Resident - Palmetto Health Residency Programs

Transcription

Resident
Physician Manual • 2013-14
1
EMERGENCY REFERENCE
CODE BLACK
CODE ORANGE
External disaster
Radiological accident
CODE PINK
CODE BLUE
Adult life-threatening situation
Child abduction
CODE PURPLE
CODE BLUE JR.
Pediatric life-threatening situation
Threat of violence
CODE BROWN
CODE RED
Bomb threat
Fire
CODE GRAY
CODE SILVER
Severe weather
Helicopter operations
CODE GREEN
CODE WHITE
Internal disaster
Nursing assistance required
CODE YELLOW
Hazardous spill
2
R.A.C.E.
Rescue patient(s) from danger
Activate the alarm
Contain the fire
Extinguish the fire
Emergency Numbers
Palmetto Health Baptist
5000
Palmetto Health Baptist Easley 27799
Palmetto Health Richland
6222
P.A.S.S.
Pull the pin
Aim the nozzle
Squeeze the handle
Sweep the nozzle
across the base of the fire
The policies and procedures contained within this manual may be revised or updated periodically.1 Any questions
concerning policies, procedures or benefits should be addressed to the Medical Education Administrative office at 434-6861.
Some departments may have supplemental policy manuals providing additional guidance. Your specific department will provide these
for you. In addition, faculty and other USC employees involved in residency training must adhere to USC and USC School of Medicine
policies, which may be different.
A hard copy of the Hospital Policy and Procedure manual is available with signatures.
The Palmetto Health Resident Manual is updated on an annual basis and made available to each resident.2 The Graduate Medical
Education Department will endeavor to have this distribution schedule coincide with the timetable for signing resident contracts.
Nothing in the policies contained in this Manual shall be construed to constitute a contract, and Palmetto Health has the right to modify any policy at
its discretion.
2
Throughout this Manual, the word “resident” refers to all general and subspecialty residents. The latter are sometimes referred to as “fellows.”
1
3
4
5
6
ATM
Vending
Nurse
Station
Telephone
Restrooms
Family/
Lobby Waiting
Stairs
Elevator
Information
MAP KEY
To 3 Medical Park
Gift Shop
To Heart Hospital
Health
InformationMedical
Radiology
Records
Services
Registration
Chapel
Special
Procedures
Radiology
Observation
Ultrasound Care Unit
(ROCU)
MRI
Digital Radiology
Nuclear
Medicine
EMERGENCY
ENTRANCE
To Children’s Hospital
To Children’s Hospital
Emergency
Registration
CHILDREN’S
EMERGENCY
ENTRANCE
Children’s
Emergency
Registration
Hyperbaric
Medicine
Auditorium
Endoscopy
Patient Security
Relations Services
Respiratory
Classroom 1B Care Services
Admissions &
Registration
Classroom 1A
MAIN ENTRANCE
Cafeteria
Physical
Rehabilitation
Services
Laboratory
5 Medical Park
MAIN HOSPITAL
SECOND FLOOR
5 Medical Park
MAIN HOSPITAL
FIRST FLOOR
FLOOR
5 East Patient Rooms 531-556 . . . . . . . . . . . . . . . . . . . . 5
• Medical ICU
• Medical Step Down Unit
5 West Patient Rooms 503-527. . . . . . . . . . . . . . . . . . . . 5
• Surgical Trauma ICU (STICU)
• Surgical Step Down Unit
PATIENT ROOMS
Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Surgery Adult Family/Lobby Waiting. . . . . . . . . . . . . . 3
Special Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Security Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Respiratory Care Services . . . . . . . . . . . . . . . . . . . . . . . . 1
Radiology Services Registration . . . . . . . . . . . . . . . . . . 2
Radiology Observation Care Unit (ROCU) . . . . . . . . 2
Physical Rehabilitation Services . . . . . . . . . . . . . . . . . . 2
Patient Relations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Outpatient Surgery Registration . . . . . . . . . . . . . . . . . . 3
Outpatient Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Operating Rooms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Nuclear Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Newborn Nursery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Neonatal Intensive Care Unit (NICU) . . . . . . . . . . . . . . 5
MRI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Health Information - Medical Records . . . . . . . . . . . . 2
Labor & Delivery (Birthplace) . . . . . . . . . . . . . . . . . . . . 4
Laboratory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Hyperbaric Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Gift Shop . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Emergency Registration . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Digital Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Classroom 1B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Classroom 1A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chapel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Children’s Emergency Registration. . . . . . . . . . . . . . . . 2
Cafeteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Birthplace Shoppe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Birthplace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Auditorium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Adult Surgery Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Admissions & Registration. . . . . . . . . . . . . . . . . . . . . . . . 1
DEPARTMENT LISTING
7
ATM
Vending
Nurse
Station
Telephone
Restrooms
Birthplace Shoppe
4 West
Patient Rooms 401-428
5 Medical Park
MAIN HOSPITAL
FOURTH FLOOR
Family/
Lobby Waiting
Stairs
Elevator
Information
MAP KEY
Newborn
Nursery
4 East
Birthplace
Labor & Delivery
(Birthplace)
Restricted Access
To 3 Medical Park
Outpatient
Surgery
Registration
Elevators to
Parking Garage
Levels P3 & P4
Outpatient
Surgery
5 Medical Park
MAIN HOSPITAL
THIRD FLOOR To Heart Hospital
Adult Surgery
Recovery
5 West
5 Medical Park
MAIN HOSPITAL
FIFTH FLOOR
Surgery
Adult Family/Lobby Waiting
Operating
Rooms
5 East
• Medical ICU
NICU
Waiting
Neonatal
Intensive
Care Unit
(NICU)
FLOOR
• Medical ICU
PATIENT ROOMS
Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Surgery Adult Family/Lobby Waiting. . . . . . . . . . . . . . 3
Special Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Security Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Respiratory Care Services . . . . . . . . . . . . . . . . . . . . . . . . 1
Radiology Services Registration . . . . . . . . . . . . . . . . . . 2
Radiology Observation Care Unit (ROCU) . . . . . . . . 2
Physical Rehabilitation Services . . . . . . . . . . . . . . . . . . 2
Patient Relations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Outpatient Surgery Registration . . . . . . . . . . . . . . . . . . 3
Outpatient Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Operating Rooms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Nuclear Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Newborn Nursery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Neonatal Intensive Care Unit (NICU) . . . . . . . . . . . . . . 5
MRI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Health Information - Medical Records . . . . . . . . . . . . 2
Labor & Delivery (Birthplace) . . . . . . . . . . . . . . . . . . . . 4
Laboratory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Hyperbaric Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Gift Shop . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Emergency Registration . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Digital Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Classroom 1B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Classroom 1A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chapel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Children’s Emergency Registration. . . . . . . . . . . . . . . . 2
Cafeteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Birthplace Shoppe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Birthplace . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Auditorium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Adult Surgery Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Admissions & Registration. . . . . . . . . . . . . . . . . . . . . . . . 1
DEPARTMENT LISTING
8
9
10
Section A
Administrative and
General Information
12
Table of Contents
Mission and Value Statements........................................................15
JCAHO................................................................................................33
Standards of Behavior.......................................................................16
Licensure.............................................................................................33
Institutional Commitment..............................................................19
Library.................................................................................................33
Patient’s Bill Of Rights......................................................................20
MD Consult........................................................................................35
Medical Executive Committee.........................................................23
Prescription Writing.........................................................................35
Organizational Charts......................................................................24
New Innovations...............................................................................36
Dates of Site Visits and Internal Reviews......................................25
On-Call rooms....................................................................................36
Office of Graduate Medical Education Staff..................................26
Pagers..................................................................................................36
Palmetto Health Residency Department Contacts.......................27
Parking................................................................................................37
ACGME...............................................................................................29
PPD Skin Test.....................................................................................37
AIDET.................................................................................................31
Procedures Consult...........................................................................37
Benefits...............................................................................................31
Professional Liability Insurance......................................................38
Certifications......................................................................................31
Release of Information.....................................................................38
Committees........................................................................................31
Residency Certificates.......................................................................38
Computer EPIcenter..........................................................................31
Resident Forums...............................................................................38
Controlled Substance........................................................................31
Resident Lounges..............................................................................39
Counseling..........................................................................................32
Risk Management.............................................................................39
Credit Union.......................................................................................32
Safety Training...................................................................................39
Disaster...............................................................................................32
Smoke-Free Policy.............................................................................39
E-mail..................................................................................................32
Student Loan Deferments................................................................39
Exposures...........................................................................................32
USMLE Step 3....................................................................................39
Interpreters........................................................................................32
Websites of Interest..........................................................................39
ID Badges............................................................................................32
Substance Use and Dependency Article.........................................40
13
Table of Contents
OUR HOSPITALS
Palmetto Health is the region’s largest, most comprehensive, locally owned, not-for-profit health care
resource. It leads the region in the number and volume of inpatient and outpatient services provided
because of the depth and breadth of available services including general, acute and critical care;
the number and diversity of specialty physicians providing the full array of treatment from primary to
emergency care and beyond; care that is delivered with compassion by a staff that records high levels
of satisfaction in their work and achieves the highest level of patient satisfaction in the nation; and
because of its emphasis on leadership development, patient safety and quality outcomes. All patients
are provided needed care regardless of ability to pay.
The 1,138-bed system in Columbia, a JCAHO-accredited institution, has more than 8,400 employees
and 1,000 physicians. The hospitals of Palmetto Health provide care for 70 percent of the residents
of Richland County and more than 55 percent of the healthcare for the combined Richland/Lexington
county area. The latest technology and treatment protocols go hand-in-hand with quality patient care.
Palmetto Health is composed of four outstanding hospitals, Palmetto Health Richland and Baptist in
Columbia, and the Heart Hospital and Children’s Hospital in Columbia.
Our hospitals are highly respected, long-time members of the community. Each year, we treat nearly a
half million patients, welcome more than 6,600 babies into the world, treat more than 80,000 pediatric
patients and 3,000 cancer patients, accommodate more than 160,000 emergency department visits,
perform nearly 50,000 mammograms, and make close to 32,000 home care visits.
Through a formal affiliation agreement with the University of South Carolina, Palmetto Health is closely
allied with the University’s School of Medicine.
AFFILIATIONS
Major participating institutions are listed below (the majority of Palmetto Health’s graduate medical
education activities take place at Palmetto Health Richland).
»» Palmetto Health Richland
»» Palmetto Health Baptist
»» University of South Carolina Neuropsychiatry Clinic
»» Williams Jennings Bryan Dorn
»» Department of Veterans Affairs Medical Center (VA Medical Center)
»» William S. Hall Psychiatric Institute
»» Shriners Hospital - Greenville
14
Residency Programs
Child & Adolescent Psychiatry
Dentistry
Emergency Medicine
Family Medicine
General Psychiatry
Internal Medicine
Neurology
Obstetrics and Gynecology
Ophthalmology
Orthopaedic Surgery
Pediatrics
Surgery
Fellowship Programs
Critical Care
Emergency Medical Services
Emergency Medicine Ultrasound
Endocrinology
Forensic Psychiatry
Geriatric Psychiatry
Geriatrics
Infectious Disease
Pulmonary Medicine
Simulation
Sports Medicine
Ultrasound (Primary Care, USC
School of Medicine)
Principles
OUR MISSION
Palmetto Health is committed to improving the physical, emotional and spiritual health of all individuals and communities we serve; to
providing care with excellence and compassion; and, to working with others who share our fundamental commitment to improving the
human condition.
OUR VISION
To be remembered by each patient as providing the care and compassion we want for our families and ourselves.
OUR VALUES
Compassion
Caring for people in need and benevolence for people in general.
Dignity
Respecting one’s worth as a human being.
Excellence
Pursuing the highest level of service and quality in all that we do.
Integrity
Adhering to a code of trust, fairness and honesty.
Teamwork
Achieving common goals together.
15
Standards of Behavior
MAKING OUR VISION A REALITY
Our attitudes should always reflect Palmetto Health’s five corporate values, and we conduct ourselves in accordance with the following
Standards of Behavior. These standards were developed by a diverse team of Palmetto Health employees and are modeled by all our
team members every day. We use the word “customer” to describe those individuals who depend on our expertise. Customers are our
patients, their families, visitors, vendors and coworkers. These standards define the behaviors our customers can expect from all Palmetto
Health employees.
As an employee of Palmetto Health, I value COMPASSION! I will…
DEMONSTRATE COURTESY
»» Be approachable
»» Introduce self by name and job title (AIDET)
»» Speak in a calm voice and listen attentively
»» Use positive body language and present myself professionally
»» Offer comfort measures when appropriate
»» Maintain a safe and welcoming environment
»» Refrain from personal conversations in the presence of customers
»» Treat others with respect and care
»» Greet others by name when possible
RESPOND IN A TIMELY MANNER
»» Ensure all call lights and phones are answered promptly
»» Resolve customers’ needs (Service Recovery)
»» Contact the appropriate person for issues I cannot resolve personally (Service Recovery)
»» Apologize for delays, keep customers informed and reschedule appointments as appropriate (AIDET and Service Recovery)
»» Provide a comfortable atmosphere for waiting customers
OFFER DIRECTIONAL ASSISTANCE
»» Escort customers who are unfamiliar with our facilities
»» Call Security or Volunteer Services for assistance when necessary
As an employee of Palmetto Health, I value DIGNITY! I will…
PROTECT PRIVACY
»» Knock before entering patient rooms and closed doors
»» Use language and terminology that is easily understood
»» Encourage questions and offer choices as appropriate
»» Explain what I am about to do and why (AIDET)
»» Ensure gowns and equipment are sized appropriately for patients
»» Adhere to organizational policies, HIPAA requirements and JCAHO standards regarding privacy and confidentiality
»» Limit discussions of customer information to what is necessary to provide quality care
RESPECT DIVERSITY
»» Prohibit language and/or actions that demean anyone’s heritage, race, nationality, appearance, beliefs, gender, age, disability and/or
sexual orientation
»» Display, sensitivity and respect for others’ cultures and backgrounds
»» Provide interpreters, amplification devices, closed caption television or other necessary equipment for appropriate patient care
»» Inform patients and their families about services relevant to their spiritual preferences
»» Support fair treatment for all as outlined by Palmetto Health vision and goals.
COMMUNICATE CLEARLY
»» Answer the phone with the Palmetto Health standard phone greeting.
»» Use proper e-mail and telephone etiquette
»» Refrain from gossip and abusive language or behaviors
»» Attempt to resolve issues one-on-one before using the chain of command
»» Coach in private and commend in public
16
As an employee of Palmetto Health, I value EXCELLENCE! I will …
EXCEED CUSTOMER EXPECTATIONS
»» Welcome others with eye contact, a smile and a friendly greeting
»» Recognize our customers’ sense of urgency and show them we value their time
»» Inform customers about their plan of care and provide explanations for delays (AIDET)
»» Listen attentively to customers and avoid interrupting them
»» Apologize for problems or inconveniences and initiate actions to resolve them (Service Recovery)
»» Treat each customer as if he or she is the most important person in our facility
»» Thank customers for trusting Palmetto Health to meet their needs (AIDET)
EXHIBIT A POSITIVE ATTITUDE
»» Keep personal problems from interfering with work responsibilities
»» Come to work with a smile and an attitude of optimism
»» Create and participate in a team environment where honest feedback is seen as valuable and not as criticism
MAINTAIN A PROFESSIONAL APPEARANCE
»» Know and abide by my department’s dress code
»» Wear my I.D. badge at all times (Palmetto Health ID badges shall be worn above the waist, preferably on the lapel area of the
employee’s attire. Name and picture should be clearly visible.)
»» Demonstrate good personal hygiene
SEEK CONTINUOUS LEARNING
»» Seek self development—Utilize the tools that are provided to grow personally and professionally
»» Complete mandatory hospital-wide and unit-specific competencies
»» Actively read books and other resources that are provided
»» Know, grow and own my position
As an employee of Palmetto Health, I value INTEGRITY! I will …
BE ACCOUNTABLE FOR MY ACTIONS
»» Be honest and reliable
»» Set a good example
»» Speak positively about Palmetto Health, my customers and co-workers
»» Apologize for my mistakes and take corrective actions (Service Recovery)
»» Abide by Palmetto Health’s policies, standards of behavior and with all applicable laws, regulations and policies
»» Assume personal responsibility for receiving and responding appropriately to official departmental, campus and system-wide
communications
ACT LIKE AN OWNER
»» Maintain Palmetto Health’s equipment and facilities
»» Conserve hospital resources
»» Accurately report defective equipment to the appropriate department in a timely manner
»» Treat Palmetto Health resources as if they are my own
As an employee of Palmetto Health, I value TEAMWORK! I will…
BUILD RELATIONSHIPS
»» Respect the ideas, opinions, expertise and diversity of my co-workers
»» Assist co-workers who are struggling with their workloads
»» Serve as a resource to other departments as needed
»» Coordinate with others to facilitate timely, safe transitions for our customers
»» Report on time, as scheduled, prepared and ready to begin work
»» Accept changes to assignments and/or schedules
ENSURE SAFETY AND QUALITY
»» Maintain a safe, clean work area and surrounding environment
»» Properly tag and report hazardous equipment and conditions
»» Demonstrate proper safety procedures
17
TAKE PRIDE IN PALMETTO HEALTH
»» Follow through with my commitments
»» Find a co-worker who can fulfill a request when I cannot
»» Properly dispose of litter
»» Report spills, debris and/or necessary repairs to the correct department
»» Take pride in Palmetto Health and treat our facility as if I own it!
GLOSSARY
AIDET
A-ACKNOWLEDGES THE CUSTOMER:
»» Smiles, makes eye contact and greets them in a pleasant manner.
I-INTRODUCES SELF:
»» States name, role and competencies.
»» Highlights skill and expertise of self and other healthcare team member.
D-DURATION:
»» Gives the customer a time expectation.
»» Keeps the customer informed as to the amount of time a procedure or process will take.
»» Includes letting them know if there is a wait time; gives time expectation of that wait.
E-EXPLANATION:
»» Keeps customers informed by explaining all processes and procedures.
»» Assists customers to have clear expectations of what will be occurring.
T-THANKS THE CUSTOMER:
»» Consistently thanks customers for their time and, if a patient, for choosing us for their care.
»» Expresses appreciation that they have chosen us as their health care facility.
»» Asks if there is anything else he/she can do for the customer before ending the interaction.
Service Recovery
Service recovery is defined as “the handling of customer dissatisfaction, complaints or any problems or difficulties with our organization.”
Service Recovery is initiated when a customer receives less than excellent service. Simply stated, Service Recovery is the art of making
things right when things go wrong!
When a service failure is brought to your attention, it’s time to ACT!
A- APOLOGIZE FOR NOT MEETING THE CUSTOMER’S EXPECTATIONS.
C- CORRECT THE SERVICE ISSUE.
T- THANK THE CUSTOMER FOR BRINGING THE ISSUE TO YOUR ATTENTION, AND ASSURE
PROPER FOLLOW THROUGH TO PREVENT A RECURRENCE.
18
Institutional Commitment
SUPPORT FOR GRADUATE MEDICAL EDUCATION
Palmetto Health, in partnership with the University of South Carolina School of Medicine and other affiliated institutions, regards medical
education, graduate medical education, graduate dental education, research, and lifelong learning as integral to its commitment to provide
safe, compassionate, appropriate and effective care to its patients. The Palmetto Health Board of Directors, administrators, faculty and
staff are likewise committed to providing its graduate medical education programs with the necessary financial support for administrative ,
educational and clinical resources, including personnel, to ensure their quality.
It is our firm belief that educating future physicians and dentists in our graduate medical and dental education programs furthers our
mission of improving the physical, emotional, and spiritual health of all individuals and communities we serve; providing care with
excellence and compassion; and working with others who share our fundamental commitment to improving the human condition.
We therefore commit ourselves to providing graduate medical education programs that enable physicians in training to develop
competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills,
professionalism, and systems-based practice and to participate in a wide range of scholarly activities under the guidance and supervision
of the faculty and staff. We further commit to conducting these programs in compliance with the Institutional, Common, and Program
requirements of the Accreditation Council for Graduate Medical Education, its Residency Review Committees, the Commission on Dental
Accreditation, and the Accreditation Council for Continuing Medical Education.
Signature on File
William L. “Freddie” Freeman, III
Chair, Board of Directors
Signature on File
Charles D. Beaman, Jr.
Chief Executive Officer, Palmetto Health
Signature on File
Katherine G. Stephens, PhD, MBA, FACHE
System Vice President, Medical Education & Research and DIO
Signature On File
James I. Raymond, MD
Chief Medical Officer
19
Rights and Responsibilities
PATIENT’S BILL OF RIGHTS
As a patient in our Joint Commission-accredited health care facility, you have many rights that we are committed to protecting and
promoting. Whenever possible, we will inform you of your rights in advance of furnishing or discontinuing your care. Your rights include:
1. To have the staff promptly notify a family member
representative and your physician of your admission to the
healthcare facility.
2. To considerate and respectful care, and to give us feedback
about your care. You have the right to personal dignity.
3. To have your cultural, psychosocial, spiritual and personal
values, beliefs and preferences respected. You have the right
to wear appropriate personal clothing and religious or other
symbolic items, as long as they do not interfere with diagnostic
procedures or treatment. You have the right to pastoral and
other spiritual services.
4. To participate in the development and implementation of your
plan of care, and to know the identity and professional status
of those involved in your care, including if the care giver is a
student or trainee or is professionally associated with other
individuals or health care institutions involved in your care.
5. To make informed decisions about your care, treatment and
services. This includes being informed of your health status:
being involved—prior to and during the course of treatment—
in your care planning and treatment, being informed as to
all proposed technical procedures and treatment—including
the potential benefit(s) and potential drawback(s) or risk(s) as
well as alternatives for care, being able to request or refuse
medically appropriate treatment to the extent permitted by
law and health care facility policy, and to be informed of
the medical consequences of such action. If you refuse a
recommended treatment, you will receive other medically
needed, indicated and available care.
6. To formulate an advance directive (such as a Living Will or
Durable Power of Attorney for Health Care) with the expectation
that the staff and practitioners will honor the directive to the
extent permitted by law and Palmetto Health policy. If you
have a written advance directive, you should provide a copy
to the health care facility, your family and your doctor. These
documents express your choices about your future care or
name someone for you if you cannot speak for yourself.
7. To expect that, within capacity and policies, the health care
facility will make a reasonable response to any patient’s
request for appropriate and medically indicated care and
services, including the management of pain. Our health care
facility is committed to providing individuals impartial access to
treatment or accommodations that are available or medically
indicated, regardless of race, creed, sex, national origin, or
sources of payment for care.
8. If requested or if medically appropriate and legally permissible,
you may be transferred to another facility after being informed
about the need for, risks, benefits, and alternatives to transfer.
You will not be transferred until the other facility agrees to
accept you and you agree to transfer.
20
9. To personal privacy, to receive care in a safe setting, and
to be free from all forms of abuse or harassment. You have
the right to refuse to talk with or see anyone not officially
connected with the health care facility, including visitors, or
persons officially connected with the health care facility but
not directly involved in your care. You have the right to expect
that any discussion or consultation involving your care will be
conducted discreetly and that individuals not directly involved
in your care will not be present without your permission. You
have the right to be interviewed and examined in surroundings
designed to assure reasonable visual and auditory privacy.
This includes having the right to have a person of one’s own
sex present during certain parts of a physical examination,
treatment or procedure performed by a health professional
of the opposite sex and the right not to remain disrobed any
longer than is required for accomplishing the medical purpose
for which disrobing is needed.
10. To access people outside of the health care facility by means
of visitors and by verbal and written communication, as long
as it does not interfere with treatment.
11. If you do not speak or understand the predominant language
of the community, access to an interpreter can be provided.
12. To be free from restraints of any form that are not medically
necessary. For behavior management, all patients have the
right to be free from seclusion and restraints except in the
case of an emergency, when there is an imminent risk of an
individual physically harming himself/herself or others, and less
restrictive interventions would be ineffective.
13. To confidentiality of your clinical records, except in such cases
as suspected abuse or public health hazards and/or when
reporting is permitted or required by law. You have the right
to have your medical record read only by individuals directly
involved in your treatment or in the monitoring of quality. Other
individuals can only read your medical record on your written
authorization or that of your legally authorized representative.
You have the right to expect all communications and other
records pertaining to your care, including the source of
payment for treatment, to be treated as confidential.
14. To access information contained in your clinical records
within a reasonable time frame, and to have the information
explained or interpreted as necessary, except when restricted
by law and/or as long as it does not interfere with treatment.
15. To know if this health care facility has relationships with other
health care facilities, educational institutions or other outside
parties that may influence your care.
16. To consent or decline to take part in research affecting your
care. If you choose not to take part, you will receive the most
effective care the health care facility otherwise provides.
Rights and Responsibilities
17. To examine and receive an explanation of your bill, regardless
of source of payment. You have the right to know about
payment methods. At your request and your expense, you
have the right to consult with a medical specialist.
18. To expect reasonable continuity of care when appropriate and
to be informed of realistic care alternatives when the health
care facility services are no longer appropriate.
19. To be informed of the health care facility policies and practices
that relate to your care, treatment and responsibilities. You
have the right to know about the health care facility resources,
such as patient representatives, patient complaints and
grievance processes, or ethics committees, that can help you
promptly resolve problems and questions about the health
care facility services.
20. To ask questions about the care you are receiving. Contact
your nurse, or if you wish for your nurse to contact your
physician, a call will be placed to that physician or to the
physician who is covering your care that day. If requested,
the nurse will provide a telephone number for your physician
and can assist you with making the call. You have the right to
know who is involved in your care. Every caregiver at Palmetto
Health will be wearing an identification badge clearly stating his
or her name, department and job or title.
21. To voice a concern about your stay and be involved in
resolving dilemmas about care, treatment and services. Your
concerns are very important to us and we would appreciate
the opportunity to resolve them. If you have a concern/
grievance, please speak with the staff or request to speak
with the unit/department supervisor/manager. If you would
rather express the concern/grievance to a patient liaison,
call the appropriate number at the bottom of this notice.
Staff are available to assist you anytime during your stay
and will seek prompt resolution to your concern/grievance.
