of pain is the patient�s self-report (a subjective measure). Sometimes healthcare professionals may believe that they are the best judges of a person�s pain; however, many studies demonstrate that healthcare professionals either over-estimate or underestimate a patient�s pain.

Pain Chart
4

For patients who cannot respond verbally and/or rate their pain numerically, the Faces Pain Scale (FPS) for adults and children can be used. This scale consists of images of faces with various expressions (e.g., smiling, frowning, grimacing). The patient selects the face that is consistent with his/her current level of pain.

If a patient has cognitive/expressive deficits, observation of nonverbal expression and behavior or report of a family member or significant other needs to be considered when assessing pain intensity.

Each healthcare institution should use a pain intensity rating that will elicit a full assessment. Besides intensity, the complete pain assessment includes the following:

Location of pain

Character or Quality (throbbing, shooting, sharp, cramping, aching, burning, etc.)

Onset, duration, variations, rhythms (is the pain better or worse at certain times, certain hours?)

Alleviating factors - what makes the pain better

Aggravating factors - what makes the pain worse

Effects of pain (impact on daily life, function, sleep, appetite, relationships with others, mood, emotions, concentration, etc.)

Pharmacological Management of Pain

Opioid analgesics are the cornerstone of pharmacological management for acute pain, especially when the pain is moderate or severe. Other agents such as NSAIDs may control mild to moderate pain or reduce opioid dose requirements for more severe pain. The intravenous (IV) route is the route of choice with acute pain only until oral intake is tolerated. Once oral intake is tolerated, the route should be changed to oral. Intramuscular administration of medications is not recommended for treatment of any type of pain. Absorption of medication is variable with the intramuscular route and IM injections hurt!

Medications are the cornerstone of the management of cancer pain because they are effective, relatively low risk, inexpensive, and usually have rapid onset. Three major classes of medications are used alone or, more commonly, in combination to manage cancer pain; 1) NSAIDs, ASA, and acetaminophen, 2) opioid analgesics, 3) and adjuvant or co-analgesic medications. Adjuvant medications are those medications that are not usually thought of as analgesics but which, when given with known analgesics, have synergistic effects or exhibit analgesic activity of their own. Adjuvant nonopiod pain medications include:

Muscle relaxants
Antihistamines

In the past, patients with chronic nonmalignant pain were excluded from long-term therapy with opioids for fear they would become addicted or psychologically dependent. Although often confused with addiction, tolerance and physical dependence are not equivalent to addiction. Physical dependence is just that; if the opioid is suddenly stopped or an antagonist medication such as naloxone is given, symptoms of withdrawal will occur. Tolerance is a decrease in one or more effects of the opioid, whether it is decreased analgesia, sedation, or respiratory depression. When tolerance to analgesia occurs, patients may need increased doses of opioids to achieve the same pain relief. Although most patients who take opioids several times daily for more than one month develop some degree of tolerance and physical dependence, the risk of addiction can be very small � in some studies less than one percent. Recent studies have shown that along with other modalities, opioids might be a reasonable treatment addition for chronic pain in patients who are not terminally ill. The oral route of administration is the optimal route for administration of medications for chronic pain. (News Medical, 2015).

Effective pharmacologic management of all types of pain requires that the regimen be individualized. In addition to choosing a suitable medication or medications, optimal doses must be selected. As with acetaminophen and ASA, all NSAIDs have ceiling (maximum) doses that, if exceeded, may precipitate toxicity without improving analgesia. Opioids, however, have no maximum dose. Generally, with opioids, the goal is to use the smallest dose that relieves the maximum amount of pain with the fewest side effects. Equally important for effective pharmacologic management of pain, the medication should be given:

Before pain occurs or increases (e.g. before a painful event such as wound debridement) or,

Around the clock (ATC) or at regularly scheduled times if pain is present most of the day.

A rule of thumb is if the pain is present 12 or more hours out of 24 hours, ATC dosing should be considered. The analgesics should be routinely scheduled to prevent the recurrence of pain. Along with ATC dosing, supplementary analgesia (rescue dose) should also be available.
Common Side Effects with Long-term Opioid Treatment

All opioid analgesics share common side effects, the most common being constipation, nausea and/or vomiting, sedation and mental clouding, respiratory depression, and dry mouth, which can effect dental, as well as general, health. Although side effects are usually less serious than the under treatment of pain, they warrant discussion. Tolerance to all the side effects, except constipation, develops with time.

Constipation will not diminish with time and can become a significant clinical problem if preventive measures are not instituted. Opioids reduce the motility of the intestines. Reduced activity and decreased appetite can make the problem worse. Constipation can be alleviated by eating foods high in fiber and by drinking eight to ten glasses of water a day (if not contraindicated by other problems). Exercise can help too. When starting on routine opioids, patients need to start on a stool softener/laxative preparation and be continually reassessed to ensure the current bowel regimen is working.

When patients complain of nausea and/or vomiting after opioid administration has begun, it is often helpful to administer an antiemetic on a fixed schedule for several days until tolerance to this side effect develops. At that point, PRN dosing is usually adequate. Depending on the antiemetic chosen, patients need to be monitored for the possibility of increased sedation.