If you want to contact an outside agency before the hospital
representative, you may also contact the Department of Health
and Environmental Control, 2600 Bull Street, Columbia, SC
(803)898-3432, and/or The Carolinas Center for Medical
Excellence, 246 Stoneridge Drive, Suite 200, Columbia,
SC 29210, (803)251-2215 or (800)922-3089. If you have
concerns about patient care and safety in the hospital that
have not been addressed by the hospital, you may contact
Joint Commission at (800) 994-6610 or [email protected].
21
Rights and Responsiblities
PATIENT’S RESPONSIBILITIES
As a patient in our Joint Commission accredited health care facility you have many responsibilities. This is to inform you that you, your
family and/or your designated advocate are responsible for:
1. Providing, to the best of your knowledge, accurate and
complete information about present symptoms, reason for
your visit, past illnesses, hospitalizations, use of medications
(prescribed, non-prescribed and herbals), and other matters
relating to your health.
5. Following the health care facility’s rules and regulations
concerning patient care and conduct.
2. Helping ensure your safety by knowing your health care
providers and reporting concerns, perceived risks, or
unexpected changes in your care, treatment, medical
condition and/or service provided to you. If you have any
suggestions for improving patient safety, please let us know.
7. Providing information for insurance and for working with the
health care facility to arrange payment when needed.
3. Speaking Up—Asking questions when you do not understand
what you have been told about your diagnosis, medical tests,
treatment plan, medications, care or what you are expected to
do.
9. Being considerate of other patients, helping control noise and
disturbances, abiding by non-smoking policies, and respecting
others’ property.
4. Participating in decisions about your treatment and following
the care, service or treatment plan developed. You should
express any concerns you have about your ability to follow and
comply with the proposed care plan or course of treatment
to staff and/or your physician. Every effort is made to adapt
the plan to your specific needs and limitations. When such
adaptations to the care, treatment and/or service plan are not
recommended, you are responsible for understanding the
consequences of the care, treatment and service alternatives
and the possible outcomes if you do not follow the care,
treatment or service plan.
22
6. Being considerate and respectful of the health care facility’s
personnel and property.
8. Promptly meeting any financial obligation agreed to with the
health care facility.
10. Recognizing the effect of lifestyle on your personal health.
For more information about your rights or responsibilities or to give
us feedback on your care, please contact Patient Relations, (803)
296-5129 at Palmetto Health Baptist, (803) 434-6237 at Palmetto
Health Richland and (864) 442-7559 at Palmetto Health Baptist
Easley.
Palmetto Health Medical Executive Committee
Officers of the Medical Staff
Richland
Helmut Albrecht, MD, Chief of Staff
Frederick Dreyer III, MD, Vice Chief of Staff
Stephen Watson, MD, Secretary of the Medical Staff
Chief of Each Clinical Department
Baptist
Donen Davis, MD, Chief of Staff
TBD, Vice Chief of Staff
Gregory Malcolm, MD, Secretary of the Medical Staff
Richland
Anesthesia. . . . . . . . . . . . . . . . Turner, James F., MD
Cardiac Services . . . . . . . . . . . Prosser, Leverne M., MD
Childrens Hospital . . . . . . . . . . Stephenson, Kathryn A., MD
Dentistry. . . . . . . . . . . . . . . . . . Curtis, James W., Jr., DMD
Emergency Medicine. . . . . . . . Privette, Troy W., Jr., MD
Family Medicine. . . . . . . . . . . . Anderson, William D., III, MD
Internal Medicine. . . . . . . . . . . Weissman, Sharon, MD
Nephrology . . . . . . . . . . . . . . . Powell, Thomas B., MD
Neurology. . . . . . . . . . . . . . . . . Selph, James F., III, MD
Neurosurgery. . . . . . . . . . . . . . Webb, Sharon W., MD
OB/GYN. . . . . . . . . . . . . . . . . . Burgis, Judith T., MD
Orthopaedics. . . . . . . . . . . . . . Koon, David E., Jr., MD
Pathology. . . . . . . . . . . . . . . . . Guerry, Paul L., III, MD
Psychiatry . . . . . . . . . . . . . . . . Raynor, Jeffrey D., MD
Radiology. . . . . . . . . . . . . . . . . Savoca, William J., MD
Surgery . . . . . . . . . . . . . . . . . . Burke, James R., MD
Urology . . . . . . . . . . . . . . . . . . Beasley, John G., MD
Dean . . . . . . . . . . . . . . . . . . . . Hoppmann, Richard A., MD
Chief Medical Officer . . . . . . . . Raymond, James I., MD
Credentials Committee Chair. . Nottingham, James M., MD
Physician Executive, PHR . . . . Risinger, Jennifer D., MD
PH Board Representative. . . . . Gerard, William C., MD
Baptist
Anesthesia. . . . . . . . . . . . . . . . Parks, William B., III, MD
Dentistry. . . . . . . . . . . . . . . . . . Curtis, James W., Jr., DMD
Emergency Medicine. . . . . . . . Cruea, Steven L., MD
Family Medicine. . . . . . . . . . . . Fitzgibbon, Rodney, II, MD
Internal Medicine. . . . . . . . . . . Edwards, Thomas S., MD
Neurology. . . . . . . . . . . . . . . . . Mareska, Michael C., MD
Neurosurgery. . . . . . . . . . . . . . Lozanne, Karl A., MD
OB/GYN. . . . . . . . . . . . . . . . . . Wild, Mark D., MD
Ophthalmology. . . . . . . . . . . . . Harder-Smith, Donna R., DO
Orthopaedics. . . . . . . . . . . . . . DaSilva, Robert M., MD
Pathology. . . . . . . . . . . . . . . . . Rizzo, Kathryn A., DO
Pediatrics. . . . . . . . . . . . . . . . . Coates, Eric W., MD
Psychiatry . . . . . . . . . . . . . . . . Raynor, Jeffrey D., MD
Radiology. . . . . . . . . . . . . . . . . Taffoni, Matthew J., MD
Surgery . . . . . . . . . . . . . . . . . . Taber, Scott W., MD
Urology . . . . . . . . . . . . . . . . . . Beasley, John G., MD
Chief Medical Officer . . . . . . . . Raymond, James I., MD
Credentials Committee Chair. . Patrick, Elizabeth A., MD
Physician Executive, PHB . . . . Mayson, Mark J., MD
PH Board Representative. . . . . Herlong, James H., MD
23
Palmetto Health Organizational Chart
Palmetto Health
Board of Directors
Samuel Tenenbaum
Charles Beaman, Jr.
Rebecca Richardson
President,
Palmetto Health Foundation
Chief Executive Officer
Director,
Corporate Audit Services
John Singerling
President, Operations
Dr. James Raymond
Senior Vice President,
Medical and Academic
Paul Duane
Executive Vice President,
Finance
Marty Bridges, COO, Baptist
Dr. Ed Catalano, VP,
Medical Affairs
Marty Bridges, SVP, Clinical
Finance
Stan Hickson, COO, Rich. /
SVP, Supt. Opperations
Dr. Ellis Knight, SVP,
Physician & Clinical
Integration
Ben Cunningham, VP,
Finance
Gwen Hill, Interim VP,
Human Resources
Dr. Mark Mayson, VP,
Medical Affairs
Michelle Edwards, SVP,
Information Technology
Mark Loos, System VP,
Clinical Service Lines
Kathy Stephens, Ph.D. VP,
Medical Ed. & Research
Caroline Seigler, System VP,
Nursing Policy
Dr. Shawn Stinson, VP,
Clinical Quality/Patient Safety
Howard West
Senior Vice President, Legal
Vince Ford
Senior Vice President,
Community Services
Revised March 21, 2013
Todd Miller, VP, Marketing
and Communications
Carolyn Swinton, System
VP, Nursing Practice
Dr. James Raymond, SVP,
Medical and Academic
Sarah Richter, System VP,
Clinical Operations
Jim Lathren
President, Leadership Institute
Julian Gibbons
Vice President, Community
and Government Relations
Candace Knox
Director, Planning and
System Development
Revised January 3, 2012
24
Dates of Site Visits and Internal Reviews
Calculated
Actual
Most recent
Effective
Projected
mid-point
internal
Program
site visit date
date
next site visit
date
review date
Dental
Emergency Medicine
Family Medicine
Family Medicine - Sports Medicine
Institution
Internal Medicine
Internal Medicine - Endocrinology
Internal Medicine - Geriatrics
Internal Medicine - Infectious Disease
Internal Medicine - Pulmonary
Neurology
OBGYN
Ophthalmology
Orthopaedics
Pediatrics
Psychiatry - Child and Adolescent
Psychiatry - Forensic
Psychiatry - General
Psychiatry - Geriatric
Surgery
Surgery - Critical Care
3/13/2008
3/13/2008
3/1/2015
2/26/2009
9/25/2009
9/1/2019
6/8/2011
9/26/2011
9/1/2016
6/9/2011
9/26/2011
9/1/2016
11/2/2010
4/13/2011
4/1/2016
11/8/2005
1/27/2006
5/1/2016
11/9/2005
1/27/2006
5/1/2016
11/10/2005
1/27/2006
5/1/2016
8/18/2011
1/27/2012
5/1/2016
7/30/2009
2/1/2010
5/1/2016
6/7/2011
7/1/2012
5/1/2016
4/10/2013
8/14/2012
5/16/2013
5/1/2016
4/19/2010
6/18/2010
6/1/2022
2/22/2008
7/28/2008
7/1/2017
11/3/2010
4/15/2011
4/1/2016
5/16/2007
4/12/2013
4/1/2018
8/15/2012
4/12/2013
4/1/2018
11/4/2010
4/15/2011
4/1/2016
4/9/2013
8/1/2013
9/6/2011
3/14/2012
3/15/2014
3/15/2014
10/6/2013
1/29/2009
1/29/2009
1/29/2009
7/15/2014
7/17/2012
11/30/2013
4/9/2011
11/7/2014
12/8/2012
1/13/2011
10/7/2013
10/6/2015
10/6/2015
10/7/2013
4/12/2011
12/13/2010
10/26/2012
3/29/2012
6/10/2008
10/14/2008
8/12/2008
8/30/2012
7/8/2011
2/3/2011
4/8/2008
6/14/2011
2/23/2011
25
GME Staff Contacts
26
Name
Address
PhoneFax
1301 Taylor St.
(803) 296-2152
Suite 9A
Columbia, SC 29201
(803) 296-3363
[email protected]
Katherine G. Stephens,
15 Medical Park
(803) 434-6861
PhD, MBA, FACHE
Suite 202
Vice President, Medical
Columbia, SC 29203
Education and Research & DIO
(803) 434-4419
[email protected]
Margie Bodie, BS, C-TAGME 15 Medical Park
(803) 434-4429
Administrative Director,
Suite 202
Resident/Student Services
Columbia, SC 29203
(803) 434-4419
[email protected]
Donnie Coker
Director, Operations and
Special Projects
15 Medical Park
(803) 434-4707
Suite 202
Columbia, SC 29203
(803) 434-4419
[email protected]
Renee Connolly, PhD
GME Specialist
15 Medical Park
(803) 434-4406
Suite 202
Columbia, SC 29203
(803) 434-4419
[email protected]
Stephanie Hall
Executive Assistant
1301 Taylor St.
(803) 296-2152
Suite 9A
Columbia, SC 29201
(803) 296-3363
[email protected]
Anne Marie Hyer
Administrative Assistant
15 Medical Park
(803) 434-4416
Suite 202
Columbia, SC 29203
(803) 434-4419
[email protected]
Margie Malone
Coordinator, Accreditation
Standards
15 Medical Park
(803) 434-2184
Suite 202
Columbia, SC 29203
(803) 434-4419
[email protected]
Jill Reid
Administrative Associate
15 Medical Park
(803) 434-4426
Suite 202
Columbia, SC 29203
(803) 434-4419
[email protected]
Karen White
Administrative Coordinator,
Resident/Student Services
15 Medical Park
Suite 202
(803) 434-4419
[email protected]
(803) 434-7184
E-mail
Residency/Fellowship Department Contacts
Department
Chair
Program Director
Dental Education
434-6567
10 Medical Park
James Curtis, DMD
David Hicklin, DMD
Marcia Benson-Twiggs
434-6622
434-4424
[email protected]@palmettohealth.org marcia.benson@palmettohealthorg
Dorn VA Medical Center
776-4000
Building 103, Mail Route #141
Carole Pillinger, MD
695-7933
[email protected]
Tom Wiseman
776-4000, x. 4193
[email protected]
Emergency Medical Services
434-7088
3 Medical Park, Suite 350
Bill Gerard, MD
434-3308
[email protected]
Sherry Allen
434-3790
[email protected]
Emergency Medicine
434-7088
Bill Gerard, MD
434-3308
[email protected]
Sherry Allen
434-3790
[email protected]
Emergency Medicine Ultrasound
434-7088
Bill Gerard, MD
Pat Hunt, MD
434-3308
[email protected] [email protected]
Thomas Cook, MD
315-9966
[email protected]
Coordinator
Sherry Allen
434-3790
[email protected]
Family Medicine
Edward Mayeaux, MD
434-6116
434-2418
3209 Colonial Drive
Charles Carter, MD
434-3937
Thomasina Michael
434-2420
Family Medicine - Sports Medicine Edward Mayeaux, MD
434-2423
434-6116
3209 Colonial Drive
Jason Stacy, MD
Shannon Mewborn
4334-2423
434-2419
[email protected]@uscmed.sc.edu
Internal Medicine
540-1000
Shawn Chillag, MD
MaryBeth Poston, MD
Rachel Jones
540-1000
540-1070
545-5321
[email protected] [email protected]@uscmed.sc.edu
Internal Medicine - Endocrinology
733-3112
Shawn Chillag, MD
Ali Rizvi, MD
540-1000
540-1000
Internal Medicine - Geriatrics
434-4333
3010 Farrow Road, Suite 300
(Carolina Medical Plaza)
Shawn Chillag, MD
Rachelle Gajadhar, MD
Rhonda Harden
540-1000
540-1000
434-1437
[email protected] [email protected]@palmettohealth.org
Internal Medicine - Infx. Disease
744-1651
Shawn Chillag, MD
Sharon Weissman
Sanchia Mitchell
540-1000
744-7606
[email protected] [email protected]@uscmed.sc.edu
Internal Medicine - Pulmonary
799-5022
Shawn Chillag, MD
Linda Perkins, MD
Lorie Collins
540-1000
799-5022
758-2978
[email protected] [email protected] [email protected]
Neurology
Souvik Sen, MD
545-6050
[email protected]
Swamy Venkatesh
545-6050
OB/GYN
779-4928
Judith T. Burgis, MD
779-4928
[email protected]
Sarah Smith, MD
Ruth Adams
551-0422
779-4928, x. 240
Megan Gleaton
545-5316
[email protected]
Rhonda Harden
545-6072
27
Residency/Fellowship Department Contacts
Department
Chair
Program Director
Coordinator
Ophthalmology
Bethany Bray Markowitz, MD Barbara Tandon
434-6836
434-7063
28
Orthopaedic Surgery
434-6812
John Walsh, MD
434-6812
[email protected]
David Koon, MD
Tonya Holmes
434-6812
434-6879
Pediatrics
434-6155
Caughman Taylor, MD
434-7387
Robert Holleman, MD
434-7606
Ashley Lynn
434-7606
Psychiatry - Child & Adolescent
434-2808
Meera Narasimhan, MD
434-4266
John E. Bragg, MD
Angie Berkley
434-2808
434-1422
Psychiatry - Forensic
434-2808
434-4266
Richard Frierson, MD
434-2808
Andree Robinson
434-2018
Psychiatry - General
434-1433
434-4266
Craig A. Stuck, MD
Donna Smith
434-1433
434-1433
Psychiatry - Geriatric
296-3569
434-4266
Angie Berkley
434-1422
[email protected] [email protected]@palmettohealth.org
Simulation
434-6991
15 Medical Park, basement
Eric Brown, MD
434-6991
[email protected]
Surgery
545-5800
Robert Stephen Smith, MD
545-5800
[email protected]
Robert Stephen Smith, MD Leah Johnsey
545-5800
545-5800
Surgery - Critical Care
545-5800
Robert Stephen Smith, MD
545-5800
[email protected]
Robert Stephen Smith, MD Leah Johnsey
545-5800
545-5800
James G. Bouknight, MD
296-3569
General Information
ACGME
The Accreditation Council for Graduation Medical Education (ACGME) is a private, non-profit professional organization that accredits about
8,000 residency programs in the United Sates educating more than 100,000 residents. Its mission is to improve health care in the United
States by ensuring and improving the quality of graduate medical education of physicians. The ACGME is governed by a 27 member
Board of Directors.
Major interests of the ACGME are: resident curricula and standards of resident education, support of the program directors and faculty
who teach residents, patient and resident safety, learning environments, Institutions that are appropriate for graduate medical education
and chronically troubled institutions that need help with graduate medical education. The goals of the ACGME are to establish the
educational standards of graduate medical education, and to evaluate the quality of medical education programs.
ACGME CORE COMPETENCIES
Each resident must achieve competency in each of the 6 ACGME competencies prior to completion of residencies. Programs may have
further specifications according to their ACGME residency committee. The programs integrate the following 6 ACGME competencies into
their curriculum:
Patient Care
Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and
the promotion of health.
Medical Knowledge
Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences,
as well as the application of this knowledge to patient care.
Practice-based Learning and Improvement
Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence,
and to continuously improve patient care based on constant self-evaluation and life-long learning. Residents are expected to develop skills
and habits to be able to meet the following goals:
»» identify strengths, deficiencies, and limits in one’s knowledge and expertise;
»» set learning and improvement goals;
»» identify and perform appropriate learning activities;
»» systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement;
»» incorporate formative evaluation feedback into daily practice;
»» locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems;
»» use information technology to optimize learning; and,
»» participate in the education of patients, families, students, residents and other health professionals.
Interpersonal and Communication Skills
Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration
with patients, their families, and health professionals. Residents are expected to:
»» communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural
backgrounds;
»» communicate effectively with physicians, other health professionals, and health related agencies;
»» work effectively as a member or leader of a health care team or other professional group;
»» act in a consultative role to other physicians and health professionals; and,
»» maintain comprehensive, timely, and legible medical records, if applicable.
»»
Professionalism
Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents
are expected to demonstrate:
»» compassion, integrity, and respect for others;
»» responsiveness to patient needs that supersedes self-interest;
»» respect for patient privacy and autonomy;
»» accountability to patients, society and the profession; and,
»» sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race,
religion, disabilities, and sexual orientation.
29
General Information
Systems-based Practice
Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to
call effectively on other resources in the system to provide optimal health care. Residents are expected to:
»» work effectively in various health care delivery settings and systems relevant to their clinical specialty;
»» coordinate patient care within the health care system relevant to their clinical specialty;
»» incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as appropriate;
»» advocate for quality patient care and optimal patient care systems;
»» work in inter-professional teams to enhance patient safety and improve patient care quality; and
»» participate in identifying system errors and implementing potential systems solutions.
THE CLINICAL LEARNING ENVIRONMENT REVIEW PROGRAM (CLER)
What are the objectives of CLER?
Since the release of the Institute of Medicine’s report on resident hours and patient safety, there have been calls for enhanced institutional
oversight of duty hour limits and of efforts to enhance the quality and safety of care in teaching hospitals. In response, the ACGME
established the Clinical Learning Environment Review (CLER) program as a key component of the NAS, with the aim to promote safety
and quality of care. CLER focuses on six areas important to the safety and quality of care in teaching hospitals and the care residents will
provide in a lifetime of practice after completion of education:
»» engagement of residents in patient safety;
»» engagement of residents in quality improvement (including opportunities for reducing health disparities);
»» enhancing practice for care transitions;
»» promoting appropriate resident supervision;
»» duty hour oversight and fatigue management; and,
»» enhancing professionalism in the learning environment and in reporting to the ACGME.
ADMINISTRATOR ON DUTY SUPPORT (AOD)
The Hospital Administrator on Duty {A.O.D.} is responsible for the daily operational flow of the medical center. As
a direct extension of the Chief Operating Officer and the Vice Presidents, the A.O.D. is your influential partner that
brings a wealth of medical knowledge and hospital policy guidance to the table to support your patient care decision making. The AOD can be reached 24 hrs a day on pager 803-352-0996. You may also text-page the AOD via the
Administrator on Duty Webpage found on the Palmetto Health Richland MyPal intranet under the Richland tab. We
encourage you to contact the AOD “Early & Often” whenever there is a question or concern regarding the Placement,
Care or Transfer of a patient within or outside of our medical center. By allowing the AOD to support you, together,
we can navigate whatever the situation to a Safe and Successful Outcome for the patient, their family and our staff.
AOD PAGING VIA MYPAL INSTRUCTIONS
PHR My Pal
1. Click on Richland
2. When page opens you will see Administrator on Duty at the top of the Left Menu
3. Click on Administrator on Duty and the AOD Webpage will open.
4. You will See AOD Paging at the top of the Left Menu on the new page.
5. Click on AOD Paging and the page will open giving you the following instructions:
Please include the following information in your text message:
1 Unit: {STICU, 4 West, Stork’s Landing}
2. Who Has Need: {Staff/Patient/Family}
3. Urgency of Page: {STAT or ASAP}
4. Call Back Number: {Use Unit Main Number: I.E. STICU 7500}
5. Name of Staff Member Sending Text Message
6. Need to Call Back: {Call to confirm}
I.E.: STICU: We need a Six Pack of Coke; ASAP; Ext. 7500; Ivy Harmon}
To page the AOD please click on 803-352-0996
Once an AOD pager number has been selected, the window will open to www.metrocall.com and the staff member will enter the text
message and then select the send button.
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AIDET TRAINING
Residents will be expected to understand the AIDET model (acknowledge, introduce, duration, explanation, thank you) used by all clinical
and non-clinical staff at Palmetto Health in the care of patients and their families, along with Palmetto Health’s Standards of Behavior. This
model promotes patient compliance.
BENEFITS INFORMATION
The health and dental plans as well as other benefits offered to you can be found on Palmetto Health intranet by clicking on Human
Resources, Total Rewards, and Benefits plans. Tutorial format can be found there as well. This information will also be located on New
Innovations.
CERTIFICATIONS
Residents are required to send a copy of their program required certification (e.g. ACLS, ATLS, FCCS, PALS, BLS, NALS or ALSO)
to Graduate Medical Education in a timely fashion. The Palmetto Health Training Center (434-5910) can schedule training. Training
instructions and schedules are located on the Palmetto Health intranet under Training. The physical location of the training center is at the
Palmetto Health Simulation Center, 15 Medical Park, 3555 Harden Street Ext., Columbia, SC 29203. Certifications must be kept up-todate (see HR policy #145, Section C of Resident Manual).
COMMITTEES
It is an ACGME requirement and institutional policy that residents and fellows participate in development and review of process and
policies in the following ways:
»» GMEC – (Resident Council Officers)
»» GME Internal Review Committees
Resident representation is an integral part of the following medical staff committees and other hospital committees:
»» Allied Health
»» By-Laws
»» Children’s Hospital Surgery
»» Credentials
»» Glycemic Control Team
»» ICU
»» Maternity Care
»» Medical Staff’s Medical Executive Committee
»» Neonatal Care (NICU)
»» OR/PACU
»» Patient Blood Management
»» Patient Care & Safety
»» Patient Throughput
»» Pharmacy & Therapeutics
»» Multidisciplinary Trauma
»» Security Advisory Council
COMPUTER-EPICENTER INFORMATION SYSTEM AT PALMETTO HEALTH RICHLAND
The Department of Clinical Quality Informatics plays an important role in improving the quality of patient care and safety by standardizing
best practices, reducing unnecessary variation, and reducing medication errors. Through the development and advancement of evidencebased order sets toward implementation of Computerized Provider Order Entry (CPOE) and work with performance improvement
initiatives, the goal is to close the loop between requirements, recommendations and care provided. The CQI Department assists Palmetto
Health’s providers with educational support on various clinical applications including some of the following:
»» CPOE (computerized provider order entry)
»» EPIcenter (electronic medical record)
»» EPImobile (patient information for handheld devices)
»» Radiology and cardiology image retrieval
»» VPN and remote access
CONTROLLED SUBSTANCE LICENSURE (STATE & FEDERAL DEA)
Residents are eligible to obtain a controlled substance license (state DEA) if they have a valid South Carolina medical or dental license.
Applications will be completed prior to orientation. NOTE: if a resident does not obtain a state AND federal DEA license, he/she cannot
write controlled substance prescriptions. The state DEA license ($125) has to be renewed by October 1st of each year and the federal DEA
license ($731) is a three-year license. Each resident is assigned a unique expiration date. Be sure that your state DEA renewal invoices are
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sent to Graduate Medical Education by the deadline for payment. A copy of the updated registration should be sent to the GME office.
The same process is required for federal DEA renewals that are due if you are in four-, five- or six-year programs.
COUNSELING, STRESS MANAGEMENT, IMPAIRMENT
For residents who are in need of counseling, medical or psychological services:
Palmetto Health E-Care, the employee assistance program, assists staff and their families with the resources that they need to resolve
personal, family or job related problems. They are staffed with well trained, caring professionals are located in a confidential area of
campus with a stand alone record system. See more information at www.palmettohealth.org/body.cfm?id=1856, or call 296-5879.
CREDIT UNION
The Palmetto Health Credit Union has offices at Nine Richland Medical Park on the Palmetto Health Richland campus and at 1501 Sumter
Street building on the Palmetto Health Baptist campus. Residents are eligible to join the Credit Union, which provides a convenient way to
save or borrow money, via payroll deductions.
DISASTER RESPONSIBILITIES FOR DEPARTMENT OF MEDICAL EDUCATION
1. House staff personnel (residents) in the hospital at the time the disaster plan is implemented will report to the physician in charge of
the Emergency Department.
2. Upon notification by the designated hospital representative that the disaster plan is in operation, the Vice President for Medical
Education will make the decision to call or designate someone to call the Department Chairmen/Directors of Education (DC/DE).
3. Upon arrival at the hospital, the DC/DE or their designee will assess the situation and implement specific departmental plans and
resident callback as deemed necessary.
4. After appropriate resident callback has been accomplished, the DC/DE should then report to the physician resource area located in
the Physician’s Lounge for further instructions and assignments.
5. If the severity of the disaster warrants, the Chief Medical Officer/DIO or his/her designee will call support personnel assigned to
Medical Education. Personnel will report directly to the Personnel Pool to be reassigned as needed.
E-MAIL
All residents are assigned a Palmetto Health e-mail account and must be used for all business e-mail communications. E-mails can be
accessed from any computer with internet access. It is the responsibility of the resident or fellow to retrieve e-mails in a timely manner.
With some exceptions, most e-mail addresses appear: [email protected]. External e-mail address to check e-mail
is: https://mymail.palmettohealth.org/owa/. More explanation will be provided during IT segment of Palmetto Health Orientation.
EXPOSURES – BLOODBORNE PATHOGENS EXPOSURE PLAN
The following exposures require immediate attention:
»» Needle Stick / Sharp Injury
»» Contamination of open cut by blood, saliva, urine, pus, stool, or other bodily fluids
»» Splash to mucous membranes (eyes, mouth) by bodily fluids
Steps if Exposed:
»» Clean affected area immediately
»» Notify your Supervisor
»» Complete EOI form to be signed immediately by Supervisor for Employee Health
»» Immediately report to Employee Health Mon-Fri, 7:30 a.m.-4:30 p.m., (803) 434-7442
»» Any other time of day or night, notify the AOD (Administrator on Duty) first before reporting to the ED. Report to Employee Health the
next business day for further follow up.
FOREIGN LANGUAGE/SIGN LANGUAGE INTERPRETER ACCESS
The inability to communicate with patients can interfere with patient care and patients have a legal right to receive healthcare in a way that
does not discriminate against them on the basis of language skills or national origin. Palmetto Health provides Spanish interpreters 24/7.
The number to call for services is 434-8500. Listen for the prompts. For sign language interpreters, please contact Patient Relations at
434-6237 or, if an event occurs overnight or on weekends, page AOD (Administrator on Call-operator will have access).
IDENTIFICATION BADGES
All residents at Palmetto Health will be issued a picture ID card, which is required to be worn at all times (See Lewis Blackman Act). The
Palmetto Health Richland Security Office (#434-7351, First Floor of 5MP) issues identification cards. Identification cards lost or damaged
will be replaced at a charge of $15. Each resident is assigned a five-digit employee ID number that is issued at Orientation and must be
used on forms, re-enrollment of benefits, and safety training annually.
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JOINT COMMISSION ON ACCREDITATION OF HEALTH CARE ORGANIZATIONS (JCAHO)
As a resident providing health care at Palmetto Health, you will play a significant role in maintaining compliance with JCAHO standards.
JCAHO site visits are no longer scheduled. So it is expected that you become familiar with the standards provided in the JCAHO
Handbook located under services on the Palmetto Health intranet and to be ready at all times.
JCAHO evaluates and accredits more than 4,500 Hospitals. JCAHO is an independent not-for-profit organization that is the nations’
predominant standards-setting and accrediting body in health care today. They are responsible for developing state-of-the-art professional
standards and evaluating the compliance of Hospitals against these benchmarks.
To maintain accreditation, organizations experience extensive on-site reviews by JCAHO teams (usually a physician, nurse, administrator)
approximately every three years. They evaluate the organization’s performance in areas that affect patient care and how well staff are
educated and guided toward improved performance.
At the end of the survey, the team scores the Hospital on how well it meets JCAHO standards. They access Patient Rights and
Organization Ethics, Assessment of Patients, Care of Patients, Education to Patients and Families, Continuum of care, improvement
of Organization performance, Leadership, Management of Environment of Care, Management of Human Resources, Management of
Information, Surveillance, Prevention and Control of Infection, Medical Staff, Residents, and Nursing.
JCAHO Goals
»» Improve Accuracy of Patient Identifiers
»» Sentinel Event – Blood Transfusion Errors
»» Patient, Procedure, Site Verification
»» Improve Effectiveness of Communication Among Caregivers
»» Look Alike, Sound Alike Drugs
»» Medication Errors Related to Potentially Dangerous Abbreviations
»» Improve Safety of Using High-Alert Medications
»» Eliminate Wrong-Site, Wrong-Patient, Wrong-Procedure Surgery
»» Improve the Safety of Using Infusion Pumps
»» Improve Effectiveness of Clinical Alarm Systems
»» Reduce Risk of Health Care Acquire Infections
LICENSURE
All medical residents are required to have a valid license to practice medicine in the State of South Carolina. Depending on your
circumstances, this license may be a limited license or a permanent license. Limited license application fees ($160) are paid for by
Palmetto Health for residents. Permanent license application fee of ($580) is paid by Palmetto Health but the resident is responsible for
the FSMB/FCVS fee of ($430-460) for online credentialing of the application – a requirement of SC Medical Board, as well as the CBC
fingerprinting application and fee, and AMA Physician Profile request and fee (NOTE: send copies of renewed license wallet cards to
Graduate Medical Education in a timely fashion prior to June 30).
LIBRARY
The Josey Health Sciences Library at Palmetto Health Richland provides access to, and instruction in the efficient and effective use of,
information resources that enhance the educational and clinical practice missions of Palmetto Health. The library serves all administrative
and management staff, medical staff, residents and fellows, affiliated health sciences students, nurses, and, selectively, to area health care
professionals. Fees may apply to some groups for some services; a printed fee schedule is available on request. The requestor is advised
of applicable fees before the service is provided. Use of library computers is limited to research, patient care and other Palmetto Healthrelated purposes. The library is located on the sixth floor across from resident call rooms. Operating hours are 8 a.m.-5 p.m. Monday Friday (closed weekends and holidays). 24-hour ID badge access to the library is available to:
»» Residents
»» Fellows
»» Medical Faculty
Library staff
Cynthia Garrett Library Manager [email protected]
Marline Robinson
Administrative Coordinator
[email protected] Main Contact Info
Phone: 803-434-6312 / Fax: 803-434-2651
[email protected]
Library collection and circulation
The print collection includes approximately 3,000 book titles and 400 journal titles. The non-print collection includes microfilm/microfiche,
audio/video cassettes, compact discs and 35mm slides from the Ciba/Netter anatomical collection, as well as access to more than 4,000
electronic resources at USC SOM via proxy.
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Books, journals, and electronic resources in the Library’s collections support health administration, clinical medicine, nursing and allied
health subjects. In addition to computer workstations, the library has study carrels, a current periodicals reading area and a small learning
resource room with audiovisual playback equipment.
Journals and books marked “REF” or “CORE” are for in-library use only and can not be checked-out. Items needed for slide production or
other processing by Instructional Media are exceptions and need to be coordinated with the librarian.
Loan periods
Books: 3 weeks / AV materials: 1 week
Items should be returned via the book return drop located in the hallway outside the library in order to assure accurate check-in.
One renewal is allowed.
Overdue items
Books/AVs: $.50/day
Slides: $.10/day [$10 maximum fine]
Overdue and fine notices are mailed weekly. If items are not returned and records cleared after the third notice, library privileges are
suspended. Lost or damaged items will be billed at the current replacement cost. The borrower accepts financial and replacement
responsibility for all items at the time of check-out. Items checked-out from the library are the sole responsibility of the borrower
Collection development
While suggestions for new resources are welcome, budgetary constraints require us to prioritize which print materials and electronic
resources are considered for purchase. Those priorities include:
»» Palmetto Health priorities served (i.e., the importance of the item to the Palmetto Health community);
»» strengths and weaknesses of the existing collection in the subject area;
»» currency, popularity, and timeliness of the topic;
»» item’s publication date and cost;
»» the anticipated importance of the topic in the future;
»» favorable review(s);
»» the author(s)/editor(s) qualifications and reputation;
»» the language of the work;
»» its format and the library’s ability to provide the tools to use the format, and the appropriateness of including textual material in the
field in the library’s collection.
To suggest an item for purchase, please e-mail Cynthia Garrett or call 434-2694. A suggestion form is available in the Library.
Reference / computer searches
Patrons can ask library staff to perform a computer search of published literature for citations/full text articles on specific topics, or they
can search the literature themselves. They can search the biomedical literature in PubMED or in the databases to which the library
subscribes through EBSCOhost.
Printing / photocopying / document delivery
Library visitors can print from any library computer to a networked printer, free of charge. Use Print Preview to print only needed material.
Printing personal items is $.10/page.
The library copier can be accessed as follows:
Coins – $.10/page ($1, $5, or $20 dollar bills accepted)
Copy code/cards – $.07/page (residents, physicians, medical staff, and affiliated students are provided a copy code by library staff) Copy
cards are available for purchase ($.50/card) from library staff.
Copy codes are for single copies of professional materials; copying personal items is $.10/page.
At the patron’s request, library staff will set aside journal issues so that the patron may photocopy needed articles. The patron will be
notified when items are ready. Photocopying within four working days is encouraged so items can be re-shelved for use by other patrons.
Another service available to patrons is document delivery through interlibrary loan (ILL). If the library does not own or have electronic
access to a specific title, library staff will try to obtain a copy of the material from another health sciences library. Lending libraries, with
whom we do not have a reciprocal lending arrangement may charge a fee for this service (the cost can range from $5 to $20 per article).
Patrons will be invoiced for any charges.
Library orientation / education
The library staff provides instruction to groups and individuals in the most effective use of library resources. Demonstrations and one-onone training are used to familiarize patrons with computers and mechanical equipment in the library. The goal is to help patrons become
proficient and independent in their access, evaluation, and use of library resources, wherever their location and whatever their format.
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Summary of services
»» Loan books and audiovisual items from the Library collection
»» Locate and acquire/borrow items from other health sciences libraries
»» Search electronic databases for information/citations on topics
»» Answer brief reference questions
»» Provide instruction on use of library equipment and resources
»» Pull items owned by the library for patron’s use
MD CONSULT
Palmetto Health GME also provides MD Consult. A service of Elsevier, a world leader in health care and medical science publishing, MD
Consult operates a family of electronic information resources that meet the clinical content needs of physicians and other health care
professionals. This site brings the leading medical resources together into one integrated online service to help physicians efficiently find
answers to pressing clinical questions and make better treatment decisions.
»» Leading Medical Reference Books: The complete text of over 50 leading medical reference books. Users can search the entire
collection simultaneously to pinpoint the specific information needed. Also, search and compare over 50,000 high-quality images.
»» Full-Text Journals and Clinics of North America: Full text articles are available through a powerful search engine that includes
the complete contents of over 80 journals and Clinics of North America. PDFs are available for many of the journal and Clinics of
North America articles.
»» Journal Databases: Simultaneously search the full text of our online journals and millions of MEDLINE abstracts.
»» Guidelines: Access our collection of more than 1,000 peer-reviewed practice guidelines, which are regularly updated and organized
by topic and authoring organization for easy browsing.
»» Patient Education: Nearly 10,000 printable, patient handouts which you can customize, adding your own notes, patient
instructions, and contact information.
»» CME: Grand Rounds activities across 15 specialties. Free CME credit for the first five conferences that you submit for credit. Plus
Clinical Cornerstone and FREE CME, sponsored by Exerpta Medica.
»» Drug Information: MD Consult drug information is provided by Gold Standard.
MEDICATION ORDERING / PRESCRIPTION WRITING
Thousands of deaths are annually recorded as a result of medical ordering errors. As a resident, you will be writing medical orders on a
regular basis and will play a vital role in eliminating medication errors by adhering to the following:
All medication orders must contain the following to meet the required minimum standard:
»» Legible handwriting, (printing if needed)
»» Patient name, medical record number, unit
»» Legible signature and ID number of prescriber
»» Drug name (written in entirety)
»» Dosage
»» Route of Administration
»» Frequency or rate
»» If marked as PRN, a PRN reason is required
»» Range orders (example: 5-10 mg every 4-6 hours) are prohibited
»» Weight when necessary (antimicrobial form, peds patients)
»» Body surface area of chemotherapy orders
»» List of Prohibited Abbreviations is available through “PHDOC” and the Palmetto Health formulary website “phformulary.net”
General Guidance
Write legibly on all medication orders and prescriptions. Printing in all capital letters is easier to read and will reduce the number
of phone calls requesting order clarification. Avoid all abbreviations on orders/prescriptions. A specific set of abbreviations are prohibited
at Palmetto Health Richland. Use of these abbreviations may prompt a call from a nurse or pharmacist for clarification. These prohibited
abbreviations include:
»» U or IU for units for International Units. Write out “units”. “U”s have been mistaken for a zero or four, which is particularly dangerous in
insulin doses
»» Lead, don’t trail. Use leading zeros when the number is less than one, but do not use trailing zeros for numbers greater than one. For
example, 5.0 can look like 50 and .5 can look like 5. Breaking this rule has proven deadly.
»» MS04, MS and MgS04. These abbreviations for morphine and magnesium are easy to misread. Write out the name “morphine” and
“magnesium”. While it may sound ridiculous that a health care professional would mix up these two medications, it has happened
right here at Richland.
»» Qd, qid or qod. Too many times these abbreviations look interchangeable when written on an order. Write “daily”, “every day”, “four
times daily” ad so forth.
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Other examples of abbreviations that may be misinterpreted are:
»» ug. This abbreviation has been read as “mg”, which results in a thousand-fold medication error. Write out as “mcg” or “microgram”.
»» AD, AS, AU, OD, OS, OU ad, as, au, od, os and ou. Use right, left, both or each in place of these Latin abbreviations and eye or ear
to designate the body site.
»» SC or SQ. Write out subcutaneously. This abbreviation can easily be mistaken for numbers trailing the intended dose.
»» Roman numerals (I, ii, iii and etc.). If spaced too closely together or if the number of dots don’t match the number of lines. It is
impossible to know if 1, 2, or 3 is intended. Don’t use Roman numerals.
»» X # d. Unless they are equal, no one will know if you want a specific number of days or doses. Spell it out.
Include the indication and/or purpose for all medications, especially on “as needed” orders. Even if you think the medication
may be used for only one purpose, someone else may think differently. Not only will this reduce the potential for errors in dispensing, but
it will enhance patient education on outpatient prescriptions. Write complete medication orders and prescriptions. Include the patient’s
names, medication names, strength, dose, dosage form, route of administration, frequency and duration. Differentiating between various
dosage forms (ex. extended release, slow release, IV, IM, suppository, oral liquid) is necessary for many medications.
Provide dosages “per dose”, not solely by volume or by dosage unit. For example write “Use 5mg”, not 5ml, or 1 tab.
Avoid medical jargon (i.e. Banana Bag, Rally Pack). List the ingredients needed in the product.
Include patient information in addition to the patient’s name. Age, allergies, height, and weight can also help avoid an error
especially in the very your or very old.
Use both generic and brand names on the prescription or medication order to clarify look-alike medications.
Use preprinted order forms whenever possible.
Avoid misspelling medication names. When in doubt, check it out. Call your pharmacist.
NEW INNOVATIONS
Palmetto Health GME provides New Innovations software as an interactive tool in the area of medical education and department
administration, to unify data into a centralized data warehouse and to complete tasks, historically performed using multiple, incompatible
methods, through one common interface. It is a web based residency management software program. The program maintains information
about you. It can range from your demographics, evaluations, procedures, to duty hours and other necessary information. Presently, each
program uses the software at different levels. Your program coordinator will discuss with you the ways in which they use the software
and what level of participation is expected from you. If you have any technical questions about New Innovations, please contact Margie
Malone, Medical Education, at 803.434.2184 or e-mail [email protected]
ON-CALL ROOMS/RESIDENT LOUNGES
The main Residents’ Lounge is presently located on sixth floor of Palmetto Health Richland (PHR) to the left of the Library. The space
is equipped with an on-call fridge, additional fridge/microwave, TV, four computers/printer, and work out equipment. The Emergency
Medicine/Psych/Ophthalmology, Family Medicine, Internal Medicine, Orthopedic, and Surgery call rooms are also located on the 6th floor
across from the Library.
The Surgery Residents’ Lounge is located on the 3rd floor of PHR; equipped with fridge/microwave, TV, 4 computers/printer. The Pediatric
call room suite is located in the Children’s Hospital on 3rd floor and Ob/Gyn call room suite is located on 4th floor of PHR. The Pulmonary
call room is currently located on 10th floor of PHR. NOTE: The Student Lounge and call room is located on 6th floor of PHR.
IMPORTANT: Please keep the doors of the call rooms secured at all times for your safety and others. Security can be reached at 4347351.
PAGERS
Keep messages deleted. The pager can hold 19 messages. Anything after 19 will not show on your pager.
Be sure to check your battery light. Replace when it gets low.
Protect your pager by keeping it in the holder, away from water or being dropped. The charge for a replacement pager is $97 for
Statewide, $47.50 for In-House.
Spare statewide pagers. If a spare is needed, you will need to call the Service Desk at ext. 44357. The on call Telecommunications
Engineer will coordinate with you and Security to meet at the Switchboard in the basement so you can sign out a loaner pager.
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The Switchboard is responsible for alerting your pager for most codes. Trauma codes are called by Air Ambulance. Codes can be added
to your pagers if needed, however, once they are added, you will receive those codes 24/7. The only way not to receive them is to turn off
your pager or have me remove the code.
Your pager works on a frequency. Because of construction and obstacles, your pager may experience zones which the frequency will
not penetrate, so you will not receive pagers. Inside the VA hospital is one area that has been identified. If you experience a problem in
an area, please report it to the HelpDesk at 4-4357 as it could be a problem with a transmitter in the area. If you are carrying two or more
statewide pagers, allow several inches between each one. If they are side by side, it can cause the pagers to miss pages.
To page an in-house pager (115XXXX) with a numeric message:
Internally from a phone with a 434 exchange, dial 41111, you will be prompted to enter the pager number and then your numeric
message. Pressing the # key once will signal end of message and transmit the numbers.
Externally, dial 434-6624; you will be prompted to enter the pager number and then your numeric message. Press # at the end of your
numeric message
To page a statewide pager (803-352-XXXX) with a numeric message:
Dial the pager number. If you are in house, you will need to dial “9” first for an outside line. You will not need to dial 803 unless you are out
of our calling area. You will be prompted to enter your numeric message. Press # at the end of your numeric message.
To send a text message to a pager from Outlook:
Address your message to the pager number @page.palmettohealth.org
EX:
[email protected]
[email protected]
DO NOT FORWARD AN ATTACHMENT. If you want to send an existing e-mail to a pager, cut and paste it into a new message.
Forwarding to a pager will lock up the system. If this occurs, you will have to send your text messages through USA Mobility until the
system can be repaired. Any messages that are in the queue when it is locked up are usually dumped, meaning others will not get their
intended messages. Be careful when entering the pager number and address to ensure the system does not get bogged down with
errors. Limit is 255 characters, but be brief. No one wants a message that long on their pager. You can also build a group to send text
messages to. You would build this group as you would any group of outside addresses. Be sure to put each member of your group as:
[email protected] or [email protected]
To send a text message through e-mail using USA Mobility: (Statewide only)
from your e-mail service or from Outlook, address your message as follows:
[email protected]
To send a text message from the internet with no e-mail: (Statewide only)
Go to www.USAMobility.com, About halfway down the page on the left hand side, you will see “Send a Message” Click “go” Put in the
entire pager number (10 digits). Click “Continue” Type in your message. Click “Send”
If you experience any problems with your pager, please call the Service Desk at 4-4357 (HELP) This extension works from any in house
phone, Richland or Baptist. They will create a ticket that goes to Telecommunications. Please leave a contact phone number where
you can be reached if Telecommunications cannot reach you by your pager. Remember, after hours there are spares at the Richland
Switchboard. NOTE: Emergency codes with descriptions are displayed on the first page of your manual. Please review.
PARKING
Palmetto Health Richland campus provides designated parking areas for residents during patient care shifts and this information is located
in the Parking Policy under Section B of this manual.
PPD SKIN TEST OR CHEST X-RAY
The hospital requires a health physical as well as completion of PPD skin testing or chest x-ray prior to employment. Every year thereafter,
no later than June 15th, the residents must have an annual PPD skin test or chest x-ray completed, as do all clinical employees as
described in Health Works Procedures 1030 and 1040 (NOTE: Off-cycle residents must have an annual PPD skin test or chest x-ray
completed by their annual anniversary date).
PROCEDURES CONSULT
Palmetto Health GME provides Procedures Consult, a new online multimedia training and reference tool that helps physicians, medical
residents and students prepare for, perform and test their knowledge of top medical procedures. It is designed to meet the procedural
needs of physicians through every stage of their career. Residents and students can watch videos of experts performing procedures,
once or as many times as necessary, before performing procedures themselves. This program can assist physicians who are looking for
avenues to maintain their skills and knowledge and have a new, easy way to access important reference content. Procedures Consult
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helps reduce the potential for medical errors and complications by providing immediate, 24/7 access to information on high-risk/highvolume procedures as well as medical procedures performed infrequently, but are critical to patient safety.
PROFESSIONAL LIABILITY INSURANCE
Palmetto Health has purchased “claims made” professional liability protection from Continental Insurance Company to protect all
employees including Resident/Fellow officers. This protection was purchased through Palmetto Healthcare Liability Insurance Program
(PHLIP) that is a captive insurance program. The limits of professional liability afforded is $1,200,000 per claim that involves an employed
Resident/Fellow. This coverage is subject to an aggregate limit of $17,250,000. All aggregate liability limits are shared among the
participating members of PHLIP. There are multiple hospital and hospital system members of PHLIP. (coverages are subject to periodic
change by the PHLIP Board of Directors.)
Palmetto Health has also purchased high excess professional liability protection through PHLIP. The high excess limit is $20,000,000 per
claim, except where is it found that the acts of the insured individual were willfull, reckless, or grossly negligent, in which case the high
excess per claim limit is reduced to $3,000,000. The high excess policy has a $30,000,000 annual aggregate limit which is also shared by
all members of PHLIP. (Coverage’s are subject to periodic change as determined by PHLIP Board of Directors).
It is the responsibility of Palmetto Health and not individual Resident/Fellows to purchase the extended reporting period (ERP)
endorsement or “tail” coverage. Employed Resident/Fellows are scheduled on the Palmetto Health provider list. This provider list reflects
the effective date and, as applicable, the termination or graduation date of each provider. Professional liability protection is afforded to
each Resident/Fellow for claims that occur within the effective date of coverage and until the graduation or termination effective date.
Professional liability insurance protection is provided to each Resident/Fellow within the scope of the Resident/Fellow’s educational
program duties and does not extend to any activities outside the scope of the educational program.
This professional liability insurance will only provide coverage for the Resident/Fellow in the performance of duties and obligations of
this Agreement. IT IS THE SOLE RESPONSIBILITY OF THE Resident/Fellow TO OBTAIN AND PROVIDE FOR PROFESSIONAL AND
GENERAL LIABILITY INSURANCE COVERAGE FOR ALL EMPLOYMENT OR PROFESSIONAL ACTIVITIES (ie, “moonlighting”) ENGAGED
IN BY THE Resident/Fellow WHICH ARE NOT AN OFFICIAL PART OF THE Resident/Fellow’S TRAINING PROGRAM.
(See Moonlighting GME Policy, Section B & Permission Form)
RELEASE OF INFORMATION
Please refer all requests for patient information and other topics to Palmetto Health’s Media/Public Relations office. Please see Palmetto
Health’s Media/Public Requests for Patient Information Policy (Formerly Release of Information Policy No. D.7.), and Palmetto Health’s
Medical Record Information Release policy D.5.
RESIDENCY/FELLOWSHIP CERTIFICATES
Residency/Fellowship Certificates will be awarded at the end of your training period. Should you leave before completing the entire
program, a certificate will be issued to cover the approved curriculum months verified by your Program Director. Your Program Director
and the GMEC are the final authority on whether credit is given for completing only part of a residency-training program. Residents/fellows
must complete the Palmetto Health clearance process and any program-level exit process before the Residency or Fellowship certificates
are released.
RESIDENT FORUMS
The following mechanisms are in place for the residents to communicate relevant information concerning their work environment and their
educational programs.
»» Resident Council – This forum is open to participation by all residents. It is presided over by elected resident officers and is used to
inform the residents of matters of interest to them and to serve as a forum to express their concerns. The Vice President for Medical
Education/DIO attends all meetings.
»» Chief Residents’ Rounding – This bi-annual meeting is scheduled with the Chief Residents in their respective programs with the Vice
President for Medical Education/DIO. The purpose of this meeting is to identify best practices and opportunities for improvement
related to their clinical work environment.
»» Annual Resident Survey – In the spring of each year, ALL residents complete an electronic survey on their graduate medical education
experiences. This information is compiled in an anonymous way and is used to recognize excellence and/or develop improvements.
RESIDENTS’ AUXILIARY
The Residents’ Auxiliary is sponsored by Palmetto Health, and the organized social activities are planned by resident spouses who
graciously take their time to organize these functions (e.g., Frankie’s Fun Park events, Super Bowl parties, Wine Tasting, Couples’ Night
Out, Holiday Drop-In, Oyster Roasts, etc.) to support residents and their immediate family members.
38
General Information
RISK MANAGEMENT/SUBPOENAS
Risk Management (434-6192) or the Legal Office (296-2234) will be available to assist you with questions regarding subpoenas and assist
you with review of medical records that you need pulled for review. Their office may contact you regarding cases that involve Palmetto
Health for meetings or depositions related to these legal cases. The Risk Management office will contact you on all Palmetto Health related
cases, so it is suggested that you refer all other attorney calls to Risk Management. Do not talk to anyone unless you are 100% sure of
who you are talking with.
SAFETY TRAINING, OSHA, AND CORPORATE COMPLIANCE UPDATE
The hospital provides an initial update on mandatory safety training, current Infection Control guidelines, and Corporate Compliance
and HIPAA at Orientation as well as provision of one pair of safety glasses to each new resident. Annually, it is the responsibility of
each resident to complete mandatory safety training by designated deadline of Palmetto Health. Online testing is currently required or
documentation of resident compliance for appropriate record keeping along with any forms to be signed and/or tests to be taken.
SMOKE-FREE POLICY
Palmetto Health is smoke-free on all campuses. There are no designated smoking areas on campus, so staff must go off site to smoke.
This policy applies to patients and their families as well. Visitors who refuse to comply should be reported to the Security Office (4347351). Staff who refuse to comply with or enforce the smoke-free policy should be reported to their supervisor. Employees are encouraged
to attend smoking cessation classes that are offered.