Transitory sedation and mental clouding are common when opioid doses are increased, but tolerance usually develops rapidly. Persistent drug-induced sedation is usually best treated by reducing the amount of opioid for each dose and increasing the dosage frequency. This strategy will decrease the peak concentrations in the blood while maintaining the same total dose. Central nervous system (CNS) stimulants, such as caffeine or methylphenidate, may be added to increase alertness if the above approach is ineffective in reducing sedation.

Patients receiving long-term opioid therapy usually develop tolerance to the respiratory-depressant effects of these agents. Be aware - occasionally, respiratory depression occurs when pain is abruptly relieved and the sedative effects of opioids are no longer opposed by the stimulating effects of pain. In a symptomatic patient, physical stimulation may be enough to prevent significant hypoventilation. The opioid antagonist naloxone should be administered cautiously to those who are receiving opioids on a long-term basis. Symptomatic respiratory depression should be treated cautiously using a dilute solution of naloxone (0.4 mg in 10 ml of saline), administered as 0.5 ml (0.02 mg) boluses every minute. Naloxone should be given in doses to improve respiratory function, but not to reverse analgesia, since a return to full alertness may be accompanied by a severe withdrawal syndrome as well as a return of pain.

Far more common than acute respiratory depression is sub-acute overdose, in which sedation gradually builds and is followed by a slowing of respiratory rate and then by respiratory failure. The degree of sedation, rather than the respiratory rate, is a better indicator of impending respiratory depression. This complication is best managed by withholding one or two doses and then reducing the standing dose by 25% of its current level.

Opioids may also occasionally cause other side effects such as urinary retention, pruritus, myoclonus, seizures, hallucinations, confusion, sexual dysfunction, and sleep disturbances.
Nonpharmacologic Techniques of Pain Management

Nonpharmacologic techniques of pain management are once again gaining popularity. It is estimated that Americans spend $33.9 billion annually out-of-pocket on complementary and alternative medicine (CAM), the greatest proportion going to alternative methods of pain control. Health professionals need to know about these approaches in order to assist patients in making educated decisions. Analgesics are the mainstay of pain relief; however, even with the optimal use of analgesics, most pain is best treated with a combination of analgesic and non-analgesic approaches. For some types of mild pain, non-analgesic approaches alone may provide sufficient relief. Non-analgesic techniques are a supplement for, but do not replace, pharmacologic interventions for moderate to severe pain. (CCS, 2012).

Cognitive-behavioral interventions are methods that are thought to influence feelings, and if thought (and behaviors) can be changed, so can feelings and even sensations, such as pain. Cognitive-behavioral methods require the patient�s active participation.

Relaxation is a state of relative freedom from both anxiety and skeletal muscle tension, a quieting or calming of the mind and muscles. Although relaxation is a learned technique, it can be achieved quickly in a motivated patient.

Distraction from pain is the focusing of attention on stimuli other than the pain sensation. The stimuli focused upon can be auditory, visual, or tactile-kinesthetic (hearing, seeing, touching, and moving). By focusing attention and concentration on stimuli other than pain, pain is placed on the periphery of awareness. Distraction does not make the pain go away, nor does the effectiveness of the use of distraction indicate the absence of pain. Music and humor are extremely effective means of distraction.

Imagery/visualization involves mentally creating a picture by using one�s imagination. This may be a focus on a close person, a place of enjoyment, a past event, or anything that is thought to bring pleasure. Since the mind is occupied, the pain is reduced in focus.
Non-invasive Mechanical Interventions for Pain

Massage is soothing and relaxing, both physically and mentally. Massage may decrease pain by relaxing muscle tension and increasing capillary circulation, thereby improving general circulation.

Vibration is a form of electric massage. When vibration is applied lightly, it may have a soothing effect similar to massage. Vibration applied with moderate pressure may relieve pain by causing numbness, paresthesia, and/or anesthesia of the area stimulated.

Heat/Cold � Heat reduces inflammation and promotes relaxation. It can be in the form of hot tub baths, heating pads, or heat packs. Cold is often more effective in relieving pain than heat. Applications of cold reduce muscle spasms secondary to underlying skeletal muscle spasm, joint pathology, or nerve root irritation. Methods of cold application include ice massage, ice bags, and gel packs. Alternating heat and cold may be more effective than the use of heat or cold alone.

Transcutaneous Electrical Nerve Stimulation (TENS) provides low voltage electricity to the body via electrodes placed on the skin. TENS may help with acute or chronic pain. Electrical stimulation of sensory nerves helps block pain signals going to the brain.

Acupuncture is a neurostimulatory technique that treats pain by the insertion of small, solid needles into the skin at varying depths. Various theories exist to offer explanation of how acupuncture works.
Invasive Therapies for Pain

With rare exception, less invasive analgesic approaches should precede invasive approaches. If drug therapy, cognitive-behavioral interventions, and/or non-invasive mechanical interventions do not alleviate pain, invasive therapies such as nerve blocks and neurosurgery may be useful.
Latex Sensitivity

While we are talking skin absorption, the first thing each of us reaches for when the ick hits the emesis basin is a pair of disposable gloves. Remember that latex is a high reactivity substance for some individuals, both staff and patients. The American College of Allergy, Asthma and Immunology classify allergic reaction to latex as type I, type IV, and irritant reaction: (Behrman, 2013).