STUDENT LOAN DEFERMENTS
Certain medical school loans are deferrable for part or all of your residency-training period through forbearance or hardship. At the
beginning of your residency, you should contact your respective loaning institution and request deferment, forbearance, or hardship forms
or inquire of grace period eligibility. These Institutions will not contact you. If you do no take care of confirming your training, they will
begin billing you and turn unpaid payments into the Credit Bureau. Upon receipt of these forms, please sign them and send them to the
Department of Graduate Medical Education and they will verify dates of deferment on your behalf and mail these documents for you. If you
have questions, please contact the Department of Graduate Medical Education. Remember these loans will need verification of deferment
annually prior to July 1.
USMLE STEP 3
Your program may elect to design a schedule to allow you to take USMLE Step 3 during your intern year. Graduate Medical Education
pays up to $705, with a paid receipt, as a benefit one time only. Please be advised that successful completion of USMLE Step 3 or
COMLEX 3 is mandatory (See GMEC USMLE Step 3 Policy and process/timeline in Section B). Graduate Medical Education office pays
this application fee for first 12 months of training.
WEB SITES OF INTEREST
»» Association of American Medical Colleges (AAMC) – www.aamc.org
»» Accreditation Council of Graduate Medical Education (ACGME) – www.acgme.org
»» Drug Enforcement Administration – http://www.deadiversion.usdoj.gov/index.html
»» Education Commission for Foreign Medical Graduates (ECFMG) – www.ecfmg.org
»» Federation of State Medical Boards (FSMB) – www.fsmb.org
»» National Plan & Provider Enumeration System (Medicare/Medicaid NPIs) – https://nppes.cms.hhs.gov/nppes/welcome.do
»» Palmetto Health GME/Residencies – http://www.palmettohealth.org/bodyResidency.cfm?id=1387
»» Palmetto Health Intranet - under Training, Community Education Center (Certification training)
»» Palmetto Health Intranet - Resident Competencies, under Services
»» Palmetto Health Intranet – PHDOC
»» SC DHEC Drug Control –http://scdhec.net/administration/drugcontrol/registration-forms.htm
»» SC Dept of Labor, Licensing and Regulation (Dental/Medical Boards) – http://www.llr.state.sc.us/pol/medical/
»» University of South Carolina School of Medicine - www.uscmed.sc.edu
»» Veterans Administration Hospital – www.va.gov/columbiasc/Trainee_Internet_Pages/Student_Trainee_home_Page_htm
39
Substance Abuse
SUBSTANCE USE AND DEPENDENCY AMONG RESIDENT PHYSICIANS
BY JAMES RAYM OND, MD
Introduction
“The civilized man,” Bertrand Russell wrote over fifty years ago,
“is distinguished from the savage mainly by prudence… The
worshipper of Bacchus reacts against prudence. In intoxication…
he discovers an intensity of feeling which prudence has destroyed;
he finds the world full of delight and beauty, and his imagination is
suddenly liberated from the prison of everyday preoccupations.”
In this elegantly misleading passage, Russell makes intoxication
sound almost virtuous. For true “worshipper(s) of Bacchus” (the
chemically dependent) and the physicians involved in their care,
however, the picture is entirely different. Neither virtue nor vice
is involved: it is a morally-neutral disease characterized by a
downward spiral of predictable physical and emotional ailments.
Worst of all, it affects many others besides the individual which
makes it a public, as well as a private, concern.
While the exact prevalence of chemical dependency in the United
States is unknown, most studies place it in the range of eight
to 15 percent.2,3,4 It is also a remarkably “democratic” disease,
affecting all strata, classes, and groups of society. This includes,
of course, the medical profession. For more than a hundred
years, the literature has contained scattered reports of physician
substance abuse. (The cases of Halstad, Freud, and Doctor Bob,
the co-founder of Alcoholics Anonymous, are perhaps the best
known.)5 Although controversy persists as to the exact prevalence
of this disorder among physicians, its recognition as a legitimate
problem within the profession has grown since the American
Medical Association’s ground-breaking report concerning the “sick
physician” (1973).6 As a consequence state medical societies,
licensing boards, and hospital medical staffs have taken steps to
identify these “impaired” individuals.7
Unfortunately, some of these bodies still view the issue in punitive,
rather than rehabilitative, terms. This may partly explain why
physicians have more difficulty than the general population in
seeking help.8 Once in treatment, however, they have a better longterm prognosis than any other segment of society.7
As a subset within medicine, logic would suggest that physiciansin-training might be at special risk. Not only is it the most
demanding phase of a physician’s career, it is also the stage at
which legal authorization to prescribe addictive substances is
first granted. This review briefly examines the special problems of
resident substance use and dependency.
Etiologic Factors
1
Throughout much of recorded history—and until about fifty years
ago—addiction was viewed primarily as a moral, social, and
legal problem.9 Today most experts agree that it is a multifaceted
disease with a host of causative factors (both biological and
environmental).10, 11 Over the last two decades, attempts to identify
these etiologies have been at the center of addiction research.
While a summary is beyond the scope of this review, it is worth
mentioning a few of these because of their potential utility as
diagnostic aids. As will be seen, the majority of this effort has
focused on alcoholism; the conclusions, however, are applicable to
chemical dependency in general.
Perhaps the oldest and most reliable observation concerns parental
alcoholism and its higher than- expected appearance in offspring,12
40
a pattern noted literally since antiquity.13 Of more recent vintage is
the observation that affected individuals consistently viewed their
childhood relationship with the same-sex parent as distant and
emotionally-inert. This has led some to regard it as a major factor
in the “isolation” which these individuals typically experience as
adults—a feature often considered pathognomic of alcoholism.14
Another observation involves the manner in which alcoholics
respond to external stimuli. The majority seem to be so-called
stimulus augmenters: that is, they react to uncomfortable stimuli
in a consistently exaggerated fashion.15 It has been postulated
that this may lead augmenters to seek relief through addictive
chemicals which elevate the stimulus threshold, thereby reducing
the discomfort.14
An additional and somewhat surprising correlation concerns
alcoholism and intellectual capabilities. Contrary to the common
stereotype of the street derelict, alcoholics as a group seem to be
more perfectionistic and intellectually fastidious than the general
population.16 With respect to physicians, it has even been noted
that a high academic rank in the graduating class (including election
to Alpha Omega Alpha) may actually be an independent risk factor
for alcoholism, and possibly chemical dependency in general.17
Finally, what role (if any) does stress play as an etiology? This
question is particularly relevant to residency training where levels
are notoriously high. To date, this work has demonstrated little
correlation between work-place stressors and addiction.18, 19, 20 The
vast majority of these studies, however, investigated occupational
stress in its broad sense, rather than isolating its constituent
components.
One area of focus virtually neglected in these studies has been the
role of work-place abuse and harassment.
A recent study by Richman et al.,21 however, may force a
reconsideration of this stressaddiction paradigm. Examining
abuse in the context of medical training, they found a direct
correlation in both males and females (who had certain “personality
vulnerabilities”) with drinking outcomes. Perhaps this, and other
studies like it, will add momentum to efforts already underway
to “humanize” the process of educating residents and medical
students.
Prevalence Of Resident Substance Use And
Dependency
Because of the methodologic limitations of published studies,
most of the questions raised about the prevalence of substance
disorders among residents remain unanswered.7, 22 For example,
conclusions in the medical literature are largely based on data
from voluntary surveys or from treatment facilities, all of which are
inherently biased. In addition, the majority of addiction problems
first become evident when physicians approach mid-career; it is
therefore difficult to draw meaningful comparisons between earlier
use and later abuse. In spite of these limitations, however, it is
possible to draw some cautious insights from a few of the betterdesigned studies.
The largest of these—Hughes et al. (1991)23 — investigated the
prevalence of substance use in third-year residents. They surveyed
approximately 1,800 of these individuals and compared the results
to a published national sample of age-matched peers.
Substance Abuse
Table 1. Signs/Behaviors Suggesting Chemical Dependency
Early
Later
�� Frequent somatic complaints
�� Patient complaints
�� Monday illnesses
�� Deterioration of personal appearance
�� Excessive tardiness
�� Pilfering of drugs
�� Failure to respond to pages
�� DUI citation(s)
�� Unexplained absences
�� Overt signs of intoxication
�� Unprovoked anger
�� Unexplained weight changes
�� Domestic discord
�� Depression
�� Extramarital affairs
�� Declining personal/clinical performance
�� Excessive drinking at social events
Their principal finding was that residents, both male and female,
had higher rates of alcohol and benzodiazepine use in the past
month and year than their non-physician peers. (This gender parity
is of interest because other epidemiologic studies consistently
cite higher use rates in males than in females.) On the other hand,
residents had lower rates of illicit substance use—marijuana,
cocaine, psychedelics, and heroin—than the matched population.
Also noteworthy was that opiate use, though not more frequent
than in the general population, invariably began during residency
training (as did the use of benzodiazepines).
A follow-up study by the same investigators (1992) examined
resident substance use by specialty. 24 Of eleven specialties
surveyed, they found that all had slightly higher rates of alcohol
consumption in the past month and year than their age peers. With
respect to internal comparisons, however, they found that two
specialties had higher rates of nonalcohol substance use than the
others: psychiatry and emergency medicine. Psychiatry residents
reported more current use of benzodiazepine and marijuana,
while emergency medicine residents reported more current use
of cocaine and marijuana. (Except for benzodiazepines, however,
this use was not higher than in the general population.) They
also noted that pediatric and pathology residents were the least
likely to use non-alcohol substances, while the remainder of the
specialties (anesthesiology, family medicine, internal medicine,
surgery, obstetrics-gynecology, radiology and “other”) were arrayed
between the two extremes. The authors voiced particular surprise
with respect to anesthesiology because of previous reports in
which anesthesiologists were regularly “over-represented” in
studies of chemically-dependent physicians.25 Some of the findings
from these two surveys have been confirmed in other studies
while others have not.26, 27, 28, 29 Perhaps the most striking example
of the latter is a recent a study by Knight et al. (1999) examining
the prevalence of alcohol abuse in pediatric residents.30 Using
the 25-item Michigan Alcoholism Screening Test (MAST), they
surveyed 115 trainees in a large urban pediatric program over
three consecutive years. Twelve residents (15 percent) had MAST
scores suggestive and six (seven percent) indicative of alcoholism.
Twenty-eight (35 percent) admitted to having experienced alcoholassociated amnesia (“blackouts”). Only one individual (one percent),
however, had sought professional help. The surprised journal
editor added the following note: “This… is a wake-up call for those
who are unaware of (or close their eyes to) the serious problem of
alcohol abuse in residents (even pediatricians!).”
While this limited research provides some useful information, it also
demonstrates the difficulty in reaching any firm conclusions about
the prevalence of substance disorders among resident physicians.
At the very least, it points up the need for larger collaborative
studies.
Our 10-Year Experience
Our institution, in conjunction with the University of South Carolina
School of Medicine, sponsors sixteen graduate medical education
programs (totaling 230 resident physicians). Since 1991 we have
identified five trainees with chemical dependency: three in primary
care and two in the surgical specialties. Each completed an
intensive treatment program and, to the best of our knowledge,
all are currently functioning well in their professional and personal
lives. Since the true prevalence of chemical dependency is
unknown in this group, it is pointless to speculate about what our
numbers “should” be. Although one might intuitively expect the
percentage to be higher, discussions with other medical education
directors indicate that our experience is typical of comparably-sized
programs. Part of the problem, no doubt, concerns the difficulties
inherent in its early diagnosis.
Detection And Diagnosis
Contrary to popular belief, deterioration of the resident’s clinical
and academic performance is a relatively late sign of chemical
dependency.31 Using it as a touchstone, therefore, may lead to
overlooking its diagnosis. In addition, behaviors that in retrospect
might have been suggestive of a problem are often ignored,
rationalized, or covered up by family and colleagues—the wellknown phenomenon of enabling. Yet in spite of these caveats,
there are a number of common warning signs which should alert
one to its possibility. (Table 1.)
The earliest manifestations5, 25 include tardiness to scheduled
events, failure to respond to pages, and unexplained absences.
Frequent somatic complaints, mysterious Monday illnesses, and
unprovoked outbursts of anger are other typical behaviors. If
married, there are often rumors of domestic discord or extramarital
affairs. Excessive drinking at social events may also be observed
with regularity. Later signs5, 7 include patient complaints about the
resident, poor personal hygiene, and citations for “driving under the
influence.” Although less frequent, the individual may pilfer drugs.
He or she may even display signs of intoxication during working
hours: familiar breath odor, unsteady gait, tremor, or somnolence.
41
Substance Abuse
Later still, the resident may manifest overt depression. Finally, there
is deterioration in the quality of the resident’s clinical and academic
work.
Intervention, Treatment And Aftercare
Once the diagnosis of chemical dependency is certain, a formal
intervention should be arranged.31 This requires individuals
skilled and experienced in the procedure—usually members of
the hospital’s or the state medical society’s physician advocacy
committee. At a minimum, the goal should be to secure the
resident’s agreement to undergo a formal evaluation at a
specialized center. If the resident refuses (and the diagnosis is
certain), it is entirely proper to terminate employment and to report
the action to the appropriate authorities. Although coercive, this
may be necessary to secure the individual’s cooperation. The
most difficult cases are those in which the diagnosis is suspected
but not certain. Here too, the goal should be to have the resident
thoroughly evaluated by professionals. Following intervention
and evaluation, the individual should begin intensive therapy at a
facility experienced in treating health professionals.8 Depending
upon the severity, this may last from three to six months or more.
Proven regimens include inpatient detoxification (if necessary),
complete medical and psychiatric testing, rehabilitative therapy,
and Alcoholics Anonymous (AA) or Narcotics Anonymous (NA)
meetings.
Following discharge the individual should be closely monitored in
conjunction with a detailed aftercare plan which should include at
a minimum regular attendance at AA or NA meetings, supportive
peer group sessions (Caduceus meetings), and regular urine drug
screening.32 Participation in the state medical society’s recovering
physician program is mandatory. Resident physicians also benefit
from the added surveillance of having a structured educational
environment. Following treatment it is customary for intensive
monitoring to continue for five years. There is good evidence that
surveillance may then be suspended because of the low relapse
rate after that point.25, 32 Overall, the five-year success rate for
physicians treated in this manner is in the 75-95 percent range.5, 7, 33
Conclusion
»» While the prevalence of chemical abuse in resident physicians
has not been precisely determined, it is probably similar to that
of agepeers in society. With respect to recent use, however,
there is some evidence that alcohol and benzodiazepines are
consumed more frequently.
»» Certain specialties appear to be at higher risk than others for
chemical dependency. Psychiatry, emergency medicine, and
anesthesiology have been cited most frequently, although the
evidence is conflicting. At present it is difficult to draw any firm
conclusions.
»» Although early diagnosis requires a high index of suspicion,
there are certain signs and behaviors which occur frequently
enough to be helpful. It should be noted, however, that
deterioration of clinical performance is a relatively late sign and
many cases may be overlooked if this is used as a benchmark.
»» Finally, with expert intervention, treatment and monitoring, the
long-term prognosis is excellent.
42
References
1. Russell B. A History of Western Philosophy. New York:
Touchstone Book, 1976.
2. Secretary of Health and Human Services. Seventh special
report to the U.S. Congress on alcohol and health. U.S.
Department of Health and Human Services, January 1990.
3. Lewis DC, Gordon AJ: Alcoholism and the general hospital:
The Roger Williams Intervention Program. Bull NY Acad Med
59: 181, 1983.
4. Moore RD, Bone LR, Geller G, et al: Prevalence, detection,
and treatment of alcoholism in hospitalized patients. JAMA
261:403, 1989.
5. Yarborough WH: Substance use disorders in physician training
programs. J Oklahoma State Med Assoc 92:504, 1999.
6. American Medical Association Council on Mental Health. The
sick physician: Impairment by psychiatric disorders, including
alcoholism and drug dependence. JAMA 233:684, 1973.
7. O’Connor PG, Spickard A: Physician impairment by substance
abuse. Med Clin North Am 81:1037, 1997.
8. Talbott GD, Martin CA: Treating impairedphysicians: Fourteen
keys to success. Va Med113:95, 1986.
9. Musto D. The American Disease: Origins ofNarcotic Control.
New Haven, CT: Yale UniversityPress, 1973.
10. Morse RM, Flavin DK: The definition of alcoholism. JAMA
268:1012, 1992.
11. American Psychiatric Association: Diagnostic and Statistical
Manual of Mental Disorders, 4th ed. Washington, D.C.,
American Psychiatric Association, 1994.
12. Goodwin DW: Alcoholism and heredity: A review hypothesis.
Archs Gen Psychiat 36:57, 1979.
13. Warner RH, Rossett HL: The effects of drinking on offspring:
An historical survey of the American and British literature. J
Stud Alc 36:135, 1975.
14. Gitlow SE, Hennecke L: Etiology of alcoholism: A new
theoretic mosaic. Semin Adolesc Med 1:235, 1985.
15. Coger RW, Dymond AM, Serafetinides EA, et al: Alcoholism:
Averaged visual evoked response amplitude-intensity slope
and symmetry in withdrawal. Biof Psychiat 11:435, 1976.
16. Bissell LB, Haberman P: Alcoholism in the Profession. New
York: Oxford University Press, 1984.
17. Bissell LB, Jones RW: The alcoholic physician: A survey. Am J
Psychiatry 133:1142, 1976.
18. Jex SM, Hughes P, Storr C, et al: Relations among stressors,
strains and substance use among resident physicians. Int J
Addict 27:979, 1992.
19. Cooper ML, Russell M, Frone MR: Work stress and alcohol
effects: A test of stress-induced drinking. J Health Soc Behav
31:260, 1990.
20. Mensch BS, Kandel DB: Do job conditions influence the use of
drugs? J Health Soc Behav 29:169, 1988.
21. Richman JA, Flaherty JA, Rospenda KM: Perceived workplace
harassment experiences and problem drinking among
physicians: Broadening the stress/ alienation paradigm.
Addiction. 91:391, 1996.
22. Brewster JM: Prevalence of alcohol and other drug problems
among physicians. JAMA 255:1913, 1986.
Substance Abuse
23. Hughes, PH, Conrad SE, Baldwin DC, et al: Resident
physician substance abuse in the United States. JAMA
265:2069, 1991.
24. Hughes PH, Baldwin DC, Sheehan DV, et al: Resident
physician substance use by specialty. Am J Psychiatry
149:1348, 1992.
25. Talbott G, Gallegos KV, Wilson PO, et al: The Medical
Association of Georgia’s Impaired Physicians Program: Review
of the first 1,000 physicians: Analysis of specialty. JAMA
257:2927, 1987.
26. Myers T, Weiss F: Substance use by internes and residents:
An analysis of personal, social and professional differences. Br
J Addict 82:1091, 1987.
27. McAuliffe W, Rohman M, Santangelo S, et al: Psychoactive
drug use among practicing physicians and medical students.
N Engl J Med 315:805, 1986.
28. Maddus J, Timmerman I, Costello R: Use of psychoactive
substances by residents. J Med Educ 62:852, 1987.
29. McNamera RM, Margulies JL: Chemical dependence in
emergency medicine residency programs: Perspective of the
program directors. Ann Emerg Med 23:1072, 1994.
30. Knight Jr, Palacios J, Shannon M: Prevalence of alcohol
problems among pediatric residents: Arch Pediatr Adolesc
Med 153:1181, 1999.
31. Talbott G, Gallegos K. Intervention with health professionals.
Addiction and Recovery 10(3):13, 1990.
32. Angres DH, Talbott D, Angres K. Chemical dependency
for professionals: The Rush and Talbott Recovery System
Program. Healing the Healer, Treating the Chemically
Dependent Physician. Madison, CT: Psychosocial Press,
1999.
33. Miscal B: Monitoring recovering physicians: The New Mexico
experience. Am Coll Surg Bull 76:22, 1991.
43
GME Policies
44
Section B
GME Policies
GME Policies
Table
Of Contents
Administrative
Evaluation
Annual Institutional Review (Air)...................................................48
Annual Program Review...................................................................49
Annual Program Review Template (Form)....................................50
GMEC Special Review.......................................................................51
Certificate Of Graduation Policy.....................................................52
Change In Size Or Number Of Residency Programs....................53
Disaster-Triggered Educational Response......................................55
Eligibility.............................................................................................56
Graduate Medical Education Committee.......................................57
Immigration Policy For Physician Trainees...................................58
Inclement Weather Policy.................................................................59
Learning And Working Environment.............................................60
Non-ACGME Fellowship Programs................................................61
Patient Safety & Quality Improvement..........................................62
Promotion/Reappointment.............................................................63
Record Retention For GME Program Applicants..........................64
Record Retention For Former Residents And
Requests For Information Policy.....................................................65
Selection..............................................................................................66
Annual Time Line Requirements....................................................67
Transfer Of Residents.......................................................................68
Workplace Violence...........................................................................69
Evaluation Of Residents/Fellows....................................................98
Evaluation Of Rotations/Faculty Members By Residents...........99
Final Summative Resident/Fellow Evaluation Forms............... 100
Final Resident/Fellow Evaluation Form (Graduate).................. 100
Summative Resident/Fellow Evaluation Form
(Non-Graduate)............................................................................... 101
Summative Resident/Fellow Evaluation Form
[Preliminary Year(s)]...................................................................... 102
Compensation And Benefits
Agreement Of Appointment............................................................71
Agreement Of Appointment (Form 2013-2014)..........................72
Compensation & Benefits................................................................76
Leaves Of Absence.............................................................................78
Leave: Salary Continuance..............................................................80
Leave: Educational Leave.................................................................81
Leave: Family And Medical Leave...................................................82
Leave: Jury Duty And Court Witness............................................84
Leave: Maternity Leave....................................................................85
Leave: Military Leave Of Absence..................................................86
Leave: Paternity Leave.....................................................................87
Leave: Sick/Medical Leave & Long Term Disability.....................88
Leave: Vacation And Holiday Leave...............................................89
Licensure, Registration, Certification Requirements...................90
Meals While On Duty.......................................................................91
Parking Regulations..........................................................................92
USMLE Step 3 Requirements..........................................................95
USMLE Step 3 Flowchart.................................................................96
Workers’ Compensation...................................................................97
Professional Responsibilities
Blood & Body Fluids Exposure..................................................... 103
Business Courtesies And Gifts And Vendor Interactions......... 116
Code Of Conduct............................................................................ 118
Confidentiality................................................................................ 125
Conflict Of Interest (Potential).................................................... 126
Disciplinary Action......................................................................... 129
Dismissal Of Residents.................................................................. 130
Disruptive Behavior....................................................................... 131
Disruptive Behavior Procedure..................................................... 132
Disruptive Behavior Incident Reporting (Form)
For Resident’s/Fellow’s.................................................................. 133
Dress Code And Personal Appearance......................................... 134
Duty Hours...................................................................................... 135
Alertness/Fatigue Management And Mitigation....................... 137
Grievance, Due Process, And Appeals......................................... 138
Harassment..................................................................................... 140
Health Information Management For Inpatients...................... 141
Health Information Management For Teaching Clinics........... 142
Illness/Injury Reporting................................................................ 143
Impairment..................................................................................... 144
Lewis Blackman Patient Safety Act.............................................. 145
Moonlighting/Other Professional Activities Request............... 147
Off-Campus Elective Rotations Policy......................................... 149
Off-Campus Elective Rotation Request And Authorization.... 150
Off-Campus Elective Rotations (International)......................... 153
Assumption Of Risk And Release................................................ 154
Professionalism............................................................................... 156
Remediation Policy......................................................................... 157
Social Networking Policy............................................................... 159
Solicitation....................................................................................... 160
Subpoenas To Employees.............................................................. 161
Substance Abuse Policy.................................................................. 162
Supervision Of Medical Students................................................ 166
Supervision Of Palmetto Health Resident Physicians.............. 167
Tobacco-Free Workplace................................................................ 169
Transitions Of Care........................................................................ 170
47
GME Policies
Annual Institutional Review (AIR)
STATEMENT OF POLICY:
The GMEC demonstrates effective oversight of the Sponsoring Institution’s accreditation through an Annual
Institutional Review (AIR).
PROCEDURES:
1. Institutional performance indicators include:
a.
ACGME notification of institutional accreditation status;
b.
results of the most recent CLER visit;
c.
results of the most recent institutional self-study visit;
d.
aggregate results of ACGME surveys of residents/fellows and faculty members; and,
e.
aggregate results of ACGME-accredited programs’ performance indicators.
f.
verification of DIO and program director continuing professional development and education applicable to their roles as
educational leaders.
2. The AIR includes monitoring procedures for action plans resulting from the review.
3. An executive summary of the AIR is submitted annually to the Governing Body (Palmetto Health Board) and the Senior Institutional
Executive (SIE) of the Sponsoring Institution.
48
February 12, 2013
Date of Initial GMEC Approval
February 12, 2013
Date of Last GMEC Review
Signature on File
Signature On File
GME Policies
Annual Program Review
PURPOSE:
To establish a formal, systematic process to annually evaluate the educational effectiveness of the Residency Program curriculum, in
accordance with the program evaluation and improvement requirements of the ACGME and the Palmetto Health GMEC.
Representative personnel from the Residency Program will be organized as a Program Evaluation Committee to review the program’s
goals and objectives and the effectiveness with which the curriculum has achieved those objectives during the academic year. In addition,
accomplishments and remaining needs in faculty development will be assessed. The meeting(s) of the Program Evaluation Committee will
be documented in the form of written minutes. The group will prepare an explicit plan of action, to specify initiatives to improve program
performance identified as a result of the review process. The action plan will be presented to the entire program faculty.
PROCEDURES:
1. Prior to the review, the Program Director will:
»» establish and announce the date of the review meeting
»» identify two (2) or more representative members of the program faculty to participate in the review
»» identify at least two (2) program residents to participate in the review (one resident for fellowships with only one (1) resident); one at
a senior level and one at a lower level
»» identify an administrative coordinator to assist with organizing the data collection, review process, and report development
»» solicit written confidential evaluations from the entire faculty and resident body for consideration in the review
»» authorize the administrative coordinator to compile the materials, listed below, to be used in the review
2. At the time of the initial meeting, the Committee will consider:
»» the ACGME Common, specialty/subspecialty-specific Program, and Institutional Requirements in effect at the time of the
evaluation;
»» the most recent accreditation letters of notification from previous ACGME reviews and progress reports sent to the respective
Review Committees;
»» achievement of action plan improvement initiatives identified during the last annual review
»» reports from previous GMEC Special Reviews of the program;
»» results from internal or external resident/fellow, faculty and patient surveys;
»» annual performance data provided by the ACGME;
»» transitions of Care protocol;
»» achievement of correction of citations and concerns from last ACGME program survey
»» residency program goals and objectives
»» faculty members’ confidential written evaluations of the program
»» residents’ annual confidential written evaluations of the program and faculty
»» resident performance and outcomes assessment, as evidenced by:
•
performance of program graduates on the certification examination
•
aggregated data from general competency assessment
•
in-training examination performance
»» faculty development needs and effectiveness of faculty development activities during the past year
»» ACGME and/or other available resident survey results
»» any other issues that might come before the panel
3. Additional meetings may be scheduled, as needed, to continue to review data, discuss concerns and potential improvement
opportunities, and to make recommendations. Written minutes will be taken of all meetings.