Type I reactions are also known as Immunoglobulin E (IgE) reactions. They are systemic reactions that are generally immediate and possibly life threatening. Type I reactions occur due to skin contact or inhalation of latex proteins. The symptoms may include facial flushing, rhinitis, vomiting, diarrhea, wheezing, dyspnea, facial or laryngeal edema, bronchospasm, and anaphylaxis.

Type IV reactions are delayed hypersensitivity, or dermatological symptoms. They may not appear for several days after exposure. The symptoms include pruritus, edema, erythema, and vesicles.

Irritant reactions are the most common type of latex reaction. It is a nonallergenic condition due to latex gloves. The back of the hands may have a dry, itchy rash. Be discerning as irritant reactions may also have other causes, such as irritation from soaps or detergents, other chemicals, or incomplete hand drying.

A wide variety of products contain latex: medical supplies, personal protective equipment, and numerous household objects. Most people who encounter latex products only through general home use have no health problems from the use of these products.

Latex allergy should be identified during the initial assessment for allergies. When a latex sensitive patient is admitted, follow the facility policy. This usually involves extra signage, requesting non-latex equipment and perhaps even moving to a private room.

Workers should take the following steps to protect themselves from latex exposure and allergy in the workplace:

Use non-latex gloves for activities that are not likely to involve contact with infectious materials, like food preparation, routine housekeeping and maintenance.

If you choose latex gloves, use powder-free gloves with reduced protein content. So-called hypoallergenic latex gloves do not reduce the risk of latex allergy. However, they may reduce reactions to chemical additives in the latex.

When wearing latex gloves, do not use oil-based hand creams or lotions (which can cause glove deterioration) unless they have been shown to reduce latex-related problems and maintain glove barrier protection.

After removing latex gloves, wash hands with a mild soap and dry thoroughly.

Use good housekeeping practices to remove latex-containing dust from the workplace:

Learn to recognize the symptoms of latex allergy: skin rashes; hives; flushing; itching; nasal, eye, or sinus symptoms; asthma; and shock.

If you develop symptoms of latex allergy, avoid direct contact with latex gloves and other latex-containing products until you can see a physician experienced in treating latex allergy.

Hazardous Flammable Combustible - Liquids, Vapors, and Gases

A major hazard in all hospitals is the widespread use and storage of hazardous, flammable, and/or combustible liquids and gases. Many liquids have vapors that are flammable or combustible and can be ignited by a spark from a motor, friction, or static electricity. Handling and storage directions must be followed and are located on the SDS for that material. All flammable liquids should have the following label(s):
GHS Chemical Hazard Symbol

Flammable

Flammable
4



Explosive

Explosive
4

Compressed Gas

Compressed Gas
4



Harmful / Irritant

Harmful Irritant
4

Access the full list of new warning pictograms from OSHA here: https://www.osha.gov/dsg/hazcom/hazcom-faq.html

OSHA HCS HazCom 2012 Final Rule
https://www.osha.gov/dsg/hazcom/ghs-final-rule.html

Compressed gases are under pressure and flammable, so they must be handled with extreme care. An exploding cylinder can have the same destructive effect as a bomb. Storage areas for compressed gas cylinders should be well ventilated, fireproof, and dry. Cylinders should not be stored near steam pipes, hot water pipes, boilers, highly flammable solvents, combustible wastes, unprotected electrical connections, open flames, or other potential sources of heat or ignition. Cylinders should be properly labeled. The valve protection cap should not be removed until the cylinder is secured and ready for use.

Compressed gases used in hospitals include acetylene, ammonia, anesthetic gases, argon, chlorine, ethylene oxide, helium, hydrogen, methyl chloride, nitrogen, and sulfur dioxide. Acetylene, ethylene oxide, methyl chloride, and hydrogen are flammable, as are the anesthetic agents� cyclopropane, diethyl ether, ethyl chloride, and ethylene. Although oxygen and nitrous oxide are labeled as nonflammable, they are oxidizing gases that will aid combustion.
Antineoplastic Drugs, Hazardous Drugs, Toxic Substances

Pharmaceuticals are chemicals. Certain pharmaceuticals have a higher risk of toxicity, both when taken as directed and/or during incidental exposure. It is important to be aware of high alert medications such as those identified in the 2014 Institute for Safe Medication Practices high alert list, which includes such classifications as; insulins, opioids, antithrombotic agents, antiarrhythmics, chemotherapeutic agents, and many more.

Exposure to hazardous drugs may occur to clinical and non-clinical workers in the following settings: (NIOSH Hazardous Drugs, 2014).

When reconstituting of drugs or further dilution,

When expelling air from syringes filled with hazardous drugs or during the administration of drugs,

When dust is generated through counting out oral doses and tablets from multi-dose bottles or unit-dosing uncoated tablets in a unit-dose machine.

When crushing tablets to make oral liquid doses,

When compounding powders into custom dosage capsules

When drugs are present on drug vial exteriors, work surfaces, floors, and final drug products (bottles, bags, cassettes, and syringes),

When handling body fluids, clothing, dressings, linens and other materials contaminated with body fluids or hazardous drugs,

When handling contaminated waste at any step of preparation or administration process,

When specialized procedures (intraoperative intraperitoneal chemotherapy) are performed,

When handling unused hazardous drug waste, hazardous drug-contaminated waste, decontaminating and cleaning drug preparation or clinical areas,

When transporting infectious, chemical or hazardous waste containers,

When removing and disposing of PPE used during the handling of hazardous drugs or waste.