4. As a result of the information considered and subsequent discussion, the Committee will:
»» identify any deficiencies in the program, and prepare an explicit plan of action to address them
»» develop recommendations for improving the residency program, through enhancement of identified strengths
5. The final report and action plan will be approved by the Committee, reviewed and approved by the program’s teaching faculty, and
documented in faculty meeting minutes. A report will be provided to the DIO and presented to the GMEC.
February 24, 2010
February 12, 2013
Signature on File
Signature On File
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GME Policies
Annual Program Review Template (Form)
Date of Review Meeting(s): Participants:
Program Director:
Senior Resident: Other: Junior Resident: Faculty Member(s): Data considered by the Annual Review Panel include:
• The ACGME Common, specialty/subspecialty-specific Program, and Institutional Requirements in effect at the time of the evaluation;
• The most recent accreditation letters of notification from previous ACGME reviews and progress reports sent to the respective Review
Committees;
• the most recent APR report; and status report on action plans developed for educational improvement that were identified in previous
annual review;
• reports from previous GMEC Special Reviews of the program;
• results from internal or external resident/fellow, faculty, and patient surveys;
• annual performance data provided by the ACGME;
• Residency program goals and objectives; and
• Other items as deemed necessary.
1. Summary of Faculty Confidential Annual Written Evaluations of the Program:
2. Summary of Residents’ Confidential Annual Written Evaluations of the Program:
3. Summary of Findings:
a.
Status of each ACGME citation;
b.
Status of action plan issues identified in last Annual Program review;
c.
Status of issues identified in GMEC Special Review, if applicable;
d.
Summary of annual performance data provided by the ACGME;
e.
Transitions of care protocol;
f.
Residents’ Performance
g.
Faculty Development
h.
Graduates’ Performance
i.
Program Quality
4. Program strengths to be reinforced:
5. Deficiencies in the program, to be addressed in the Action Plan for the Academic Year: (copy of Action Plan attached)
6. Approved by: (signed by each member of review panel)
7. Date action plan reviewed with and approved by faculty (also note in faculty meeting minutes)
* Revised February 12, 2013
50
GME Policies
GMEC Special Review
The GMEC provides evidence of quality improvement efforts by maintaining a GMEC Special Review process for
programs that warrant intervention beyond the APR.
PROCEDURES:
1. Minimum components of a GMEC Special Review protocol and template include:
a.
criteria for initiating a GMEC Special Review; which will be designed to meet the ACGME/RRC requirements
b.
committee membership from within the Sponsoring Institution but not from within the department of the ACGME-accredited
program under review that is comprised of:
i.
at least one faculty member;
ii.
at least one resident/fellow; and,
iii.
additional internal or external reviewers and administrators which may include the DIO, as determined by the GMEC.
c.
interviews with:
i.
the program director;
ii.
at least two core faculty members;
iii.
at least one peer-selected resident/fellow from each PGY-level in the ACGME accredited program; and,
iv.
other individuals as deemed appropriate by the GMEC Special Review committee, depending on the circumstances of
the review.
d.
Specific outcome measures.
2. The GMEC Special Review protocol outlines a reporting structure, monitoring procedures, and a timeline, including written
recommendations and procedures for follow-up to improve ACGME-accredited program performance in specified areas.
February 12, 2013
February 12, 2013
Signature on File
Signature On File
51
GME Policies
Certificate Of Graduation Policy
The GME office provides certificates of graduation for all sponsored training programs to formally confirm
completion of internship, residency, and/or fellowship training.
PROCEDURES:
1. The GME office sends a proposed promotion/graduate list to Program Directors for review and verification prior to the designated
spring GMEC meeting in which promotion and graduation approval is conducted.
2. The GME office then sends a list of approved graduate names, specialty, and dates of training to respective Program Coordinators to
verify certificate information with each graduating resident. After verification of accuracy by each resident, the approved list is returned
to the Administrative Director for Resident/Student Services, who arranges for certificates to be printed.
3. Upon receipt of printed certificates, the GME office reviews them for accuracy and sends them to the Designated Institutional Official,
CEO, Dean, and respective Chairs and Program Directors for signature.
4. Programs may not issue certificates to graduates until the GME office has received the resident’s final summative evaluation and GME
clearance form. Programs are allowed to frame and ceremonially present certificates during graduation functions that occur before
final summative evaluations are completed. If so, Programs must collect certificates at the end of graduation functions and retain
them until receiving verification of receipt of final summative evaluations and GME clearance forms from the GME office.
5. Alumni who request replacement certificates are responsible for the cost of replacement.
52
February 8, 2011
February 12, 2013
Signature on File
Signature On File
GME Policies
Change In Size Or Number Of Residency Programs
Palmetto Health’s goal is to optimally size and configure our GME programs to complement our mission and vision,
to meet community medical needs, to strengthen our GME training programs, to meet ACGME and Commission
on Dental Accreditation (CODA) Program requirements, and to fulfill our commitments to affiliated organizations.
“Optimal” sizing and configuration means maintaining, decreasing, increasing, eliminating, or adding residency and
fellowship positions and/or programs such that these changes are consistent with this goal.
PROCEDURES:
1. The DIO appoints members to a GME Configuration Subcommittee whose role is to monitor the size and configuration of Palmetto
Health’s GME programs and to make periodic recommendations on changes. The highest priority is placed on “preserving” those
GME programs that are most consistent with the goal stated above.
2. Requests to increase the size of a residency program or to develop a new residency program must follow the GME Residency
Programs development and approval process (see flow chart).
3. If the size of a residency program is being reduced, if a residency program is being closed, or if the Sponsoring Institution intends to
close, then as much advance notice as possible is given to the affected residents and/or fellows.
4. In the event a program is downsized, we are committed to supporting those residents or fellows currently enrolled; in the event of
program or Sponsoring Institution closure, we are committed to allowing those residents or fellows currently enrolled to complete their
education within Palmetto Health or to assisting them in obtaining positions in other accredited programs.
February 5, 2002
February 12, 2013
Signature on File
Signature On File
53
GME Policies
Change In Size Or Number Of Residency Programs
54
GME Policies
Disaster-Triggered Educational Response
In the event of a catastrophic disaster which significantly alters the residency experience at one or more residency
programs, Palmetto Health will provide administrative support for continuation of resident training.
PROCEDURES:
1. If a disaster seriously degrades the ability of Palmetto Health to carry out its mission (high quality patient care, education and
research), the resident physicians and faculty will perform all duties as outlined in the comprehensive Palmetto Health disaster plan
until the acute case of the disaster is over.
2. As soon as possible a determination will be made by leadership as to whether the individual residency programs will be able to
provide an adequate educational experience that will assure that residents can complete their program requirements within the
standard time required for certifications. Within ten days after the declaration of a disaster, the DIO will contact ACGME to discuss
due dates that ACGME will establish for the programs. The DIO will communicate the institutional decisions as quickly as possible to
the GMEC, program directors and residents, and will serve as the primary institutional contact with the ACGME regarding the issues
addressed in this policy. ACGME will provide phone numbers and email addresses for emergency and other communications on its
website for DIO’s, program directors and residents/fellows. Palmetto Health will also provide appropriate information for residents on
its website.
3. If the DIO and GMEC determine that the sponsoring Institution can no longer provide an adequate educational experience for its
residents, the sponsoring Institution will, to the best of its ability, arrange for the temporary transfer of the residents to programs at
other sponsoring institutions until such time as Palmetto Health is able to resume providing the experience. Residents who transfer
to other programs as a result of a disaster will be provided by their Program Directors with an estimated time that relocation to
another program will be necessary. Should that initial time estimate need to be extended, the resident will be notified by their Program
Directors using written or electronic means identifying the estimated time of the extension. Palmetto Health will provide information
concerning continuation of salary, benefits, and assignments during this period of interruption.
4. If the disaster prevents the sponsoring Institution from re-establishing an adequate educational experience within a reasonable
amount of time following the disaster, then permanent transfers will be arranged. The DIO will be responsible for coordinating the
transfers with ACGME. Palmetto Health will provide information concerning continuation of salary, benefits, and assignments during
this period of interruption.
5. If a disaster affects other teaching institutions, Palmetto Health will do all it can do to accept residents from the program and provide a
sound training environment.
6. Each program will be responsible for establishing procedures to protect the academic and personnel files of all residents from loss or
destruction by disaster. All electronic files will have off site backup.
February 17, 2009
February 12, 2013
Signature on File
Signature On File
55
GME Policies
Eligibility
Candidates being considered for selection into residency training programs must be able to meet eligibility
requirements by the time of appointment.
PROCEDURES:
1. Applicants with one of the following qualifications are eligible for appointment to accredited residency programs:
a.
Graduates of medical schools in the United States and Canada accredited by the Liaison Committee on Medical Education
(LCME).
b.
Graduates of colleges of osteopathic medicine in the United States accredited by the American Osteopathic Association
(AOA).
c.
Graduates of medical schools outside the United States and Canada who have received a currently valid certificate from the
Educational Commission for Foreign Medical Graduates.
d.
Graduates of medical schools outside the United States who have completed a Fifth Pathway program provided by an LCMEaccredited medical school.
e.
A US citizen, permanent resident or eligible for an appropriate VISA.
f.
Fellowship applicants must have successfully completed an ACGME accredited residency.
2. Physician trainees (residents or fellows) who are not citizens of the U.S. must have immigration authorization under the J-1 Exchange
Visitor Program. Only in very rare and unusual situations will a request for exception be considered. Such an exception requires
approval in advance by the DIO. (See Immigration Policy for physician trainees).
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August 4, 1993
February 12, 2013
Signature on File
Signature On File
GME Policies
Graduate Medical Education Committee
Palmetto Health’s DIO and GMEC have authority and responsibility for the oversight and administration of the
Sponsoring Institution’s programs and responsibility for assuring compliance with ACGME Common, Specialty/
Sub-Specialty Program, and Institutional requirements.
PROCEDURES:
1. The GMEC voting membership consists of the Directors of Education and Program Directors of each residency training program,
the Chief Medical Officer (Palmetto Health’s Chief Academic Officer and DIO designee), the Dean of the School of Medicine, Vice
President of Medical Education and Research (DIO), Quality Improvement/Safety Officer, selected faculty representatives, peerselected officers of the Resident’s Council , Program Coordinator Representative, Palmetto Health administration representatives, and
other appropriate representatives from the major participating Institutions. The DIO serves as the Chair of the GMEC.
2. The GMEC meets a minimum of six (6) times per year, and minutes are maintained.
3. The minutes of each GMEC meeting include documentation of the execution of all required GMEC functions and responsibilities, and are
forwarded to the Medical Executive Committees of Palmetto Health’s teaching hospitals for information and official action where appropriate.
4. The DIO may establish subcommittees or ad hoc groups, as deemed appropriate. Each subcommittee includes a peer selected
resident/fellow. Subcommittee actions are reviewed and approved by full GMEC.
5. The Executive Committee of the GMEC consists of the Chief Medical Officer, the Dean of the School of Medicine, and the Vice
President for Medical Education (DIO).
6. If necessary between GMEC meetings, the Executive Committee reviews issues and imposes temporary actions. However, any such
actions are presented at the next official meeting of the GMEC for final approval.
7. GMEC responsibilities include oversight of:
a.
ACGME-accreditation status of the Sponsoring Institution and its ACGME-accredited programs;
b.
the quality of the GME learning and working environment within the Sponsoring Institution, its ACGME-accredited programs,
and its participating sites;
c.
the quality of educational experiences in each program that lead to measurable achievement of educational outcomes outlined
in the ACGME Common and specialty/subspecialty-specific Program Requirements, including annual program reviews and
special program review as needed; and,
d.
all processes related to reductions and/or closures of individual ACGME-accredited programs, major participating sites, and
the Sponsoring Institution.
8. The DIO and GMEC review and approve all official correspondence with the ACGME prior to submission, including :
a.
Annual recommendations to the Sponsoring Institution’s administration regarding resident/fellow stipends and benefits, and
the number of funded positions in each ACGME accreditation program;
b.
Institutional GMEC policies and procedures;
c.
all applications for ACGME accreditation of new programs and subspecialties;
d.
request for permanent changes in resident/fellow complement;
e.
major changes in ACGME accredited programs structure or length of training education;
f.
additions or deletions from each ACGME accredited program’s list of participating sites ;
g.
appointment of new Program Directors;
h.
progress reports requested by a Review Committee;
i.
responses to interim CLER site visit reports;
j.
voluntary withdrawal of ACGME program accreditation;
k.
requests for an appeal of an adverse action by a Review Committee;
l.
appeal presentations to an ACGME Appeals panel.
9. The GMEC establishes and implements policies and procedures regarding the quality of education and the work environment for the
residents in all programs.
August 4, 1993
February 12, 2013
Signature on File
Signature On File
57
GME Policies
Immigration Policy For Physician Trainees
It is the policy of the Palmetto Health to employ physician trainees (residents and fellows) requiring immigration
authorization only under the J-1 Exchange Visitor Program, sponsored by the Educational Commission of Foreign
Medical Graduates (ECFMG). Exceptions to this policy may be made only by the DIO in rare circumstances. No
exceptions shall be made to this provision.
PROCEDURES:
1. The Program Director shall communicate the circumstances surrounding a request for an exception to the DIO.
2. If the request is approved, the processing of all USCIS (U.S. Citizenship and Immigration Services) related documentation leading to
the approval of a non-immigrant visa will be managed by the Department of Medical Education in conjunction with the corporate legal
office. This includes all communication with outside legal counsel, financial provision for legal fees and services, and any other cost
related to approval of non-immigrant work authorization. .
3. Signature authority for all visa paperwork, including that required by the ECFMG, USCIS, and/or the DHS (Department of Homeland
Security) shall be granted to only the DIO or his designee in the Department of Medical Education.
All questions regarding visa status of any physician trainee shall be directed to the DIO or his designee.
58
November 2, 1999
February 12, 2013
Signature on File
Signature On File
GME Policies
Inclement Weather Policy
Ambulatory Care Center
Palmetto Health Ambulatory Care Centers is dedicated to providing services to our patients during inclement
weather. It is our policy to remain open during normal business hours however, in case of severe weather
emergencies, it may be necessary to adjust normal work hours/schedules.
GUIDANCE:
1. In the event of inclement weather all employees of the Ambulatory Care Centers to include Registration staff, Residents and Attending
physicians will call the Ambulatory Care Centers Emergency and Severe Weather line at 1-800-503-9512 by 6:00am the morning
of the inclement weather for an update on a delay in opening. EXCEPTION: OB/GYN Residents will follow The University of South
Carolina Department of OB/GYN emergency closure schedule.
2. A delay in opening the clinics will be based on weather conditions, not school closings, and will be made the morning of the
inclement weather. If a decision is made to close the clinics the initial delay will be two (2) hours therefore, clinic will start at 10:00am.
The Emergency and Severe Weather line will be updated one (1) hour into this delay at 9:00am.
3. If the weather is not severe in your area and you see that you can get to work at the start of the work day, check with your center
manager to ensure that this is okay. Additionally, request to leave work early due to inclement conditions shall be made as soon as
possible to your department manager for consideration.
4. As per hospital policy, it is expected that all employees will make every effort to report to work as scheduled during periods of
inclement weather unless the employee’s department is closed. If an employee refuses to come to work, the absence will be unexcused and the employee will not be paid. Disciplinary measures may also be taken (refer to Human Resources Policy number 130).
September 15, 2009
December 8, 2010
Signature on File
Signature On File
59
GME Policies
Learning and Working Environment
Palmetto Health and each program ensures a culture of professionalism that supports patient safety and personal
responsibility. The learning and working environment is safe for patients, meets the physical needs of residents/
fellows, is free from harassment, and is conducive to resident/fellow education. It also provides a learning and
working environment in which residents/fellows have the opportunity to communicate and exchange information,
raise concerns and provide feedback to the Sponsoring Institution without intimidation and retaliation, and in a
confidential manner.
PRINCIPLES:
1. Palmetto Health provides appropriate physical facilities to meet each residency program’s goals.
2. Palmetto Health provides support services and develops health care delivery systems to minimize residents’/fellows’ work that is
extraneous to their ACGME-accredited programs’ educational goals and objectives, and to ensure that residents’/fellows’ educational
experiences are not compromised by excessive reliance on residents/fellows to fulfill non-physician service obligations. These
support services and systems include: Patient support services, Lab services and medical records.
3. Palmetto Health provides counseling when appropriate and other support services to meet each resident’s/fellow’s unique needs.
Arrangements are coordinated through the Department of Medical Education.
4.
Communication and reporting mechanisms for residents/fellows to communicate and exchange information, raise concerns, and
provide feedback to Palmetto Health and its residency programs include both confidential methods (e.g., contacting the Palmetto
Health Hotline at 1-888-398-2633 or http://palmettohealth.silentwhisle.com) for sensitive issues and non-confidential methods (e.g.,
meeting with the program director or the DIO, reporting at GME or institutional committees, presenting at the Residents’ Council) for
less sensitive issues.
5. Residents have access to appropriate food 24 hours a day while on duty in all institutions.
6. Residents are provided with appropriate sleep quarters in all participating sites in order to mitigate fatigue. Residents are also
provided safe transportation options.
7. Security services and personal safety measures are provided to residents at all locations participating sites, including: parking
facilities, sleep quarters, hospital and institutional grounds.
8. Each residency program recognizes that the resident/fellow’s personal and family needs must be addressed for them to function
optimally.
9. Each residency program must foster humanistic values and cross cultural sensitivity and respect for all individuals.
10. Each residency program must demonstrate a commitment to excellence in residency education and provide a supportive
environment essential for residents to be self-directed and life-long learners.
60
August 4, 1993
February 12, 2013
Signature on File
Signature On File
GME Policies
Non-ACGME Fellowship Programs
Palmetto Health’s Graduate Medical Education Committee (GMEC) has oversight authority and responsibility for all
aspects of postgraduate medical education, including non-ACGME fellowships.
PROCEDURES:
1. Fellows in non-ACGME programs may be employed by Palmetto Health or School of Medicine departments. If employed by School
of Medicine departments, they may be appointed as junior faculty. The employment decision must be made prior to a position being
offered to a candidate and requires approval in advance by the DIO or his/her designee.
2. Fellows in non-ACGME programs who are employed by Palmetto Health or School of Medicine departments may function as
licensed independent practitioners and may provide patient care in inpatient and/or outpatient settings in or beyond their areas of
training, unless prohibited by the U. S. Code of Federal Regulation and the U. S. Citizenship and Immigration Service (USCIS), e.g.,
fellows on J-1 visas., who are not permitted to work as licensed independent practitioners.
3. Where permitted, Palmetto Health or School of Medicine departments may bill for work done by fellows in non-ACGME programs in
or beyond their areas of training.
4. It is the responsibility of fellows in non-ACGME programs to obtain licensure for independent, unsupervised medical practice and
to provide proof of such licensure to the Administrative Director of Resident and Student Services prior to performing any such
professional activities.
5. It is the responsibility of fellows in non-ACGME programs to obtain and provide professional liability insurance (malpractice) coverage
for all professional activities and to provide proof of such coverage to the Administrative Director of Resident and Student Services
prior to performing any such professional activities.
6. The Program Director must monitor independent practice efforts to ensure that they do not interfere with the educational experience
of the fellow’s training program or cause undue fatigue or stress.
February 17, 2009
February 12, 2013
Signature on File
Signature On File
61
GME Policies
Patient Safety and Quality Improvement
Palmetto Health is responsible for oversight and documentation of resident/fellow engagement in improvement
processes within patient care and the learning and working environment. Residents participate in quality
improvement activities in accordance with the hospital’s official Quality Improvement Plan. All hospital-related
quality activities are monitored through Palmetto Health‘s Clinical Quality and Patient Safety department.
PROCEDURES:
1. All residents receive education in patient safety and quality improvement.
2. Palmetto Health provides mechanisms for residents/fellows to report errors, adverse events, unsafe conditions, and near misses in
a protected manner that is free from reprisal, and to contribute to inter-professional root cause analysis or other similar risk reduction
teams.
3. Palmetto Health provides data to improve systems of care, reduce health care disparities, and improve patient outcomes; and
facilitates resident participation in inter-professional quality improvement initiatives.
4. For inpatient activities:
a.
Each clinical department’s chief is responsible for the oversight of patient care activities conducted by individuals with
delineated clinical privileges in that department.
b.
Although residents are not official members of the medical/dental staff, they work under the supervision of faculty members
who are and who have ultimate responsibility for patient care under their charge.
c.
When necessary, identified patient care problems are brought to the attention of the particular faculty member and, through
the faculty member, to the attention of the resident/fellow involved in the patient’s care.
d.
Quality improvement activities are then carried out in accordance with the hospital’s Quality Improvement Plan.
5. For outpatient activities:
a.
Performance improvement activities in hospital based ambulatory settings are conducted in accordance with the Institutional
Quality Improvement Plan.
b.
Quality improvement committees, consisting of residents, faculty, nurses, and other appropriate individuals, conduct quality
improvement activities.
c.
Quality improvement committees carry out traditional quality assurance activities as well as activities to improve the overall
process of care.
d.
Results are reported to Palmetto Health quality departments.
62
November 2, 1993
February 12, 2013
Signature on File
Signature On File
GME Policies
Promotion/Reappointment
Residents are promoted on the basis of acceptable periodic evaluations which may be supplemented by written or
oral competency examinations (or other evaluation methods), by recommendation of their department’s Promotion
Committee, and by final approval of the GMEC. If it is the intent of a program not to promote a resident and not to
offer the resident a new agreement of appointment, the resident will receive advance written notice.
PROCEDURES:
1. Each department’s Promotion Committee reviews the resident’s evaluations for the preceding academic year.
2. If it is determined by the department’s Promotion Committee (utilizing departmental criteria that are reviewed annually by the GMEC)
that the resident is eligible for promotion, this recommendation is forwarded to the GMEC.
3. An additional requirement is the successful completion of all levels of the appropriate licensing examination: Step 3 of the United
States Medical Licensing Exam (USMLE) or the equivalent National Board of Osteopathic Medical Examiners (NBOME) Step 3 and
COMLEX Step 3. Documentation of successful completion must be provided to the Program Director and the Department of Medical
Education. See Separate USMLE Step 3 Policy.
4. The GMEC acts on each department’s recommendations no later than the month preceding promotion or graduation.
5. Should significant deficiencies cause a resident not to be promoted, a plan for remedial work, including performance monitoring, is
arranged by the resident’s Program Director with the approval of the GMEC.
6. In the event that a program determines that a resident’s agreement of appointment should not be renewed, or that a resident should
not be promoted to the next level of training, the Program Director must present the program’s recommendation to the GMEC at
least four months before the end of the resident’s current agreement of appointment. Upon approval of the GMEC, the Program
Director must provide written notice of intent not to renew or promote to the next level of training to the resident no later than four
months prior to the end of the resident’s current agreement of appointment. However, if the primary reason(s) for non-renewal or non
promotion occur(s) within the four months prior to the end of the agreement of appointment, the Program Director will provide the
resident with as much written notice as circumstances reasonably allow prior to the end of the agreement of appointment.
7. Should a resident receive a written notice of intent not to renew the agreement of appointment, or of intent to renew the agreement
but not promote, the resident will be allowed to implement the Palmetto Health GME Grievance & Due Process procedure.
August 4, 1993
February 12, 2013
Signature on File
Signature On File
63
GME Policies
Record Retention For GME Program Applicants
Requests from applicants for information concerning residency training and/or completed applications are retained
for variable periods of time, based on guidelines from national professional organizations.
PROCEDURES:
1. The Graduate Medical Education Committee has a specific policy and procedure for resident eligibility and selection.
2. All requests (including E-mail requests) for information and/or an application to a Palmetto Health residency program will be retained
for two (2) years where:
a.
information is requested, but no completed application is filed;
b.
the individual is deemed ineligible, or
c.
the individual is deemed eligible, but not invited for an interview.
3. All requests for information and an application received from an eligible individual, who is invited for an interview, but fails to “match”
with a Palmetto Health residency program, will be retained for seven (7) years.
4. All requests for information and an application received from an eligible individual, invited for an interview and accepted into the
program, will be retained permanently.
64
October 1, 1997
February 12, 2013
Signature on File
Signature On File
GME Policies
Record Retention For Former Residents And Requests For
Information
To permanently maintain files on all residents who participated in residency training. Files may be permanently
saved via hardcopy, microfilm, or electronically.
PROCEDURES:
1. The PH Office of GME maintains the following in the resident file permanently:
»» Copies of resident agreements of appointment
»» Copy of the ERAS application or PH resident application
»» ECFMG certificate, if applicable
»» Copies of Employee Disposition
»» Employability Attestation (I-9), W4 Tax form, Direct Deposit form
»» Visa, EAD copies if applicable (any other Proof of I-9)
»» Standards of Behavior form
»» Corporation Compliance form
»» Promotional change of status forms
»» License copies
»» Certification copies
»» Final summative evaluation
»» Permission to Moonlight form
»» Disciplinary actions records
2. The residency program maintains the following in the department’s resident file permanently:
»» Semi-Annual Formative Evaluations and Final Summative Evaluation Procedures Correspondence related to Board status
»» ERAS application access/PH resident application, letters of recommendation
»» Rotation schedules
»» Disciplinary actions records
»» Any other documentation required by individual RRC’s or the Program Director
3. The Palmetto Health office of GME processes requests for Information for the following:
»» Residency verification and credentialing
»» Deferment forms for medical school loans
4. The offices of residency programs process requests for information for the following:
»» Residency verifications for Board Certification or requests that require in-depth clinical and character information
February 17, 2009
February 12, 2013
Signature on File
Signature On File
65
GME Policies
Selection
Residents are selected from eligible applicants on a fair and equitable basis regardless of gender, age, race,
religion, color, national origin, disability or veteran status, or any other applicable legally protected status. Selection
is based upon preparedness, ability, aptitude, academic credentials, communication skills, and personal qualities
such as motivation and integrity.
PROCEDURES:
1. Candidates must meet eligibility criteria to be considered for selection.
2. All programs are required to participate in the Electronic Residency Application System (ERAS) and the National Resident Matching
Program (NRMP) with the exception of dental medicine, and non-NRMP residencies.
3. All applicants are required to complete an application form and submit this along with board scores, letters of reference, a dean’s
letter, and a medical school transcript.
4. Each department compiles the data and prepares a personal record on each applicant.
5. The department’s Resident Selection Committee (including appointed faculty and/or residents) screens applications according to
established departmental criteria (which are reviewed annually by the GMEC) and selects applicants for interview.
6. Applicants are also informed that they must submit proof of taking and passing Steps 1 and 2 of the USMLE or its equivalent as set
forth by the Federation of Medical Boards prior to starting residency.
7. A personal interview is granted to those applicants selected through the screening process. During this interview applicants are
informed of salary, vacation time, professional leave, parental leave, sick leave, professional liability insurance, hospital, disability and
health insurance benefits, call rooms, meals, laundry, employment requirements, etc. and sign an approved form documenting that
they have received this information.
8. At the end of the interviewing period, the program’s Resident Selection Committee objectively evaluates each candidate on the basis
of their preparedness, ability, aptitude, academic credentials, communication skills, and personal qualities, such as compassion,
dignity, excellence, integrity, teamwork, and motivation. The committee then prepares a list of applicants in rank order, which is
forwarded to the Department of Medical Education.
9. The Department of Medical Education verifies pertinent medical education credentials on matched applicants.
10. The program director may not appoint/select more residents than approved by their respective Review Committee.
11. Should a resident position become vacant, the Program Director and the DIO or his/her designee will determine if a replacement
should be sought. If approval is made to fill the vacancy, the Department conducts its selection process. Prior to a position being
offered to a candidate, application information on potential replacement candidate(s) must be reviewed by the Administrative Director
for Resident and Student Services and approved by the DIO or his/her designee.
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GME Policies
Annual Time Line Requirements
February
GMEC reviews all of its policies, procedures, and monitoring activities.
Resident salaries and fringe benefits are reviewed and revised at least yearly in advance of the beginning of each new
academic year, to include signature of Statement of Commitment.
Medical Education updates resident manual.
Each department’s Promotion Committee reviews the resident’s evaluation for the preceding academic year.
The GMEC acts on each department’s recommendations for the promotion of residents.
June
GMEC reviews and approves departmental policies and procedures concerning resident supervision and resident duty
hours and transitions of care.
Final Summative Evaluations to be completed on each graduating resident and copies sent to Department of Medical
Education.
July
Newly elected officers of the Resident’s Council are appointed to GMEC.
August
GMEC reviews and approves written departmental policies and procedures concerning moonlighting. Supervision level
updates are entered into computer systems.
GMEC will review departmental program criteria for resident eligibility and selection.
September
Copies of minutes of the Program’s annual review are submitted to the GME office.
October
Each residency program will devise written guidelines concerning resident accountability, monitoring and disciplinary
actions, and dismissal.
GMEC will review departmental program criteria for resident evaluation and promotion.
A summary of the composite evaluations of rotations and faculty members by residents is prepared by each residency
program at the end of each academic year and is reviewed annually by the GMEC Executive Committee.
The Department of Medical Education presents an annual report concerning the outcomes of residency training to
GMEC, Organized Medical Staff(s), and applicable Boards.
The Department of Medical Education reviews all institutional agreements.
December DIO provides recommendation of residents for appointment to Medical Staff committees through the Chief-of-Staff.
Copies of minutes of the Program’s annual review are submitted to the GME office.
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Transfer Of Residents
Transfer of residents between residency programs or Sponsoring Institutions should be a rare occurrence. Palmetto
Health Residency Program Directors should not initiate or solicit Transfer of residents. A resident considering
a change should first initiate discussions with his/her current Program Director and with the DIO. Applicants
considering transferring must meet all eligibility and selection criteria established by the appropriate Sponsoring
Institution. [Residents are considered as transferring residents under several conditions which include: when
moving from one program to another within the same or different sponsoring institution; when entering a PGY
2 program requiring a preliminary year, even if the resident was simultaneously accepted into the prelim PGY1
program and the PGY 2 program as part of the match (e.g., accepted to both programs right out of medical
school).] Neither the term “transferring resident” nor the responsibilities of the program directors apply to a resident
who has successfully completed a specialty residency and then is accepted into a subspecialty fellowship.
PROCEDURES:
1. If a resident wishes to transfer to another program, the resident must inform his/her current Program Director and the Palmetto Health
DIO as soon as practicable. The resident must obtain written notification from the current Program Director indicating that pursuing a
transfer is acknowledged.
2. Before accepting a transferring resident, the “receiving” Program Director must obtain written or electronic verification of prior
education from the current Program Director. Verification includes evaluations, rotations completed, procedural/operative experience,
and a summative competency-based performance evaluation. These will become part of the resident’s permanent file.
3. Board certification status must also be explored and documented. If the resident is changing specialties, the “receiving” program
director must contact the appropriate Board(s) to ascertain what, if any, credit the resident can receive for prior training.
4. Program Directors must provide timely verification of residency education and summative performance evaluations for residents who
transfer out of their program.
5. Before a final decision is made to accept a resident from another Sponsoring Institution, the Program Director must consult with the
DIO, and complete appropriate forms, to determine implications of the transfer.
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GME Policies
Workplace Violence
Healthcare workers have faced a significant risk of job-related violence and violence continues to increase. This
Hospital provides and maintains a safe, healthy, and efficient working environment where employees, patients, and
visitors are free from the threat of workplace violence.
GUIDANCE:
1. The safety and security of Hospital personnel, patients and visitors is of vital importance. Therefore, acts or threats of physical
violence, including intimindation, harassment or coercion, which in your judgement affects the Hospital or which occurs on Hospital
property will not be tolerated.
2. This prohibition against threats and acts of violence applies to all persons involved, including but not limited to Hospital personnel,
contract and temporary personnel, patients and visitors. Therefore, violations of this policy by any individual on Hospital property is
considered misconduct and will lead to disciplinary and/or legal action as appropriate.
3. No reprisals will be taken against any employee who reports or experiences workplace violence.
4. All Hospital personnel must refrain from engaging in acts of violence and are responsible for maintaining a work environment free from
acts or threats of violence.
5. Reporting Requirements:
5.1 Hospital Personnel shall report immediately any acts or threats of violence occurring on Hospital premises to the Security
Department, and to his/her supervisor. Each report will be evaluated by Security. When deemed appropriate, Security shall
determine what follow-up actions are necessary.
5.2 Supervisors/Managers shall report immediately any acts or threats of violence to the Security Department and their immediate
supervisor. Supervisors/Managers are additionally required to report warning signs of violence that they observe (i.e. verbal
abuse, aggressive behavior, loitering).
5.3 Contract Personnel working on Hospital premises, shall be informed of Workplace Violence requirements by contracting
department prior to doing any actual work on Hospital premises.
6. Confidentiality. Information about an incident or threat will be disclosed on a need to knowbasis only to ensure a thorough
investigation can be conducted and/or appropriate corrective action can be taken. Additionally, Palmetto Health Richland makes
every effort to ensure the safety and privacy of the individuals involved.
7. Discipline. Any employee who engages in prohibited conduct will be subject to appropriate disciplinary action, up to and including
termination. In addition, certain actions may cause the employee to be held legally liable under state and/or federal laws. Prosecution
may occur, to the extent permitted by law.
8. Medical Management. Employees, who are victims of violence will receive medical and emotional treatment.
9. Recordkeeping should be used to provide information for analysis, evaluation of methods of control, severity determinations,
identifying training needs and overall evaluations.
Recordkeeping includes the following:
»» Reportable injuries to OSHA
»» All incidents of abuse, verbal attacks or aggressive behavior
»» Workers Compensation and insurance records
»» Gathering of information to identify any past history of violent behavior, incarceration, probation reports or any other information that
assists employees to assess violent status
»» Reporting to Executive Safety Committee
»» Training program
10. Retaliation. Episodes of workplace violence can only be eliminated if employees are willing and able to report threats, violent acts,
and other unsafe conditions. To encourage employees to come forward without fear of retaliation, all complaints of retaliation will be
promptly investigated and appropriate disciplinary actions will be taken, up to and including termination.
11. Training and Awareness. Palmetto Health Richland will conduct initial prevention and awareness training for all employees, including
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management. These sessions will explain the hospital’s policy on workplace violence, as well as cover procedures for reporting and
investigation threats, violent acts, and unsafe workplace conditions. In addition, employees will be informed of their responsibilities
and of the measures they can take to protect themselves and co-workers, patients and visitors from workplace violence. Workplace
Violence information will be incorporated into New Employee Orientation by the Security Department.
PROCEDURE:
Responsibility
Employee
Security Services
Action
1. Report to the Security Department any threats or violent acts.
2. Controls access to Palmetto Health Richland.
3. Makes comprehensive report of incident and takes appropriate
investigative action.
4. Consults with external law enforcement authorities, if necessary.
Education Department
5. Works with the Security Department to coordinate a “Violence In the
Workplace” training awareness program.
Department of Human Resources 6. Employees experiencing threats, harassment, aggressive/violent
behavior or inappropriate behavior should contact Security and/
or Human Resources. Any caregiver who experiences physical or
emotional trauma as a result of interaction with workplace violence
should be referred to Health Works, Emergency Department.
*Employee may be referred to seek counseling, which is provided by
Employee Assistance Program.
Approved October 1, 2002 by
Jim Lathren
Executive Vice President and Chief Operating Officer, Palmetto Health Richland
For more information about this policy, contact Administration at (803) 434-2819.
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Agreement of Appointment
The Sponsoring Institution and Program Directors assure that residents are provided a written agreement of
appointment that outlines the terms and conditions of educational appointment.
PROCEDURES:
1. The agreement specifies the following:
1.1 resident responsibilities;
1.2 faculty responsibilities and supervision;
1.3 duration of appointment ;
1.4 financial support for resident/fellows;
1.5 conditions for reappointment and promotion to a subsequent PGY level;
1.6 grievance procedures and due process;
1.7 professional liability insurance, including pertinent information regarding coverage;
1.8 health, disability, and other insurance for residents and families;
1.9 leaves of absence (sick, parental, professional, etc.), including vacation and holidays;
1.10 timely notice of the effect of leaves on the ability of residents/fellows to satisfy requirements for program completion
1.11 access to information related to eligibility for specialty board examinations
1.12 duty hours;
1.13 policies regarding moonlighting and professional activities outside the educational program;
1.14 confidential counseling, medical psychological and other support services;
1.15 physician impairment;
1.16 procedures for handling complaints of harassment and exploitation; and
1.17 accommodations for disabilities
2. Annual renewal of the agreement of appointment depends upon promotion to the next appropriate level of training (See policy on
Promotion/Reappointment).
November 2, 1993
February 12, 2013
Signature on File
Signature On File
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GME Policies
2013-2014 Agreement of Appointment Form
SAMPLE
This agreement is entered into this 14th of February, 2012 between Palmetto Health, or “Hospital,” a multiple teaching hospital/health
system, located in Columbia, South Carolina (hereinafter “Palmetto Health”) and First Last MD (hereinafter “Resident”).
1. Appointment
The Resident is hereby employed by Palmetto Health as a Year Postgraduate in the Department of Medical Education for Program.
In this capacity, the Resident will participate in a graduate medical education program which includes, but is not limited to, classroom
and lecture sessions, patient care responsibilities, and other activities as determined by Resident’s specific graduate medical
education program.
The Resident agrees to perform all duties and services in a competent, professional, and effective manner. The Resident agrees to
abide by the policies, procedures, rules and regulations of the Hospital and its Department of Medical Education, as these policies,
procedures, rules and regulations currently exist and may from time to time be amended. Specifically, the Resident agrees to abide
by Medical Record provisions of the Palmetto Health Hospitals’ Medical and Dental Staff Bylaws, Rules and Regulations, as they
currently exist and may from time to time be amended.
The Resident agrees to abide by the Statement of Resident Responsibilities (see below).
2. Resident/Fellow Responsibilities
The goal of the residency/fellowship program is to provide the Resident with an extensive experience in the art and science of
medicine in order to achieve excellence in the diagnosis, care and treatment of patients. To achieve this goal, the Resident agrees to
do the following:
a.
Under the direction of the Program Director (or designee) and supervision by the Attending physician, assume responsibilities
for the safe, effective and compassionate care of patients, consistent with the resident’s level of education and experience.
b.
Participate fully in the educational and scholarly activities of the residency/fellowship program and, as required, assume
responsibility for teaching and supervising other residents and medical students.
c.
Develop and participate in a personal program of self-study and professional growth with guidance from the teaching staff.
d.
Participate in institutional programs, committees, councils, and activities involving the medical staff as assigned by the
program director, and adhere to the established policies, procedures and practices (to include standards of behavior) of the
sponsoring institution and its affiliated institutions.
e.
Participate in the evaluation of the program and its faculty.
f.
Develop an understanding of ethical, socioeconomic, and medical legal issues that affect the practice of medicine.
g.
Participate in educational experiences required to achieve competence in patient care, medical knowledge, practice-based
learning improvement, interpersonal and communication skills, professionalism, and systems-based practice.
h.
Keep charts, records, and reports up-to-date and signed at all times.
i.
Report accurate and honest duty hours information (III.A.6.b)
i.
Adhere to ACGME institutional and program requirements.
3. Sponsoring Institution And Program Responsibilities
a.
The Sponsoring Institution and its Programs agree to provide learning and working environment in which residents/fellows
have the opportunity to communicate and exchange information, raise concerns, and provide feedback to the Sponsoring
Institution and its respective programs without intimidation and retaliation and in a confidential manner. (II.F.1)
b.
In addition, security services and personal safety measures will be provided at all participating sites, including parking facilities,
sleep quarters, and hospital and institutional grounds. (II.F.3.c)
c.
Must support and facilitate safe and appropriate patient care and effectively collaborate with the clinical quality and patient
safety programs within the Sponsoring Institution and its major participating sites. (I.A.5)
d.
Each program will provide access to information related to eligibility for specialty examinations.
4. Faculty Responsibilities And Supervision
Faculty are responsible for and personally involved in care provided to individual patients. Faculty direct the care of the patient and
provide the appropriate level of supervision based on the nature of the patient’s condition, the likelihood of major changes in the
management plan, the complexity of care, and the experience and judgment of the resident being supervised (see Supervision of
Resident Physician Policy).
5. Duration Of Appointment
The term of this Agreement is for one (1) year beginning July 1, 2012 and ending June 30, 2012.
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6. Financial Support
The Resident shall receive as compensation for the term of this Agreement an amount equal to $Compensation.
7. Conditions For Promotion/Reappointment Of Residents
Residents are promoted/reappointed on the basis of acceptable periodic competency-based evaluations, which may be
supplemented by written or oral clinical and behavioral competency examinations or other evaluation methods; by recommendation
of their department’s Promotion Committee; and by final approval by the Graduate Medical Education Committee (see Promotion/
Reappointment policy).
8. Grievance, Due Process and Appeals
Any Resident who disputes any action of any party shall have the right to appeal said action through the Graduate Medical Education
Committee’s due process policies, as from time to time amended. Violations of the Resident agreement may also be appealed in the
same manner. Each Residency Program office will receive a copy of said policies at the time training begins and also at the time any
changes or amendments are made. The Residents’ Grievance Procedures and Due Process policy will be used for such disputes.
9. Professional Liability Insurance
Palmetto Health has purchased “claims made” professional liability protection from Continental Casualty Insurance Company to
protect all employees including Residents. This protection was purchased through Palmetto Healthcare Liability Insurance Program
(PHLIP) that is a captive insurance program. The limit of professional liability afforded is $1,200,000 per claim that involves an
employed Resident. This coverage is subject to an aggregate limit of $18,000,000. All aggregate liability limits are shared among
the participating members of PHLIP. There are multiple hospital and hospital system members of PHLIP. (coverages are subject to
periodic change by the PHLIP Board of Directors.) Palmetto Health has also purchased high excess professional liability protection
through PHLIP. The high excess limit is $20,000,000 per claim, except where it is found that the acts of the insured individual were
willful, reckless, or grossly negligent, in which case the high excess per claim limit is reduced to $3,000,000. The high excess policy
has a $30,000,000 annual aggregate limit which is also shared by all members of PHLIP. (Coverage’s are subject to periodic change
as determined by PHLIP Board of Directors).
It is the responsibility of Palmetto Health and not individual Residents to purchase the extended reporting period (ERP) endorsement
or “tail” coverage. Employed Residents are scheduled on the Palmetto Health provider list. This provider list reflects the effective date
and, as applicable, the termination or graduation date of each provider. Professional liability protection is afforded to each Resident
for claims that occur within the effective date of coverage and until the graduation or termination effective date. Professional liability
insurance protection is provided to each Resident within the scope of the Resident’s educational program duties and does not extend
to any activities outside the scope of the educational program.
This professional liability insurance will only provide coverage for the Resident in the performance of duties and obligations of
this Agreement. IT IS THE SOLE RESPONSIBILITY OF THE RESIDENT TO OBTAIN AND PROVIDE FOR PROFESSIONAL AND
GENERAL LIABILITY INSURANCE COVERAGE FOR ALL EMPLOYMENT OR PROFESSIONAL ACTIVITIES (i.e., “moonlighting”)
ENGAGED IN BY THE RESIDENT WHICH ARE NOT AN OFFICIAL PART OF THE RESIDENT’S TRAINING PROGRAM.
10. Benefits
Palmetto Health will provide the Resident the following benefits:
a.
Health Insurance: Coverage for the Resident and members of his/her immediate family, (i.e., spouse and children), is available
and is effective on the first day of the resident’s term of agreement. There is no premium cost to Residents for individual
coverage; family coverage is available, but requires premium payment by the Resident. Plans also include a prescription drug
benefit. Charges for services not covered under the basic plan (or for Resident failure to complete the health screening or
other enrollment requirements by designated dates) are the responsibility of the Resident.
b.
Dental Insurance: The Resident is eligible to participate in Palmetto Health’s low option dental plan provided at no charge for
the Resident’s individual coverage. Coverage is available for members of the Resident’s immediate family, (i.e., spouse and
children), but requires premium payment by the Resident. The Resident may elect to participate in the Hospital’s high option
dental plan with the cost of the premium difference paid by the Resident.
c.
Disability Insurance: The Resident is eligible to participate in Palmetto Health’s Long Term Disability insurance plan at no
premium cost to the Resident. LTD eligibility begins 91 days after start date.
d.
Life Insurance: The Resident is eligible to participate in Palmetto Health’s life insurance plan, with one time salary life insurance
coverage provided at no cost to the Resident. One or two times salary in additional life insurance may be purchased by the
Resident. Life insurance eligibility begins 91 days after start date.
e.
Vacation and Holiday Leave : The Resident may take up to 20 days (23 days for PGY 3 and above) off for vacation and holiday
leave. The Resident will continue to receive his/her salary as set forth above during leave. Unused leave will not be paid as
a terminal benefit. Vacation and holiday leave must be scheduled and approved in advance by the respective Director of
Education, Program Director, or his/her designee. Five of these days will be scheduled by the program near calendar year end.
(See Vacation and Holiday Leave Policy)
f.
Sick Leave: Leave (to include sick, maternity, or family medical leave) may be taken according to written GMEC and
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g.
h.
i.
j.
k.
l.
Department policies. (see Sick/Medical Leave & LTD policy)
Maternity Leave: A female Resident is entitled to be absent from the training program on maternity leave for the time period
determined to be necessary and appropriate by her physician. Such leave granted may require additional training time to meet
program requirements. (see Maternity Leave policy, Sick/Medical Leave and LTD policy, and Leaves of Absence policy)
Family Medical Leave Act: The Resident is eligible for applicable leave under the Family and Medical Leave Act (FMLA), once
the eligibility requirements are met: (1) 12 months of service with Palmetto Health and (2) 1250 productive hours worked in
the preceding 12 months. The Resident can take FMLA for his/her own serious health condition, care for a spouse, child, or
parent that has a serious health condition, caring for a newborn, adopted or formally placed foster child. Such leave granted
may require additional training time to meet program requirements. (see FMLA policy)
Other Leaves of Absence: Leave for military, disability (physical or mental), professional, personal, parental, and other approved
purposes may be granted by the Director of Education/Program Director. Such leave granted may require additional training
time to meet program requirements. (see Leaves of Absence policies)
Sleep Quarters: Palmetto Health will provide suitable sleep quarters.
Uniforms: Four (4) uniforms (lab coats) are issued to Residents during their first (1st) contract year. Hospital laundering of
uniforms (lab coats) issued to a Resident will be performed at no cost to the Resident.
Meals: Meal allowances will be provided to a Resident while on duty at Palmetto Health Richland and Palmetto Health Baptist
as specified in the policy. (See Resident Meals While on Duty policy)
11. Duty Hours
Resident duty hours and on call schedules will conform to the Accreditation Council for Graduate Medical Education (ACGME)
requirements. All Residents are expected to be rested and alert during duty hours. (see Duty Hours policy)
12. Moonlighting And Other Professional Activities
Graduate medical education is a full-time educational experience. Accordingly, the Resident shall neither accept nor engage
in employment or professional activities (moonlighting) outside of the training program without the prior written approval of the
appropriate Departmental Program Director and the DIO or DIO designee. If prior approval to moonlight is obtained, it is the sole
responsibility of the resident to obtain and provide professional liability insurance (malpractice) coverage for all employment activities
which are not an official part of the resident’s training program. However, adverse effects may lead to withdrawal of permission to
moonlighting. When Residents and Fellows participate in moonlighting, the moonlighting hours will be counted toward the 80 hour
work week limit (see Moonlighting and Other Professional Activities policy).
13. Mental Health Services
The Sponsoring Institution facilitates residents’/fellows’ access to confidential counseling, and medical, and mental health services
through the Employee assistance program (E-Care) (see Impairment and Working Environment policy).
14. Physician Impairment And Substance Abuse
Palmetto Health provides education on physician impairment (including substance abuse) to Residents. Appropriate confidential
counseling services are provided in a non-punitive fashion, when necessary (see Impairment policy).
15. Harassment
Palmetto Health provides a work environment free from sexual and other forms of harassment and will discipline any Resident guilty
of committing such conduct, (see Harassment policy)
16. Accommodations For Disabilities
Palmetto Health complies with all state and federal laws concerning qualified disabilities and does not discriminate on the basis of
disability. A resident with special needs/disabilities may request reasonable accommodation(s) that will enable the resident to perform
the essential functions of his/her assigned duties.
17. Drug-Free Workplace
The illegal manufacture, illegal distribution, illegal dispensation, illegal possession, or illegal use of narcotics, drugs, or other controlled
substances is strictly prohibited by Palmetto Health (see Substance Abuse policy).
18. OSHA And CDC Recommendations
The Resident is required to comply with Occupational Safety and Health Act (OSHA) and Center for Disease Control (CDC) standards,
which assumes that every direct contact with patient’s blood and other body substances is infectious and requires the use of
protective equipment to prevent parenteral, mucous membrane and non-contact skin exposures to the healthcare provider. Palmetto
Health agrees to provide, and make readily available, personal protective equipment to include gloves, face protection (masks and
goggles), and cover gowns.
19. Termination
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20.
It is the intent of the Resident and Palmetto Health that this Agreement shall be for a period of one (1) year, provided, however,
the Resident has the option to terminate this Agreement, with or without cause, by giving the appropriate Departmental Program
Director at least thirty (30) days prior written notice of intent to terminate. Palmetto Health has the option to immediately terminate this
Agreement “for cause”. Termination for cause includes, but is not limited to the following:
1.1. Incapacitating illness, which in the judgment of the resident’s Program Director precludes the resident from participation in the
graduate medical education program and patient care activities.
1.2 Failure by the resident to abide by policies of Palmetto Health’s teaching hospitals and participating sites, GMEC policies,
departmental policies, and resident-related provisions of the Medical and Dental Staff Bylaws/Rules and Regulations of the
teaching hospitals.
1.3 Failure by the resident to demonstrate, meet, or maintain satisfactory levels of academic, professional, and/or clinical
performance required by the residency/fellowship programs as determined by evaluations.
1.4 Failure by the Resident to comply with licensure, registration, or certification requirements and/or failure by the Resident to
maintain authorization for employment in the United States.
1.5 Actions which directly violate any of the terms of the resident agreement of appointment.
1.6 Willful or inexcusable breaches of Palmetto Health rules or regulations (see Disciplinary Action policy).
1.7 Unprofessional conduct or behavior by the House Staff Officer which in the opinion of the appropriate Departmental Director
of Education and Palmetto Health, interferes with the performance of the activities provided for under this Agreement and/
or which are determined by the appropriate Departmental Director of Education and the Hospital to be unsatisfactory for
members of Palmetto Health’s House Staff.
Governing Law
This Agreement shall be governed by the laws of the State of South Carolina.
IN WITNESS WHEREOF, THIS AGREEMENT is made effective this day of Richland, State of South Carolina.
in the County of
Katherine G. Stephens, PhD, MBA, FACHE VP for Medical Education & Research and DIO
Chief Executive Officer & SIE
Name of program director Title
Name of resident/fellow
Resident/Fellow
Name of program director Title
Name of resident/fellow
Resident
Revised February 12, 2013
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Compensation And Benefits
Residents are provided compensation and benefits as approved by the GMEC and Palmetto Health.
PROCEDURES:
Compensation
As of July 1, 2012 residents are provided the following compensation for their respective levels of
training. Compensation is based on level of curriculum, not on individual years in residency training.
PGY
1
2
3
4
5
6
Vacation and Holiday Leave*
Total maximum per year of 20 days for PGY 1 & 2 (23 days for PGY 3 & above).
Sick Leave*
12 days per year as salary continuance, as per appropriate policies
Other Leave*
Meals*
Residents are eligible for maternity, paternity, educational, military, physical disability, family medical,
and other leaves available to PH employees.
Meal allowance while on-duty. Meals provided while on-call in-house.