Healthcare workers� responsibilities in relation to antineoplastic and other hazardous drugs include:

Review guidance documents, safety data sheets (SDS) and other information resources for hazardous drugs handled,

Be familiar with and be able to recognize sources of exposure to hazardous drugs,

Prepare these agents in a dedicated area where access is restricted to authorized personnel only,

Prepare these agents within a ventilated cabinet designed to protect workers and adjacent personnel from exposure and to provide product protection for all drugs that require aseptic handling,

Use two pairs of powder-free, disposable chemotherapy gloves with the outer one covering the gown cuff whenever there is risk of exposure to hazardous drugs,

Avoid skin contact by using a disposable gown made of a low-lint and low permeability fabric. The gown should have a closed front, long sleeves and elastic or knit closed cuffs and should not be reused,

Wear a face shield to avoid splash incidents involving eyes, nose, or mouth when adequate engineering controls are not available,

Wash hands with soap and water immediately before using and after removing personal protective clothing, such as disposable gloves and gowns,

Use syringes and IV sets with Luer-lock fittings for preparing and administering these agents and place drug-contaminated syringes and needles in chemotherapy sharps containers for disposal,

When an IV line must be primed with a solutions containing hazardous medication, it should be done in pharmacy,

When additional protection is necessary, use closed-system, drug-transfer devices, glove bags and needle-less systems within the ventilated cabinet,

Handle hazardous wastes and contaminated materials separately from other trash,

Decontaminate work areas before and after each activity with hazardous drugs and at the end of each shift,

Clean up spills immediately while using appropriate safety precautions and personal protective equipment (PPE) unless the spill is large enough to require an environmental services specialist.
Agency Regulation Ongoing Required Training
TJC NPSG.03.05.01 EP.7

Education and training on anticoagulant therapy.

While having current information on all high risk therapeutics is important, take special care to be really familiar with any specifically called out in regulatory statutes.
Anticoagulants

Anticoagulants are chemicals that slow or prevent the formation of clots in the blood. They accomplish this by a variety of means, most common of which is inhibiting the ability of platelets to stick together. The frustration of anticoagulant use has always been in finding the sweet-spot. That elusive point at which the medication has a positive benefit, while avoiding adverse effects of excessive bleeding. While blood thinners, as they are often referred to are helpful in the prevention of heart attack, stroke, and thromboembolic disease, their use also means that excessive bleeding can result in significant unwanted effects.
Anticoagulant Dosing Time to Peak Half-life Antidote Remarks
Apixaban Oral) BID 3 hrs. 8-15 hrs. None Apixaban may be confused with axitinib
Dabigatran (Oral) BID 1-2 hrs. 14-17 hrs. None FDA investigation for bleeding
Edoxaban (Oral) QD 1-2 hrs. 9-12 hrs. None Do not use with nonvalvular atrial fibrillation
Rivaroxaban (Oral) QD 2-4 hrs. 11-13 hrs. None Black box warning
Unfractionated Heparin (SQ, IV) Immediate IV

20-60 min. SQ
90 min. Prothrombin Frequent labs
Warfarin (Oral) QD 3-5 days 40 hrs. Vitamin K Frequent labs

(Leung, 2015)

While the benefits of anticoagulant therapy in general outweigh the adverse effects blood thinners are a high risk, high maintenance therapy.
Electrical Safety

TJC�s environment of care guidelines as well as OSHA mention the electric needs found in today�s health environment. Health workers need to pay special attention to electrical hazards because they work with tools comprised of electrical circuits. Coming in contact with an electrical voltage can cause current to flow through the body, resulting in electrical shock and burns. Serious injury or even death may occur.

All equipment brought into a facility must be safety checked by the engineering department. Violations of standards governing the use of electrical equipment are the most frequently cited causes of electrical fires. Equipment and appliances that are frequently ungrounded or incorrectly grounded include:

Three-wire plugs attached to two-wire cords,

Grounding prongs that are bent or cut off,

Ungrounded appliances resting on metal surfaces,

Extension cords with improper grounding,

Cords molded to plugs that are not properly wired,

Ungrounded, multiple-plug spiders that are often found in office areas and at nurses� stations,

Personal electrical appliances brought by the workers from home (radios, coffeepots, fans, electric heaters) that are not grounded, have frayed cords, poor insulation, or are otherwise in poor repair.

Waived Testing

Waived tests are on the Joint Commission hot sheet at the moment, so have your staff prepared. Waived testing is the technical term now used for simple to use tests that have a low risk for error. What is being �waived� is the on-location clinical laboratory oversight requirements for certain simple tests, not the test itself. Don�t worry if the new term used for these point-of-care (POC) tests seems confusing, it is!
CDC on Waived Testing

�Under the Clinical Laboratory Improvement Amendments of 1988 (CLIA), simple, low-risk tests can be waived and performed with no routine regulatory oversight in physicians' offices and various other locations�.

Tests can be waived under CLIA if they are determined to be "simple tests with an insignificant risk of an erroneous result�.

Those testing sites preforming without regulatory oversight must hold a certificate of waiver (CW or COW) from CLIA. A valid CLIA certificate is required for Medicare reimbursement.

(MMWR, 2005)

Certain point-of-care tests such as glucose, dipstick urinalysis, fecal occult blood, urine human chorionic gonadotropin (hCG), and group A streptococcal antigen (the direct test from throat swabs) are examples of commonly used waived tests.
Agency Regulation Annual Required Training
TJC WT.03.01.01.EP.6 Annual Competence for Waived Testing Training

CLIA regulates laboratory testing and requires clinical laboratories to be certified, and believe me, medical laboratories require a basket full of certificates in order to do business. Waived testing is also overseen by CLIA, and by three federal agencies who work together with CLIA in making sure accuracy and high standards are met: (FDA, 2014).

FDA � the Food and Drug Administration

CMS � Combined Medicare Medicaid Services

CDC � Centers for Disease Control

Clear documentation of the training each person performing a waived test has completed must be readily available to auditors. This means training for each individual waived test (e.g., documentation for blood glucose meter, documentation for fecal blood strips, etc.), not a one size fits all �they had waived test training�. Please don�t shrug this off as there are currently over forty different tests in the waived category, and if you are the �person Friday� in a physician�s clinic, you will need to train and have documentation for each of the tests you use, and show a fresh test completion for every update the manufacturer makes to each specific waived test.
Agency Regulation Ongoing Required Training
TJC WT.03.03.01 EP.1,3,4 Education, training, and documented competency for every staff performing waived testing, every test they do, and for every update to that test.

Some waived test helpful suggestions:

Use the manufacturer�s instructions, from the most current lot. Instructions change over time and you are responsible for what is current now, not then.

Quality control and/or calibration as specified by the kit manufacturer is a must, do it and document it clearly. Keep those records for two years to meet CLIA requirements.

When the manufacturer supplies reagents or test kits do not tamper with them. Health personnel are notorious for doing cost saving tricks such as cutting a test strip in half lengthwise to get two uses.

Never use outdated strips or reagents.

Handle all test kits as the manufacture recommends. No tucking temperature controlled reagents in that space alongside the wheezing over-heated refrigerators� coils, for instance.

Be sure to follow all regulations that pertain to laboratory testing, such as bloodborne pathogen and hazardous waste handling.

Conclusion

The public sleeps better at night knowing that healthcare has regulatory guardians assuring quality is being given to them, the patient.

While each and every one of us in the health professions work to give the best care possible we sometimes get distracted. It is good that we have authorities, regulatory agencies, and accreditation organizations looking on from outside the fuss and flurry. They help us stay on the path of evidence based care, and give guidance when we stray.

Annual required training, not from our employer, but from organizations with a more global viewpoint aid us to keep a solid foundation in our practice of quality patient care.

Required annual mandated trainings change on a frequent basis, so it is necessary that each of us stay current with what areas are the focus of state, federal, and independent organizations to which we owe diligence. This year�s topics may differ to a small degree from the previous year, or by a great extent. Whichever it may be, we know that proof of training will be required on inspection, accreditation visit, or in our employer�s annual evaluation of our performance and readiness.

Do not fear the audit, accreditation, inspection, or survey. Be ready for each and every surprise visit by giving quality care and having those annual required trainings completed and safely documented.
References:

APA Topics, (2015), �Sexual Abuse�. American Psychological Association. Psychology Topics. Retrieved September 15, 2015 from (Visit Source).

Bartlett, J.G. (2015). �The Natural History and Clinical Features of HIV Infection in Adults and Adolescents�. In: Hirsch MS (Ed.) UpToDate. Waltham, MA.

Behrman, AJ, (2013). �Latex Allergy�. Medscape. September 21, 2015 from (Visit Source).

CCS. (2012). Complementary and Alternative Medicine. Spokane WA. Community Colleges of Spokane.

CDC Devise Associated BSI. (2015). �Bloodstream Infection Event Central Line-Associated Bloodstream Infection and Non-central line-associated Bloodstream Infection�. Centers for Disease Control and Prevention. Retrieved September 6, 2015 from (Visit Source).

CDC Division of Oral Health. (2013). �Bloodborne Pathogens Occupational Exposure�. Centers for Disease Control and Prevention. Retrieved September 12, 2015 from (Visit Source).

CDC HIV/AIDS Prevention. (2015). �HIV Basics�. Centers for Disease Control and Prevention, Division of HIV/AIDS Prevention. Retrieved May 29, 2015 from (Visit Source).

CDC NIOSH. (2013). �Stop Sticks Campaign�. The National Institute for Occupational Safety and Health. Retrieved September 6, 2015 from (Visit Source).

CDC TB Fact Sheets. (2014). �Respiratory Protection in Health-Care Settings�. Centers for Disease Control and Prevention. Retrieved September 12, 2015 from (Visit Source).

CDC Tuberculosis. (2015). �Tuberculosis�. Centers for Disease Control and Prevention. Retrieved September 6, 2015 from (Visit Source).

CDC Vaccine Information. (2014). �Recommended Vaccines for Healthcare Workers�. Centers for Disease Control and Prevention. Retrieved September 6, 2015 from (Visit Source).

CDC Violence. (2014). �Violence Occupational Hazards in Hospitals�. The National Institute for Occupational Safety and Health. Centers for Disease Control and Prevention. Retrieved September 19, 2015 from (Visit Source).

CDC Viral Hepatitis B. (2015). �Viral Hepatitis - Hepatitis B Information�. Centers for Disease Control and Prevention. Retrieved September 12. 2015 from (Visit Source).