Parking *
Free parking is provided in ASSIGNED areas.
License Fees
Limited ($150) or Permanent ($580) License Application fee paid (resident pays FCVS credentialing
fee); State ($125) and Federal ($551) DEA Narcotics License Fees paid.
Up to $705 paid toward Step III/COMLEX 3 fee for PGY 1 residents (one time only).
USMLE/COMLEX fee*
Travel for Scholarly Presentations
Educational Materials
Up to $500.00 per presentation through the GME office; may be supplemented by department
budgets.
Allowance for journals, books, and/or software.
Information Access
Electronic access provided to patient electronic medical records and to holdings of academic
libraries, journal subscriptions, and other sources (e.g., MD Consult, Up to Date, Procedures
Consult)
Lab Coats and Laundering
4 lab coats and in-house laundering
Health Insurance
Individual coverage provided. Resident may choose family coverage by paying premium difference.
Plans include prescription drug benefit.
Dental Insurance
Individual low option coverage provided. Family coverage available by paying premium difference.
Resident may choose high option by paying premium difference.
Disability Insurance
Individual long term disability plans provided. The Guardian portable LTD plan option offered to
graduating residents.
Individual coverage equivalent to base salary provided. Additional coverage available for self or
family.
Life Insurance
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Annual Salary
$49,857.60
$52,064.06
$54,312.96
$57,198.34
$59,998.85
$62,990.30
Vision Insurance
Vision care available at employee rate.
Dental Center
Dental care at Palmetto Health available at employee rate.
Medical Liability Insurance
Provided at no premium cost to resident (for education-related patient care activities).
GME Policies
Vaccines and related tests
Social Activities
Hepatitis B vaccine, Rubella/Rubeola, Tetanus Diphtheria toxoid, Tuberculin skin test, Influenza
vaccine, needle stick exposure protocol, HIV confidential testing provided at no cost to resident.
Residency program required courses (e.g., ACLS, ATLS, Courses BCLS, and PALS) provided at no
cost to resident.
Functions organized by Palmetto Health’s Resident’s Auxiliary.
Retirement Plan
403(b)/401(k) plans available to residents. Matching contributions by Palmetto Health after PGY 1.
Credit Union
Payroll deduction savings plans, loans, health savings accounts, flexible spending accounts, and
other services available.
Discounts
Discounts on retail sales, theatres, zoos, theme parks, fitness centers, many other services available
to residents through Palmetto Health Employee Discount Advantage Plan.
Wellness and Fitness Discounts
Discount on membership at the USC Strom Thurmond Wellness Center; no charge to use the USC
Blatt PE Center- small fee for guest. Discounts on YMCA memberships. Counseling, assessment,
referral and education are provided by E-Care of Palmetto Health; first five (5) appointments each
calendar year are provided at no cost to resident and members of their family.
Certification Courses
* See separate policy.
Palmetto Health employee benefits are subject to change.
September 7, 1993
February 12, 2013
Signature on File
Signature On File
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GME Policies
Leaves Of Absence
A resident/fellow is considered to be on Leave of Absence (LOA) when absent from work more than three working
days. Palmetto Health GME reserves the right to place a resident on a Leave of Absence.
TYPES: THE TYPES OF LEAVE OF ABSENCE (LOA) INCLUDE:
•
•
•
•
•
•
•
•
•
Administrative – Mandatory leave that Palmetto Health GME places resident on
Educational – Leave for personal educational development that is not required by the residency program
Maternity/Paternity – Leave related to birth or adoption of a child
Medical/Sick – Leave required due to resident’s own disability or illness
Personal/Vacation – Leave for resident’s personal reasons
Military – Granted according to applicable local, state and federal statutes
Workers’ Compensation – Leave pertaining to work-related illness or injury arising out of, or in the course of, employment and
administered by state law
FMLA – The Family and Medical Leave Act of 1993, as amended, requires covered employers such as Palmetto Health to provide
unpaid, job-protected leave to eligible employees for certain family medical and military-related reasons.
∙
Employees are eligible for leave under the Family and Medical Leave Act of 1993 (FMLA) if they have worked for Palmetto Health
for at least one year, and for 1,250 hours in the twelve (12) months preceding the first day of leave. (See separate policy on
Family Medical Leave Act)
Jury Duty/Court Witness – Leave required to serve on Jury or as a witness, when no exception is accepted by Court (See separate
policy on Jury Duty)
ELIGIBILITY:
•
Eligibility varies based on type of Leave. See specific Leave policy and consult with Palmetto Health’s benefits office, Total Rewards,
at 1-866-916-5074 or [email protected]).
EFFECT OF LEAVE ON RESIDENCY COMPLETION AND BOARD ELIGIBILITY:
•
At the discretion of the resident’s Program Director and consistent with ACGME and RRC/CODA requirements, if time away from the
resident’s educational program exceeds the maximum allowed by program requirements, the resident’s training may be extended as
additional months or fractions thereof to meet these requirements. Additional training may also be required by specialty/sub-specialty
boards for eligibility for certifying board exams (board certification requirements are provided by each program director).
NOTICE:
•
•
•
Resident notifies FMLA Source- to communicate eligibility, leave process, and designation of medical leave under FMLA (Contact
FMLA Source, Phone Number: 1-866-441-3652)
A Change of Status is submitted to Human Resources by the GME office. The resident’s program coordinator is responsible for
apprising the GME office of the LOA start date and anticipated return date.
Program Director or Human Resources may require a health care provider’s statement for an absence due to illness/injury of any
length
APPROVAL:
•
Leaves of Absence are approved at the discretion of the Program Director and DIO, with the exception of leaves mandated by federal
or state law or regulation
BENEFITS STATUS DURING LEAVE OF ABSENCE:
•
•
•
•
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Health, Dental and Vision Insurance - Health, dental, and vision will be maintained during paid leave at the same deduction rate as if
the resident were actively working. Should resident move to leave without pay status, the resident must make arrangements with the
Total Rewards Department to pay the appropriate premiums on a bi-weekly basis. Premiums that are not paid during the leave will
cause health, dental and vision insurance to be forfeited.
Flexible Spending Accounts and Health Savings Accounts: When a resident is in a Leave without Pay Status, Flexible Spending and
Health Savings Accounts contributions will cease. Upon return to work, the FSA/HSA contributions will resume.
Term Life Insurance – term life insurance will remain in effect during the portion of employment that the resident is benefit-eligible.
Upon approval, term life insurance may continue when the resident is on a medical leave of absence. The insurance could continue
until age 65 or when the resident is no longer disabled.
Long-Term Disability Insurance– Palmetto Health provides LTD for benefit eligible residents
GME Policies
RETURN TO WORK:
•
•
•
A resident returning from Leave of Absence must report to his/her Program Director or designee prior to returning to work. If a
Medical Leave of Absence involves hospitalization, contagious disease or surgery, the resident must provide a healthcare provider’s
statement of clearance to the Program Director two days prior to returning to work.
Program Coordinators must contact the GME Office to submit a Change of Status form to Human Resources upon resident’s
notification of return to work.
Failure to return to work after expiration of the Leave of Absence will be considered voluntary resignation.
February 2, 1999
February 12, 2013
Signature on File
Signature On File
79
GME Policies
Leave: Salary Continuance
Salary continuance is the term for Palmetto Health’s process of compensating certain employee groups while not at work, due to specific
reasons and subject to the approval of the director and in conformance with rules, policies, and plans which govern them. These nonwork categories include vacation, sick leave, holidays, maternity leave, paternity leave, short-term disability, educational leave, jury duty,
personal leave, administrative leave, military leave, and other applicable leave*. For residents, salary continuance includes the following:
»» Vacation and Holiday: Total Maximum of twenty (20) working days (defined as Monday-Friday) per year are provided for PGY I and 2
and twenty-three (23) working days for PGY 3 and above. All vacation and holiday time must be scheduled and approved in advance
by each department. Five (5) of these days will be scheduled by the department for a week, near the end of the calendar year.
Unused leave will not be paid at year’s end or as a terminal benefit.
»» Sick leave: 12 sick days are provided per year as salary continuance for short term and/or intermittent illnesses. (Note that residents
must contact their immediate supervisor [attending or senior resident], and their Program Director, and Program Coordinator when an
illness requires absence from duty.)
NOTE:
Time off for Maternity or Paternity Leave will be first satisfied by the use of sick and/or vacation time allowance. See specific policy on
Maternity and Paternity Leave for more detail.
All resident non-work time is recorded by Program Coordinators and monitored by Program Directors to ensure that program credit
requirements are met. Program Coordinators also provide non-work time reports to the Administrative Director of Resident and Student
Services for additional monitoring.
* See Palmetto Health FMLA, GME Leave: Salary Continuance, Sick Leave and Leaves of Absence policy and specific policies for details
and usage requirements.
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GME Policies
Leave: Personal Educational Leave
A resident/fellow is considered to be on Educational Leave of Absence (LOA) when absent from work for personal
educational development that is not related to the residency program curriculum.
PROCEDURES:
1. A resident shall request approval with as much advance notice as possible. Sixty days notice is preferred.
2. The Program Director will consult with the DIO and Palmetto Health Human Resources as appropriate when considering the request.
3. The Program Director must notify the Resident/Fellow and the Program Coordinator of the final decision.
4. Educational leave is not covered through salary continuance. It may require extension of training.
October 12, 2010
February 12, 2013
Signature on File
Signature On File
81
GME Policies
Family and Medical Leave
The Family and Medical Leave Act of 1993, as amended, requires covered employers such as Palmetto Health to
provide unpaid, job-protected leave to eligible employees for certain family medical and military-related reasons.
GUIDELINES:
1. Eligibility:
Employees are eligible for leave under the Family and Medical Leave Act of 1993 (FMLA) if they have worked for Palmetto Health for
at least one year and for 1,250 hours in the twelve (12) months preceding the first day of leave.
2. Entitlement to Leave:
2.1 Basic Leave
Eligible employees are entitled up to 12 weeks of unpaid, job-protected leave for the following reasons:
2.1.1 Incapacity due to pregnancy, prenatal medical care or child birth;
2.1.2 To care for the employee’s child after birth or placement for adoption or foster care;
2.1.3 To care for the employee’s spouse, son or daughter, or parent who has a serious health condition; or
2.1.4 A serious health condition that prevents the employee from performing his or her job.
2.1.5 For purposes of this policy, a serious health condition is defined as an illness, injury, impairment, or physical or mental
condition that involves either an overnight stay in a medical care facility or a continuing treatment by a health care
provider for a condition that either prevents the employee from performing the functions of the employee’s job or
prevents the qualified family member from participating in school or other daily activities.
2.1.6 Subject to certain conditions, the continuing treatment requirement can be met by a period of incapacity of more than
three consecutive calendar days combined with at least two visits to a health care provider, one visit and a regimen of
continuing treatment, incapacity due to pregnancy, or incapacity due to a chronic condition. Other conditions may also
meet the definition of continuing treatment.
2.2 Military Family Leave—Qualifying Exigency
Eligible employees with a spouse, son, daughter or parent on active duty or call to active duty status in the National Guard or
Reserves in support of a contingency operation can use their 12-week entitlement to address certain qualifying exigencies.
Qualifying exigencies include:
2.2.1 Short-notice deployment
2.2.2 Military events and related activities
2.2.3 Childcare and school activities
2.2.4 Financial and legal arrangements
2.2.5 Counseling
2.2.6 Rest and recuperation
2.2.7 Post-deployment activities
2.2.8 Additional activities
2.3 Military Caregiver Leave
FMLA also includes a special leave entitlement that permits eligible employees to take up to 26 weeks of leave to care for
a covered servicemember during a single 12-month period. A covered servicemember is a current member of the Armed
Forces (including members of the National Guard or Reserves) who incurs a serious injury or illness in the line of duty on active
duty that might render the servicemember medically unable to perform his/her duties. Such an injury or illness must be one
for which the servicemember is undergoing medical treatment, recuperation or therapy; or is in outpatient status; or is on the
temporary disability retired list.
3. Notice:
3.1 Requests for Family and Medical Leave (FML) must be submitted thirty (30) days in advance when the leave is “foreseeable.”
When on intermittent leave, employees are expected to make reasonable efforts to schedule medical treatment so as not to
unduly disrupt the business of the department.
To apply for FMLA, an employee must contact FMLASource at 1-866-441-3652.
3.2 Palmetto Health requires a Certification to support a request for a leave due to a serious health condition and can request
periodic recertification.
3.3 Palmetto Health requires a Certification for Serious Injury or Illness of Covered Servicemember for Military Family Leave or
equivalent support for leave to care for a covered servicemember with a serious injury or illness.
3.4 Palmetto Health may require proof that an employee is the “next of kin” and eligible for leave to care for a covered
servicemember (Military Caregiver Leave).
3.5 For leave due to a Qualifying Exigency, the following is required:
3.5.1 A copy of the covered military member’s active duty orders or other documentation issued by the military which
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GME Policies
3.6
3.7
indicates the covered military member is on active duty or call-to-active-duty status in support of a contingency
operation and the dates of the covered military member’s active duty service.
3.5.2 A Certification of Qualifying Exigency for Military Family Leave for leave due to a qualifying exigency.
Employees are expected to comply with all departmental call-in or reporting requirements and with Palmetto Health policies
concerning reporting requirements for a leave of absence, absences, or tardiness.
When an employee calls in for an absence, he/she must provide sufficient information for Palmetto Health and FMLASource to
determine if the leave/absence qualifies for FMLA protection. Employees must also inform Palmetto Health and FMLASource
if the requested leave is for a reason for which FMLA leave was previously taken or certified.
4
Approval:
4.1 Employees will be informed of eligibility and the designation of leave as FMLA.
4.2 If an employee is denied coverage, at least one reason will be provided.
5
Duration:
5.1 Eligible employees are permitted up to twelve (12) weeks of FML per year, based on a “rolling year” (a 12-month period
measured backward from the date an employee uses FML).
5.2 Employees can take FML on an intermittent or reduced-schedule basis when necessary due to the employee’s own serious
health condition or that of the employee’s spouse, child or parent. Intermittent leave can be taken for bonding with a newborn
child, or a child accepted for adoption or foster care, only with the consent of Palmetto Health (through the supervisor, in
coordination with Human Resources). Intermittent leave can be taken for a Qualifying Exigency.
5.3 Failure to return to work within six (6) months will result in separation of employment (see Leave of Absence Policy #140).
5.4 Eligible employees are entitled to 26 workweeks of leave to care for a covered servicemember with a serious injury or illness
during a single 12-month period beginning on the first day the employee takes FML and ending twelve months after that date.
6. Benefits Status During Leave of Absence:
6.1 Health, dental and vision insurance will be maintained during FML leave at the same rate as if the employee were actively
working.
6.2 Premiums that are not paid during FML leave can cause the benefit to be forfeited; however, should an employee return from
FML leave before exhausting the twelve-week FML entitlement period (twenty-six weeks if caring for injured servicemember),
insurance can be reinstated.
6.3 An employee can opt to suspend insurance while on FML. If so, the employee must request reinstatement of insurance
before exhausting the twelve-week (twenty-six week if caring for injured servicemember) FML entitlement period in order to
avoid a waiting period. Should the employee return after exhausting FML, the benefit eligibility rules for a new employee will
apply.
6.4 Other issues such as term life insurance, long-term disability insurance, and compensation are addressed in Palmetto Health’s
Leave of Absence Policy.
6.5
The use of FML will not result in the loss of any employment benefit that accrued prior to the start of an employee’s leave.
7
Return to Work:
7.1 Palmetto Health will return an employee from FML to the same or equivalent position held when the leave began or to an
equivalent position with equivalent benefits, pay and other terms and conditions of employment. An employee has no
greater right to reinstatement or to other benefits and conditions of employment than if the employee had been continuously
employed during the FML period.
7.2 The Family and Medical Leave Act of 1993 provides that a “key employee” is a salaried FML-eligible employee who is among
the highest paid 10% of all the employees employed by the employer within 75 miles of the employer’s work site. If the
employee is a “key employee,” that employee cannot be restored to his former position after FML if such denial is necessary to
prevent substantial and grievous economic injury to the operations of the employer.
8
Unlawful Acts:
FML makes it unlawful for Palmetto Health to:
Interfere with, restrain, or deny the exercise of any Right provided under FML;
Discharge or discriminate against any person for opposing any practice made unlawful by FML or for involvement in any
proceeding under or related to FML.
9. Enforcement
An employee can file a complaint with the U.S. Department of Labor or may bring a private lawsuit against an employer.
FML does not affect any Federal or State law prohibiting discrimination or supersede any State or local law or specific type agreement
which provides greater family or medical leave rights.
Signature on File
Amy C. Barry
System Vice President, Human Resources
Signature On File
President and CEO, Palmetto Health
83
GME Policies
Jury Duty And Court Witness
Jury Duty and Court Witness services performed by residents must be reported to their Program Directors prior to
serving.
PROCEDURES:
Jury Duty:
1. Residents who are requested to serve as jurors will be granted time off for this purpose. The resident will present the summons for
duty to his/her Program Director prior to absence from work.
2. The resident must present to his/her Program Director court verification indicating the time served.
3. Residents who are released early from jury duty are expected to immediately contact their Program Director or Attending regarding
their work status and assignments.
4. Residents may retain any stipends received from the court for serving on jury duty.
Court Witness:
1. Palmetto Health will pay salary continuance for time off for residents to serve as a court witness only when the resident is required to
attend at Palmetto Health’s request.
Travel expenses will be reimbursed to residents who serve as a court witness for Palmetto Health.
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October 12, 2010
February 12, 2013
Signature on File
Signature On File
GME Policies
Maternity Leave
A female resident is entitled to maternity leave paid through salary continuance.
PROCEDURES:
1. The length of maternity leave time will be determined by the resident’s physician and her Program Director. In the instance of the birth
mother, time away will be counted first against the sick leave allowance, and then vacation and holiday. After all sick, vacation and
holiday time has been exhausted; the continued approval will be based on the Program Director and DIO. This time would be treated
as leave without pay, unless medical documentation supports the need for extended leave. In such cases, additional medically
documented time will be paid through salary continuance.
2. The resident may be eligible for Family and Medical Leave (FMLA). The resident must contact FMLASource at 1-866-441-3652
regarding eligibility, the leave process and designation of leave.
3. At the discretion of the resident’s Program Director and consistent with ACGME and RRC/CODA requirements, if time away from the
See Palmetto Health FMLA, GME Leave: Salary Continuance , Sick Leave and Leave of Absence policies.
November 2, 1993
February 12, 2013
Signature on File
Signature On File
85
GME Policies
Military Leave Of Absence
Residents are entitled to a leave of absence and reinstatement upon return from leave of absence for military
service (including Reserve and National Guard duty), as provided for by applicable state and federal laws. The
provisions of such laws change from time to time and for that reason no effort is made to set forth the law in this
policy. The employee should submit his/her orders to their Program Director and the program should contact
Human Resources to apply for the leave.
PROCEDURES:
Resident must present military orders as early as possible, but no later than 30 days upon return from military service. Military pay will be
supplemented by Palmetto Health through salary continuance to the extent that the resident will not suffer income loss due to military
service. This applies only to those periods of military duty where the resident is receiving military pay (as opposed to periods of duty where
the resident is serving “for points only”, without pay) and is limited to a time period not to exceed 15 days per annum. The limit will be
extended by 30 days (total of 45 days per annum) if subject to involuntary call-up.
NOTE: Please follow up with Payroll for further guidance.
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October 12, 2010
February 12, 2013
Signature on File
Signature On File
GME Policies
Paternity Leave
Residents are entitled to paternity leave paid through salary continuance.
PROCEDURES:
1. The resident may be eligible under the Family and Medical Leave Act (FMLA) – see policy. The resident must review FMLA policy and
contact FMLASource at 1-866-441-3652 regarding eligibility, the leave process and designation of leave.
2. The length of paternity leave time will be determined by the resident/fellow and the Program Director. At the time that the resident
takes time out from work for family leave, the resident will be paid (5) sick days of salary continuance and the time will be tracked by
FMLASource.
In the instance that the father requests, if approved, any additional leave time would count first against the sick leave allowance, and
then vacation and holiday. After all sick, vacation and holiday time has been exhausted; the continued approval will be based on the
Program Director and DIO. This time would be treated as leave without pay, unless medical documentation supports the need for
extended leave. In such cases, additional medically documented time will be paid through salary continuance. Total Rewards (1-866916-5074 or [email protected]) can provide additional information.
3. At the discretion of the resident’s Program Director and consistent with ACGME and RRC/CODA requirements, if time away from the
February 8, 2005
February 12, 2013
Signature on File
Signature On File
87
GME Policies
Sick/Medical Leave & Long-Term Disability
Residents are provided leave for their own medical disability due to non-occupational illness or injury through
salary continuance.
SICK/MEDICAL LEAVE:
1. All residents must contact their immediate supervisor (senior resident or attending physician), their Program Director, and Program
Coordinator when an illness requires absence from duty.
2. Twelve (12) sick days are provided per year for medical leave and paid as salary continuance. If additional time is necessary and
approved, this time may be extended leave and will be paid through salary continuance with approval of the program director and
provision of supporting medical documentation.
3. Residents may also be eligible for Family Medical Leave Act (FMLA). The resident must contact FMLASource at 1-866-441-3652
regarding eligibility, the leave process and designation of leave.
4. Any Palmetto Health employee out on Medical Leave of Absence (five or more consecutive scheduled work days missed due to a
personal medical condition) must be cleared by Employee Health prior to returning to work. You are encouraged to be proactive in
calling Employee Health to schedule your return-to-work visit. Employees only need to bring a provider note to their Employee Health
visit clearing them to return to work if they have been seen by a provider during the Medical Leave of Absence. If Employee Health
cannot safely clear an employee without a provider’s note, then the employee will be required to obtain one.
5. At the discretion of the resident’s Program Director and consistent with ACGME & RRC/CODA requirements, if time away from the
LONG-TERM DISABILITY:
1. If a resident remains disabled beyond a period of 6 months, the resident may be eligible for Long Term Disability (LTD). The coverage
amount for approved LTD is 60% of base monthly earnings up to a maximum of $3,000 per month.
2. The current LTD carrier is The Guardian. Total Rewards (1-866-916-5074 or [email protected]) can
provide additional information on maximum duration of LTD benefits.
88
November 2, 1993
February 12, 2013
Signature on File
Signature On File
GME Policies
Leave: Vacation And Holiday Leave
Residents are provided vacation and holiday benefits paid through salary continuance.
PROCEDURES:
1. Total Maximum of twenty (20) working days (defined as Monday-Friday) per year are provided for PGY I and 2 and twenty-three (23)
working days for PGY 3 and above. All vacation and holiday time must be scheduled and approved in advance by each department.
Five of these days will be scheduled by the department for a week, near the end of the calendar year. Unused leave will not be paid at
year end or as a terminal benefit.
November 2, 1993
February 12, 2013
Signature on File
Signature On File
89
GME Policies
Licensure, Registration, Certification Requirements
Human Resources
Policy No. #145
Employees in positions requiring licensure, registration, or certification will have credentials verified with the
primary source at the time of hire and upon expiration of the credentials.
GUIDANCE:
Pre-employment Verification: New employees in positions requiring licensure, registration, or certification must have credentials verified
with the primary source at the time of hire. A copy of the primary source verification will be placed in the employee’s personnel file. No
prospective employee will be allowed to commence employment until the required primary source verification has been obtained and
reviewed by the appropriate authority.
Promotion/Transfer Verification: The Hiring Authority should verify an employee’s credentials with the primary source prior to submitting
a Change of Status (COS) request to affect a transfer or promotion to a position requiring licensure, registration, or certification. The
promotion or transfer should not take place until proper verification is obtained.
Temporary Licensure, Registration, or Certification: Whenever an employee is granted a temporary credential, the department head will
maintain a follow-up file to ensure the regular license, registration, or certificate is obtained prior to expiration of the temporary credential
and that the license, registration or certification is verified with the primary source. An employee who has not had their credentials verified
with the primary source will not be permitted to perform duties requiring licensure, registration, or certification beyond the expiration date
of a temporary permit.
Annual/Periodic Verification: Employees are responsible for ensuring that their licenses, registrations, and certifications are renewed
prior to expiration. Department leaders must verify the employee’s credentials with the primary source by the renewal date specified.
Employees will not be allowed to continue performing duties requiring licensure, registration, or certification until primary source verification
is complete. Department leaders will submit a copy of the primary source verification to Human Resources.
Noncompliance With Licensure, Registration, or Certification Requirements: If Human Resources is unable to verify licensure, registration,
or certification with the primary source, a delay or possible denial of employment for an applicant may occur. Current employees are
required to maintain current licensure, registration, and/or certification if required for current position. Appropriate counseling/corrective
action up to and including discharge, may be taken for noncompliance.
Signature on File
Gwen Hill
Interim Vice President, Human Resources
Signature On File
For more information about this policy, contact Human Resources at (803) 296-5221.
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GME Policies
Meals While On Duty
Palmetto Health provides access to food services 24 hours a day.
PROCEDURES:
1. Meals are available in all Institutional cafeterias during their hours of service.
2. A meal allowance is available in the Palmetto Health hospital cafeterias during their hours of service. Residents receive discounts on
non branded items. The meal benefit is not available at the Starbucks kiosk.
a.
Maximum meal allowances are reviewed at least annually. The per meal allowance as of July 1, 2012 is $4.54.
b.
Residents must go through a checkout line and swipe their Palmetto Health identification badge to access this benefit.
c.
If the cost of the meal exceeds the meal allocation limit, the remaining cost is payroll deducted.
d.
The per meal allowance is only available one time during each meal period; i.e. it can be used only
once between:
6:30 am and 10:00 am
once between:
11:00 am and 3:45 pm
once between:
4:45 pm and 7:00 pm, and
once between:
11:30pm and 2:30 am
3. Food services with healthy options are available in the Resident Lounge when the Palmetto Health cafeterias are closed.
4. Residents on duty at the Dorn VA Hospital receive a daily meal allowance. The allowance is paid as an add-on to the resident’s
paycheck, approximately 1-2 months after the end of the rotation.
All of the above are reviewed annually by the GMEC and Palmetto Health.