CDC Viral Hepatitis C. (2015). �Viral Hepatitis - Hepatitis C Information�. Centers for Disease Control and Prevention. Retrieved September 12. 2015 from (Visit Source).

Child Welfare Information Gateway. (2014). �Mandatory Reporters of Child Abuse and Neglect�. Washington, DC: U.S. Department of Health and Human Services, Children's Bureau. Retrieved September 17, 2015 from (Visit Source).

CMS EMTALA. (2012). �Emergency Medical Treatment & Labor Act�. CMS.gov. Retrieved September 1, 2015 from (Visit Source).

Davis, CP. (2015). �Patient Rights�. eMedicine.com. Retrieved August 28, 2015 from (Visit Source).

FDA. (2014). �Clinical Laboratory Improvement Amendments (CLIA)�. U.S. Food and Drug Administration. Retrieved September 21, 2015 from (Visit Source).

Headley, M. (2015). �Key Differences Between Accreditation Programs�. Facility Care. Retrieved September 2, 2015 from (Visit Source).

ISMP. (2014). �ISMP List of High Alert Medications in Acute Care Settings�. Institute for Safe Medication Practices. Retrieved September 26, 2015 from (Visit Source).

Leung, L.K. (2015). �Anticoagulation with Direct Thrombin Inhibitors and Direct Factor Xa Inhibitors�. In: Hirsch MS (Ed.) UpToDate. Waltham, MA.

Medline Plus Consumer Rights. (2013). �Consumer Rights and Responsibilities.� NATIONAL Institute of Health, U.S. National Library of Medicine, Medline Plus. Retrieved August 28, 2015 from (Visit Source).

MLN. (2015). �HIPAA Basics for Providers: Privacy, Security, and Breach Notification Rules�. Medicare Learning Network. Retrieved August 29, 2015 from (Visit Source).

MMWR. (2005). �Good Laboratory Practices for Waived Testing Sites�. Morbidity and Mortality Weekly Report. Centers for Disease Control and Prevention. Retrieved September 21, 2015 from (Visit Source).

National Guideline Clearinghouse. (2012). �Infection Prevention and Control of Healthcare Associated Infections in Primary and Community Care�. National Institute for Health and Clinical Excellence. Retrieved September 7, 2015 from (Visit Source).

NIOSH Hazardous Drugs. (2014). �NIOSH List of Hazardous Drugs in Healthcare Settings Allows Healthcare Workers to Minimize Exposure and Reduce Health Risks�. Centers for Disease Control and Prevention. Retrieved September 15, 2015 from (Visit Source).

News Medical. (2015). �Study Provides New Estimates of Opioid Misuse Addiction�. News-Medical.net Life Sciences and Medicine. Retrieved October 11, 2015 from (Visit Source).

OMH National CLAS Standards. (2015). �The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care�. U.S. Department of Health and Human Services, Office of Minority Health. Retrieved August 29, 2015 from (Visit Source).

Perry, AG., Potter, PA., Ostendorf, W. (2013). Clinical Nursing Skills & Techniques. St. Louis, Mo. Mosby Elsevier.

Psych Central, (2014). �21 Warning Signs of an Emotionally Abusive Relationship�. Psych Central. Retrieved September 15, 2015, from (Visit Source).

Rattue, G. (2012). �Disclosing Surgical Site Infections � Rates Vary Across US States�. Medical News Today. Retrieved September 6, 2015 from (Visit Source).

Searight HR, et. Gafford, J. (2005). �Cultural Diversity at the End of Life: Issues and Guidelines for Family Physicians�. American Family Physician. Retrieved from (Visit Source).

TJC E-dition PC. (2015). �Chapter Provision of Care, Treatment, and Services�. The Joint Commission. Retrieved September 8, 2015 from (Visit Source).

TJC Standards FAQ. (2009). �Restraint and Seclusion for Organizations that Do Not Use Joint Commission Accreditation for Deemed Status�. The Joint Commission. Retrieved September 18, 2015 from (Visit Source).

TJC Topic Library. (2014). �Hospital: 2015 National Patient Safety Goals�. The Joint Commission. Retrieved September 2, 2015 from (Visit Source).

WebMD Back Pain. (2014). �Back Problems and Injuries Prevention�. WebMD Back Pain Health Center. Retrieved September 12, 2015 from (Visit Source).

WebMD TB. (2014). �Tuberculosis Prevention�. WebMD Lung Disease and Respiratory Health Center. Retrieved September 12, 2015 from (Visit Source).

Zehnder, NG., (2015), �How Should Healthcare Workers Handle Needlestick Injuries?�, ENTtoday. Retrieved September 12, 2015 from (Visit Source).

This course is applicable for the following professions:

Advanced Registered Nurse Practitioner (ARNP), Certified Nursing Assistant (CNA), Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Dietitian/Nutritionalist (RDN), Home Health Aid (HHA), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Physical Therapist (PT/PTA), Registered Nurse (RN), Respiratory Therapist (RT)

Topics:

Administration & Leadership, CPD: Preserve Safety, CPD: Prioritize People, CPD: Promote Professionalism and Trust, Legal & Regulatory, Medical Surgical
Last Updated: 1/27/2017




Download

Submitter's Comment
1
Express and Informed Consent
(See also Voluntary Admissions and Emergency Treatment Orders)
Competence to Consent
Q. Who is eligible to consent or refuse to consent to their own treatment?
Minors cannot make their own inpatient mental health treatment decisions; this is the
responsibility of their parent or guardian. Neither can persons with a court appointed
guardian or who have a health care surrogate or proxy currently making decisions for
them. Only adults who are consistently able to make well-reasoned, willful and knowing
decisions about their own mental health or medical care can consent, refuse consent, or
revoke consent to their own treatment.
Q. If a person arrives at a receiving facility for an involuntary examination is
cooperative and willing to take medications, is this sufficient to document
“express and informed consent”?
No. "Cooperative and willing" are helpful descrip
tors, but more important is competence
of the person to make such decisions. This is defined in the law as being able to make
well-reasoned, willful and knowing decisions about one's mental health and medical
care. Without competence, as defined here, no amount of cooperation or willingness is
sufficient. The standard under the Baker Act requires more than “implied consent”
because the person may have taken the medications prior to admission and/or is not
currently refusing the medications. “Med compliance” is a behavior, but doesn’t
necessarily reflect competence.
Q. Is it true that a non-psychiatrist physician, during the involuntary examination,
can determine competency? I think the answer is yes, but just need verification.
You are correct. A non-psychiatric physician can determine competency to consent to
treatment. No professional other than a physician can do so. Whether on voluntary or
involuntary status, the physician must certify that the person is able to make well-
reasoned, willful and knowing decisions about his/her health and mental health care –
the definition of competence to consent – before permitting the individual to consent to
treatment. All voluntary patients must be certified as “competent” within 24 hours of
admission and any persons on involuntary st
atus who are refusing examination but
allowed to consent to their own treatment must also be certified.
It’s important that the documentation in the cl
inical record reflects that the individual
maintains this competence as long as treatment is provided. If at any time the individual
displays statements or behaviors that suggest he/she isn’t any longer able to make such
well reasoned decisions, treatment can’t be continued except when imminent danger
has been documented (ETO) or a legally authorized substitute decision-maker is
designated to provide consent.
2
Q. Recently we had a question come up about a patient being able to sign legal
documents brought in by the family. The patient was not deemed incompetent by
our doctor, but was not here voluntarily either. Can the patient is able to sign
legally binding documents while inpatient in a mental health hospital or CSU?
It’s unclear what kind of legal documents are involved. Just because a person hasn't
been adjudicated incapacitated by a court, doesn't mean he/she is competent for various
purposes.
If the patient is on voluntary or involuntary status and has been allowed to provide
consent to his/her own treatment, a physi
cian would have had to document the person's
competence to provide express and informed
consent on a sustained basis (not just
some "window of lucidity"). This medical statement means that the person is able to
make well-reasoned, willful and knowing medical and mental health decisions.
If the person's clinical record has notes from nurses, social workers or other personnel
that reflect the person's judgment or insight was impaired at the, the legitimacy of any
consent would be questionable, even for treatment not to mention other legal
documents. One would question how the person would meet the acuity criteria for
inpatient psychiatric care and yet be able to pass the high threshold of competence to do
so.
If a person was being held involuntarily because of "refusal" instead of "unable to
determine the exam/placement was needed", it may be possible to overcome with
sufficient documentation a presumption of incapacity.
The person could later challenge any document signed at such a time and place due to
diminished capacity or perceived coercion, whether the documents are Advance
Directives, quit claim deeds, a will, powers of attorney, or any other legal document.
Q. If a person is admitted on involuntary examination status and the box on the
BA-52 form is checked 'refusing voluntary exam' – can the patient be capable of
providing consent to their psychotropic medications and treatments as long as
the staff notes that they appeared to be consistently able to make well-reasoned,
willful and knowing decisions about their treatment?
Yes. A person may refuse admission but may be competent to consent or refuse
consent to treatment.
Q. Can a person on involuntary status still be competent to consent or refuse
consent to their own treatment?
YES. The issue of competence to consent is considered separately from the placement
issue. If the person meets the criteria for involuntary examination or involuntary
placement but is capable of making well-reasoned, willful, and knowing decisions about
their medical or mental health, he or she may continue to consent, withhold consent, or
refuse consent to treatment.
3
A person on involuntary status may or may not be competent to consent to his or her
own treatment. If the person who initiated the involuntary examination noted on the form
that the person was unable to determine the exam was necessary, as opposed to
refusing the exam, the person must be presumed to be incompetent to consent to
treatment until determined by a physician to have such capacity.
Q. Does a physician need to complete Certification of Person’s Competence to
Provide Express and Informed Consent (Form #3104) if the patient is to be
discharged from involuntary status and our facility within 24 hours of admission,
or can s/he complete the 3111 only?
The Certification of Competence is used as follows:

If the person arrives on voluntary status and is released in less than 24 hours,
the 3104 form doesn’t need to be completed.

If the person arrives on either voluntary or involuntary status and consents
to/receives psychotropic medications, the 3104 form must be used even if the
person is released within 24 hours.

If the person arrives on involuntary status and is subsequently released either
within or outside the 24 hour window and regardless of whether the person has
been medicated, the 3111 or it’s equivalent must be completed.
Q. Does competency to consent to treatment have to be documented by a
physician before consent can be sought and treatment administered?
NO. Chapter 65E-5.170(1), FAC requires that as soon as possible, but in no event
longer than 24 hours from entering a designated receiving facility on a voluntary or
involuntary basis, each person shall be examined by the admitting physician to
determine the person's ability to provide express and informed consent to admission and
treatment.
This doesn't require that the examination or completion of the form be done prior to
administering psychotropic medications. However, the law is very clear that the person
must be able to provide express and inform
ed consent for any treatment rendered, after
full disclosure of all the legally required information.
With regard to adults on
voluntary
status, one can presume the person is competent to
consent to medications and other treatment prio
r to being certified by a physician as long
as staff notes that the person appears to be able to consistently make well-reasoned,
willful, and knowing decisions about his/her medical and mental health treatment.
However, at any time the person displays statements or behaviors that would lead one
to believe that he or she is not able to make well-reasoned, willful and knowing
decisions, the treatment must be discontinued until informed consent can be obtained
from a legally authorized person, unless an emergency treatment order is issued
because of imminent danger.
If a person is admitted on
involuntary
status and the block on the BA-52 form indicates
the person was unable to determine a voluntary examination was needed is checked, a
facility would have to presume the person is incompetent to consent to medications.

Information

In March 1998, the Advisory Commission on Consumer Protection and Quality in the Health Care Industry issued its final report, which included the Consumer Bill of Rights and Responsibilities. The Commission was appointed by President Bill Clinton, and co-chaired by Donna Shalala, Secretary of the Department of Health and Human Services.

The purpose of the Bill of Rights is:

To build up consumer confidence in the health care system, by making it easy for consumers to be involved in their own health care.
To strongly support the importance of a good health care provider and that of a good provider-patient relationship.
To emphasize and support the importance of the consumers' role in making sure they have rights and responsibilities with regard to health improvement.

The Consumer Bill of Rights was developed by the federal government. This has been used by many health plans, including the federal-government-sponsored health plans.

Consumer Bill of Rights

I. Information Disclosure

You have the right to receive accurate information you can understand about your health, treatments, health plan, providers, and health care facilities. If you speak another language, have a physical or mental disability, or just do not understand something, you will be helped so you can make informed health care decisions.

II. Choice of Providers and Plans

You have the right to choose your provider, within your health plan.

III. Access to Emergency Services

If you have severe pain, an injury, or sudden illness and you are concerned that you could be seriously ill, hurt, or could die, you have the right to get emergency services whenever and wherever needed, to be seen by a doctor and get services, even if you do not ask your health plan first, and you will not be charged a penalty.

IV. Participation in Treatment Decisions

You have the right to know all your treatment options, even if they are not covered by your health plan, and make decisions about your care. Parents, guardians, family members, or others that you choose can represent you if you cannot make your own decisions.

V. Respect and Nondiscrimination

You have the right to considerate, respectful care, and to not be discriminated against by your doctors, other health care providers, or health plan representatives.

VI. Confidentiality of Health Information

You have the right to talk in private with providers and to have your health care information protected. You also have the right to review and copy your own medical record and ask your doctor to make corrections to your record if it is not accurate or complete, or if it has information that does not relate to your health care.

VII. Complaints and Appeals

You have the right to a fair, fast, and objective review of any complaint you have against your health plan, doctors, hospitals, or other health care personnel. This includes complaints about wait times, hours available, health care facilities, and the conduct of health care personnel.

Consumer Responsibilities

In addition to listing consumer rights for health care, the Advisory Commission on Consumer Protection and Quality in the Health Care Industry also listed the responsibilities of consumers. These are ways the consumer can work together with health care providers to get the best quality health outcome.

Do your best to get well and stay healthy with habits such as exercising, not smoking, and eating a nutritious diet.
Give your providers the information they need, and clearly communicate what you want and need.
Be involved in making health care decisions with your health care providers.
Work with providers to develop and carry out the treatment plans you choose.
Use the health plan's internal complaint and appeal process to address concerns that may arise.
Avoid knowingly spreading disease.
Recognize the risks and limits of medical science, and know that providers are human and can make mistakes.
Be aware of a provider's need to fairly provide care to other people and the community.
Learn about your health plan's coverage and options (when available), including covered benefits, limits, services that are not covered, rules regarding information use, and how to appeal coverage decisions.
Show respect for other people and health workers.
Make a good-faith effort to pay your health care bills.
Follow procedures outlined by your health plans and providers.
Report wrongdoing and fraud to the right resources or legal authorities.

For more information, visit the Office for Civil Rights - HIPAA website -- www.hhs.gov/ocr/hipaa.
References

Centers for Medicare and Medicaid Services. The Center for Consumer Information and Insurance Oversight. Patient's Bill of Rights. Available at: www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/Patients-Bill-of-Rights.html. Accessed October 13, 2015.
Review Date: 8/14/2015
Reviewed By: Linda J. Vorvick, MD, Medical Director and Director of Didactic Curriculum, MEDEX Northwest Division of Physician Assistant Studies, Department of Family Medicine, UW Medicine, School of Medicine, University of Washington. Also reviewed by David Zieve, MD, MHA, Isla Ogilvie, PhD, and the A.D.A.M. Editorial team


Keywords: tjc, nursing, administrative, medic, testing, research, consent, informed consent, human rights

Most Recent User Comments
There are no comments for this exhibition yet.

Leave a comment
Please log in or create an account to post a comment.
Related sponsor

Related Literature

Other related exhibitions

Related links