January 5, 1993
February 12, 2013
Signature on File
Signature On File
91
GME Policies
Parking Regulations
Palmetto Health Richland’s objective is to provide an efficient and effective parking system to accommodate all
vehicles arriving on the Palmetto Health Richland campus. Palmetto Health Richland assumes no responsibility for
lost, damaged, or stolen property in the parking lots.
If you have any questions or concerns, you may e-mail us at [email protected]
GUIDANCE:
1. All hospital employees and contractors of Palmetto Health requiring a parking space on the Richland campus:
1.1. Must register any vehicle they drive on campus by bringing an actual copy of their vehicle registration to Security Services
located on the 1st floor in 5 Medical Park. This information may be faxed to (803) 434-7341; however, it is up to you to ensure
this information was received by our department. Your contact number and employee ID number must be included for your
vehicle information to be processed.
1.1.1 Any vehicles you drive on campus, including rentals or borrowed vehicles, must be registered, even if the vehicle is not
in your name.
1.1.2 The length of time a vehicle is driven on campus has no bearing on whether or not it should be registered.
1.1.3 In the event you place a different license plate on your vehicle, the vehicle must be re-registered with the new license
plate.
1.1.4 All new vehicles must be registered when they are driven on campus. If a dealer tag or temporary tag is on the vehicle,
the bill of sale must be brought to Security Services for registration. When you receive a license plate for your new
vehicle, you must re-register the vehicle with Security Services by bringing the registration to Security Services.
1.1.4.1 If you used the same license plate as your previous vehicle, you must still register the new vehicle with
Security Services.
1.1.4.2 All vehicles must be front-end parked only to ensure the rear license plate can be identified by Security
Services.
1.1.5 All hospital employees, contractors, vendors, agency staff, and non-employee’s here for work related business (i.e.
meetings, scheduled work, unscheduled work, on call, classes, deliveries, etc) must park in their designated staff area.
1.2. Hospital employees, agency employees, and non-employees may park in the North Garage, Lot 12 or on the gravel at 1801
Sunset Blvd.
1.3. Employees of 1801 Sunset Blvd. may park on the gravel of 1801 Sunset Blvd.
1.4. Employees of 3 Medical Park may park in 3 Medical Park only if they have been issued a 3 Medical Park parking permit. The 3
Medical Park parking permit must be visibly displayed in the dashboard, rearview mirror, or back windshield of the car.
1.5. Employees of 9 Medical Park may park in 9 Medical Park garage behind the solid blue line (only employees/contractors
permanently stationed to work in 9 Medical Park).
1.5.1 Employee’s assigned to park in 9 Medical Park (that do not work in 9 Medical Park) are only permitted to park on the
top level behind the blue line.
1.6. 10 Medical Park is reserved for patients and guests, as well as those containing parking permits for the Columbia Area Mental
Health lot.
1.7. Employees of 14 Medical Park may park in 14 Medical Park garage on levels 2 and above (except top level-reserved) in
spaces against back wall of garage and Row B, spaces facing Sunset Blvd (only employees/contractors permanently
stationed to work in 14 Medical Park).
1.7.1 Employee’s assigned to park in 14 Medical Park (that are not permanently stationed to work in 14Medical Park) are
only permitted to park on the top level.
1.8. Employees who are permanently stationed in the Heart Hospital (6 Medical Park) may park in the Heart Hospital garage if
access has been granted (only employees/contractors permanently stationed to work in Heart Hospital).
1.8.1 Request for Heart Hospital Garage access has to be submitted to PHRaccess&[email protected] via e-mail by a
Heart Hospital Manager or above.
1.8.2 If an employee uses his or her badge to open the garage for anyone, other than themselves, their Heart Hospital
Garage privileges will be revoked and their manager/director will be notified.
1.8.3 If an employee piggybacks or enters the Heart Hospital Garage using someone else’s badge, that vehicle is subject to
a ticket and their manager/director will be notified.
2. Residents
2.1 Must park in the area designated by their specialty type.
2.1.1 Dental- 14 Medical Park Garage Employee Spaces (4B, 5B, 5C or Top Level)
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GME Policies
2.1.2
2.1.3
2.1.4
2.1.5
2.2
2.3
Emergency Medicine- Heart Hospital Staff Garage (Levels P1, P2)
Family Medicine- Heart Hospital Staff Garage (Levels P1, P2)
Internal Medicine- Heart Hospital Staff Garage (Levels P1, P2)
Internal Medicine/Pediatrics- Heart Hospital Staff Garage Levels P1, P2 /14 Medical Park Garage Employee Spaces
(4B, 5B, 5C or Top Level)
2.1.6 Obstetrics & Gynecology- 3 Medical Park Garage Resident Spaces (Level 4)
2.1.7 Orthopaedics- 3MP Garage Resident Spaces (Level 4)
2.1.8 Ophthalmology- 3MP Garage Resident Spaces (Level 4)
2.1.9 Psychiatry- 14 MP Garage Employee Spaces (4B, 5B, 5C or Top Level)
2.1.10Pediatrics- 14 MP Garage Employee Spaces (4B, 5B, 5C or Top Level); for evening/weekend shifts, may park in North
Garage (any area except “22 Years Plus” parking spaces)
2.1.11Surgery- 3 MP Garage Resident Spaces (Level 4)
Residents assigned to 14MP Garage can park on any level Saturday and Sunday only. Residents must resume parking on 4B,
5B, 5C or top level by 7:00 AM Monday morning
Residents who work at our 1801 Sunset Clinic may park in the gravel lot adjacent to the paved 1801 patient parking lot.
3. Physician Assistants and Nurse Practitioners
3.1. May park in the North Garage, Lot 12 or on the gravel at 1801 Sunset Blvd.
4. Physicians
4.1
Must display a Palmetto Health Physician bull’s-eye sticker on their vehicle to avoid any parking violations. These bull’s-eyes
are issued by Medical Staff Affairs (803) 434-7447.
4.2
Reserved general physician spaces are available in 3 Medical Park and the lower level of the North Garage.
5. 22+ Employees
5.1
Must have their 22+ decal/permit visibly displayed on the dashboard, rearview mirror, or in the back windshield at all times.
5.2
They may park in the North Garage (lower levels 1a and 2a) reserved for 22+ employees or other available spaces in lot 12,
North Garage or 1801 sunset gravel lot.
5.3 To apply for a 22+ decal, bring your driver’s license and vehicle registration to Security Services located on the 1st floor in 5
Medical Park, during business hours.
5.4 Only employees who have been here a consecutive 22 years, or more, qualify, as calculated by Human Resources.
6. Students
6.1
May park in “the pit” of 15 Medical Park
6.2
If “the pit” is full, students may then park in the gravel lot at 1801 Sunset.
7. 3rd Year Medical Students
7.1
May park in their reserved area by 2 Medical Park or in “the pit” of 15 Medical Park.
8. Non-Employee’s without an ID Badge (i.e. Sitters, Agency Nurse Techs, etc.)
8.1 May only park in Lot 12 or 1801 Sunset Gravel lot and are not required to register their vehicle.
9. Contractors
9.1 May only park on the top part of Lot 13 or at 1801 Sunset Gravel.
10. Off-Site Employees
10.1 Off-site employees must park in Lot 12 or 1801 Sunset Gravel lot when here for work related business.
10.1.1Off-site employees who are coming to campus for meetings and bid shifting on a regular basis should register their
vehicle with Security Services
10.1.2Once an off-site employee registers their vehicle, they are extended the option of parking in the North Garage.
11. Handicap Parking/Sticker
11.1 Handicap Stickers/Tags do not give employee’s or contract employee’s authorization to park anywhere on campus. If you
chose to use your handicap sticker/tag you must be parked in a handicap space. Otherwise, the employee must be parked in
their designated parking area.
11.2 If a vehicle is found in a handicap space without the proper handicap placard, a picture will be taken and sent to the Columbia
Police Department.
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GME Policies
12. Violations
12.1 Parked in Handicap space/area without proper placard displayed
12.2 Parked in No Parking space/area (i.e. yellow painted curbs, fire lane, wooded area, etc.)
12.3 Parked in Reserved/Designated spaces/area (i.e. Patient/Guest parking, Compact car, etc.)
12.4 Improperly Parked (i.e. parked in Two (2) Spaces, back end parked in space (Front end parking only is permitted on campus),
over the line, etc).
12.5 Blocking/obstructing driveway/access
12.6 Parked in Wrong garage/lot
12.7 Non-registration of vehicle
12.8 Parking permit/sticker not displayed
13. Penalties and Fines for Employees
13.1 Each ticket will result in a $25 fine.
13.2 Each vehicle immobilizer (a.k.a “The Boot”) will result in a $50 fine. (Vehicle Immobilizer’s are issued at our discretion; however,
they are generally applied for non-registered vehicles.)
13.3 Notification of violations will be sent to Directors.
13.4 Violators will receive an e-mail with a copy of the parking regulations.
13.5 If an employee uses his or her badge to open a garage for anyone, other than themselves, their proxy garage privileges may
be revoked (i.e. Heart Hospital Employee Garage).
14. Payment of Penalties and Fines for Employees
14.1 Seven days following the violation all fines will automatically be payroll deducted.
15. Penalties and Fines for Non-Employees/Contract Employees/Students
15.1 Violations will result in a Vehicle Immobilizer or towing at owner’s expense.
16. Payment of Penalties and Fines for Non-Employees/Contract Employees/Students
16.1 A $50 fine for all Vehicle Immobilizer removals may be enforced and must be paid before the Immobilizer will be removed.
17. Abandonment
17.1 Any vehicle left abandoned for five or more days will be towed at the owner’s expense.
17.2 Owner may contact Security Services for information regarding location of vehicle.
18. Parking Violation Appeal
18.1 All violations must be appealed within five business days from the date of issue. Appeals that are submitted on the sixth day
business day, or later, are denied.
18.2 If you would like to dispute a parking violation, it must be submitted via e-mail to
[email protected] .
18.3. If you do not have access to e-mail, you may submit your appeal in writing. You will need to
include your contact information, a copy of your violation, and your reason for disputing.
18.4 There must be substantial and valid evidence that the parking violation was not committed, or
that it occurred due to circumstances beyond control of the violator. Valid documentation of the
evidence should be provided when the appeal is submitted.
18.5 The following reasons are not valid as a basis for appeal.
»» Lack of knowledge of the regulations, for example, new to campus or have not reviewed regulations
»» Other vehicles were parked improperly
»» Only parked illegally for a short period of time
»» Stated failure of parking officer to ticket previously for similar offenses
»» Late to work, meeting, etc.
»» Inability to pay the amount of the fine
»» No other place to park.
18.6 All decisions rendered by Security Services are final and re-appeals are not available.
18.7 Security Services has the authority to dispose of a case by:
»» Upholding the charge(s) completely
»» Upholding the charge(s) but reducing the fine no less than fifty percent to whatever amount in light of extenuating
circumstances
»» Dismissing the charge completely.
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GME Policies
USMLE Step 3 Requirements
All residents (other than Dental) must pass the USMLE Step 3 exam (or the equivalent, COMLEX Step 3 exam)
before the end of PGY-2.
PROCEDURES:
1. Taking the USMLE Step 3 exam requires advance registration of at least 2 months prior to the anticipated exam date. Residents are
advised to consult their residency program coordinator and/or the administrative director of resident and student services for details
early in their residency.
2. Palmetto Health will pay the exam fee (budgeted amount) for residents who apply for the exam within 12 months of their initial
appointment at Palmetto Health. Palmetto Health will pay the exam fee only once per resident.
3. All residents must pass USMLE Step 3 and provide results to their residency program and the GME office no later than one month
prior to the end of their PGY-2 year; otherwise they will not be reappointed.
4. All residents accepted into Palmetto Health programs at PGY-2 who have not already passed USMLE Step 3 must pass the exam
and provide results to their residency program and the GME office no later than 11 months after their transfer to Palmetto Health;
otherwise they will not be reappointed.
5. If a resident transfers between programs at Palmetto Health after their initial appointment, they must pass the exam and provide
results to their residency program and the GME office no later than 11 months after the transfer date; otherwise they will not be
reappointed.
6. All residents and fellows accepted into Palmetto Health programs at PGY-3 or above must have passed USMLE Step 3 prior to
entering the program.
7. Exceptions to this policy may be made only by the DIO, and only in rare circumstances.
August 10, 2004
February 12, 2013
Signature on File
Signature On File
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GME Policies
USMLE Step 3 Application Process
Step 1
Assess your annual rotation schedule and determine the best month in which you can take the two day exam.
Step 2
Advise your Program/Prog Coordinator when you anticipate taking the test.
Step 3
Go to http://www.fsmb.org/usmle_apply.html to apply. Your fee can be paid by Visa, MasterCard or bank transfer
Step 4
Send paid receipt to your program coordinator who will send to Graduate Medical Education, who will reimburse you up to
$705.
Step 5
Download the USMLE 2013 Step 3 Certification of Identity Form to sign and affix photo, notarize – IMPORTANT! WHEN that
Form is RECEIVED by FSMB – your 90 period begins – SO please hold and factor that part of the process in when you are
looking at your best rotation months to take the exam
Step 6
You will use your USMLE Id/password and monitor your registration, print scheduling permit at USMLE Step 3 interactive site
– Candidate website
Step 7
To check the status of your 3 month registration go to www.fsmb.org. From Home page select Medical Professionals, under
“Examination & Assessment Services” click “USMLE Step 3 Examination” & then “Candidate Website”. You will need your
USMLE ID number & a password
Step 8
Notify your program coordinator of the dates that you plan to take the exam & don’t forget to ask permission in advance for 2
days off from your affected rotation. Resident receives an email that score results are in from FSMB.
Step 9
If resident misses email, go to www.fsmb.org and download a score report copy. NOTE: If a copy is not obtained at this point,
then a fee will be imposed when trying to obtain a copy later.
Step 10
A copy of score report must be sent to GME Resident & Student Services within two weeks of receipt.
Step 11 IF NECESSARY - To extend your 90 day ticket: If you are unable to test within your approved eligibility period , complete &
mail the USMLE Step 3 Eligibility Request Form & include a $65 check for this service. It must be received by FSMB no later
than 10 days after the expiration of the 90 day period. NO EXCEPTIONS.
Step 12
IF NECESSARY – Retakes: The USMLE program limits all individuals to 3 attempts per step within a 12 month period. For
more details review examination rules on FSMB website.
Step 13
Review PH GME Resident – USMLE Step 3 Policy to make sure you apply before June 30 in order to receive the $705
reimbursement and note the time lines to complete the process for re-appointment.
COMLEX Step 3
DOs who plan to sit for COMLEX Step 3 must apply through the NBOME on-line and send a receipt to GME Resident & Student Services
for reimbursement.
RESOURCES
(these recommendations do not imply endorsement)
1. Review the FSMB Bulletin and Content e-booklets provided to the resident that include test examples.
2. Another option is the KAPLAN Center - can provide one free practice test upon request. Additional prep options are available at
resident’s expense: KAPLAN Center at 1717 Gervais Street, 256-0673.
3. An additional option is USMLE WORLD, an on-line service with question download capability to PC (1300 Practice question/
simulations can be purchased)
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GME Policies
Workers’ Compensation
Human Resources
Policy No. #245
In accordance with State requirements, Palmetto Health provides Workers’ Compensation coverage for
employees who suffer work-related illnesses or injuries rising out of or in the course of employment. The Workers’
Compensation program is managed by Employee Health.
GUIDANCE:
1. An employee, volunteer or student of Palmetto Health Schools of Medical or Radiologic Technology, should immediately report all
work-related events which cause or can cause injury or illness to his supervisor and go to Employee Health/Administrator on Duty as
soon as possible for examination and preparation of an employee accident report. Employees may also report injuries, but NOT blood
and body fluid exposures, via myPal.
2. Supervisors and department heads concerned are responsible for documenting all details giving to a work-related illness or injury on
the Employee Accident Report form and returning it to Safety & Security.
3. Employee eligibility for compensation for time lost from work due to a work-related injury or illness is as follows:
3.1. 7 Days or Less: Ineligible for Workers’ Compensation and must use PTO.
3.1.1. If an employee later receives retroactive payment under Workers’ Compensation, any amount received from Palmetto
Health in excess of 100% of pay for work days missed, must be reimbursed by payroll adjustment.
3.2. 8 through 14 Days: Employee is eligible for Workers’ Compensation for days 8-14.
3.3. 15 or More Days: Employee becomes eligible for workers’ compensation pay from day 1 and will receive retroactive payment
for days 1-7.
3.4. Employees may use benefit time (PTO and PIB) to supplement workers’ compensation pay up to 100 percent of base pay up
to normal scheduled hours.
4. Medical coverage for injuries to volunteers while volunteering is provided under the Volunteers’ Medical Payments plan. Volunteer
injuries are not covered under Workers’ Compensation.
Signature on File
Gwen Hill
Signature On File
Effective July 1, 2004
Revised November 2011
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GME Policies
Evaluations of Residents/Fellows
Residents are evaluated at the end of each clinical rotation by their attending faculty. In addition, they are evaluated
at least every six months by their own program to ensure progressive resident performance improvement
appropriate to educational level. The program provides objective assessments of competence in patient
care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills,
professionalism, and systems-based practice. These evaluations become part of each resident’s permanent record.
PROCEDURES:
1. Evaluation criteria and forms, which are reviewed by the GMEC annually, are used by each program for resident evaluations.
2. These evaluation forms are completed by multiple evaluators (e.g., faculty, peers, patients, self, and other professional staff) based
upon a compilation of clinical evaluations and other criteria, to include the general competencies.
3. The Program Director and/or designated attending faculty meets with each resident at least (semi-annually) to discuss the evaluation.
4. Completed evaluations are signed by the program director and/or designated attending faculty and the resident. These evaluations
are accessible for review by the resident.
5. Copies of unsatisfactory evaluations are sent to the Department of Medical Education for review by the DIO.
6.
At the discretion of the DIO or the Program Director, unsatisfactory evaluation may be referred to the GMEC for review. The GMEC
may advise, propose, or approve specific corrective actions.
7. Evaluations, including performance monitoring, become part of each resident’s permanent record.
8. A final summative evaluation of each resident (see template) is completed prior to graduation. This evaluation documents the
resident’s performance during the final period of education, and verifies that the resident has demonstrated sufficient competence to
enter practice without direct supervision. The final summative evaluation is signed by both the resident and the Program Director; and
is kept in the resident’s permanent record. A copy of the final evaluation is sent to the Department of Medical Education.
9. A final summative evaluation of each resident who departs prior to end of training is also completed (see templates). The final
summative evaluation is signed by both the resident and the Program Director; and is kept in the resident’s permanent record. A copy
of the final evaluation is sent to the Department of Medical Education.
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August 4, 1993
February 12, 2013
Signature on File
Signature On File
GME Policies
Evaluation Of Rotations And Faculty Members By Residents
On a regular basis, residents must be given the opportunity to confidentially rate their educational experiences,
to include rotations, sites, faculty teaching and quality of supervision. A monthly schedule of evaluation is
recommended for timely feedback; however, quarterly assessments may be acceptable as determined by the
program director and/or residency educational or oversight committee.
PROCEDURES:
1. Summary Data from the resident evaluations will be compiled by the program coordinator for review by the Program Director on a
regular basis.
2. Copies of summary data are made available to the Director of Education for use in annual evaluations.
3. A summary of these composite evaluations is prepared at the end of each academic year and is reviewed annually by the GMEC
Executive Committee.
November 2, 1993
February 12, 2013
Signature on File
Signature On File
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GME Policies
Final Resident/Fellow Evaluation Form (Graduate)
Resident’s Name
Program/Specialty
SSN
VERIFICATION: Our records show that the above-named physician served in the following training program at Palmetto Health.
Completed
Program Name
From
To
Program
Type
(* if non-ACGME program)
(Yes/No)
Internship
Residency
Chief Resident Year
Fellowship
Explanation of interruption in training, if applicable:
EVALUATION OF RESIDENT’S PERFORMANCE DURING LAST 6 MONTHS OF TRAINING:
Superior
Good
Fair
Basic Medical Knowledge
Patient Care and Management
Professionalism
Poor
Comments:
FINAL SUMMATIVE EVALUATION: Based on performance and composite of evaluations by supervisors on file, Dr. has demonstrated sufficient competence to enter practice without direct supervision.
Program Director (Signature)
Name (Printed/Typed)
Date
I have reviewed this document and permit the release of this information to any third party who inquires about my professional
background.
Resident/Fellow (Signature)
Date
I attest that the information supplied on this photocopy is a copy of an official evaluation on file in the department.
Signature of personnel releasing information
Title
100
Date
GME Policies
Final Resident/Fellow Evaluation Form (Non-Graduate)
Resident’s Name
Program/Specialty
SSN
Completed
Program Name
From
To
Program
Type
(Yes/No)
Internship
Residency
Chief Resident Year
Fellowship
EVALUATION: Based on demonstrated performance and evaluations by supervisors on file.
Superior
Good
Fair
Professionalism
Poor
Explanation of why resident did not complete the program:
Date
background.
Date
Signature
Date
Title
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Final Resident/Fellow Evaluation Form (Preliminary Years)
Resident’s Name
Program/Specialty
SSN
Completed Program
Program Name
From
To
(Yes/No)
EVALUATION: Based on demonstrated performance and evaluations by supervisors on file.
Superior
Good
Fair
Professionalism
Poor
Comments:
Date
background.
Date
Signature
Title
102
Date
GME Policies
Blood & Body Fluids Exposure
DEFINITIONS:
1. Blood & Body Fluid Exposure:
1.1 As defined by the CDC in MMWR Update on U.S. Public Health Service Guidelines for the Management of Occupational
Exposures to HBV, HCV, and HIV and Recommendations for Post-Exposure Prophylaxis.
1.2 An exposure that might place HCP at risk for HBV, HCV, or HIV infection is defined as a percutaneous injury (e.g., a needle
stick or cut with a sharp object) or contact of mucous membrane or non-intact skin (e.g., exposed skin that is chapped,
abraded, or afflicted with dermatitis) with blood, tissue, or other body fluids that are potentially infectious.
1.3 In addition to blood and body fluids containing visible blood, semen and vaginal secretions also are considered potentially
infectious. Although semen and vaginal secretions have been implicated in the sexual transmission of HBV, HCV, and HIV, they
have not been implicated in occupational transmission from patients to HCP.
1.4 The following fluids also are considered potentially infectious: cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid,
pericardial fluid, and amniotic fluid. The risk for transmission of HBV, HCV, and HIV infection from these fluids is unknown; the
potential risk to HCP from occupational exposures has not been assessed by epidemiologic studies in health-care settings.
1.5 Feces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomitus are not considered potentially infectious unless they
contain (visible) blood. The risk for transmission of HBV, HCV, and HIV infection from these fluids and materials is extremely
low. (To date, there has never been a parent or caregiver of a HIV-positive infant that became infected from changing diapers
(urine/feces), caring for sick child i.e. vomiting, colds, etc from not wearing gloves.)
1.6 For human bites, the clinical evaluation must include the possibility that both the person bitten and the person who inflicted
the bite were exposed to blood borne pathogens. Transmission of HBV or HIV infection only rarely has been reported by this
route.
RESPONSIBLE POSITIONS:
Employee Health Personnel
PROCEDURE STEPS, GUIDELINES, RULES, OR REFERENCE:
Treatment of blood and body fluid exposures at Palmetto Health are designed to prevent the transmission of chiefly HIV, Hepatitis B and
hepatitis C. These procedures are also drafted to comply with the OSHA Bloodborne Pathogens standard of December 19911 and
updated in January, 2001 in the Occupational Exposure to Bloodborne Pathogens; Needlestick and Other Sharps Injuries; Final Rule.2
This was in response to the Needlestick Safety and Prevention Act.3 The updated CDC Recommendations for occupational exposures
and post exposure prophylaxis (PEP)4&6 also form the basis for this PGR.
1. Scope:
1.1. This GUIDELINE is intended only for Palmetto Health employees including employee-physicians and volunteers. This PGR is
NOT intended for the evaluation and treatment of the general population (i.e., non-workers), and employees of other entities
except as detailed below.
2. During and After Hours Treatment:
2.1. Employees with blood or body fluid (BBF) exposures are sent to Employee Health (EH) when open.
2.2. USC medical students are seen in their employee health clinic and not Employee Health.
2.3. All workers (including USC medical students and other students) are seen by the Administrator on Duty for BBF exposures
after hours.
2.4. The general population (i.e., non-workers) is always seen in the emergency room, not in Employee Health.
2.5. All workers that come to Employee Health receive first aid and evaluation of the exposure source. For contract/agency
workers, the agency is to be contacted for further instructions if worker testing or treatment is recommended. These
individuals complete a hospital occurrence report rather than an Employee Occurrence Report (EOR).
3. Initial Assessment of Employee:
3.1. First Aid:
3.1.1. Provide immediate care to the exposure site.
3.1.2. Give adult Td as needed per EH Immunizations Policy.
3.1.3. Record on EOR.
4.
Evaluate Risk of Exposure:
4.1. The employee completes the top portion of Employee Occurrence Intake.
4.2. The nurse initiates the BBF Checklist, which serves to track the entire evaluation and treatment process.
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104
5.
Evaluate Exposure Incident:
5.1. The exposure should be evaluated for the potential to transmit HBV, HCV, and HIV based on the type of body substance
involved and the route and severity of the exposure. Blood, fluid containing visible blood, or other potentially infectious fluid
(including semen; vaginal secretions; and cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids) or tissue
can be infectious for bloodborne viruses.
5.2. Exposures to these fluids or tissue through a percutaneous injury (i.e., needlestick or other penetrating sharps-related event) or
through contact with a mucous membrane are situations that pose a risk for blood borne virus transmission and require further
evaluation.
5.3. For skin exposure, follow-up is indicated only if it involves exposure to a body fluid previously listed and evidence exists of
compromised skin integrity (e.g., dermatitis, abrasion, or open wound).
5.4. For human bites, possible exposure of both the person bitten and the person who inflicted the bite must be considered. If a
bite results in blood exposure to either person involved, post-exposure follow-up should be provided.
6.
Evaluate Exposure Source for Bloodborne Pathogens:
6.1. Consent:
6.1.1. Inpatients are considered to have given permission for testing for the presence of HIV, hepatitis B and hepatitis C
infection in their admission consent. Specific consent is sought from outpatient sources but legally is not required, since
South Carolina law has mandated source patient testing “without his consent.”5
6.2. Blood work:
6.2.1. Employee Health (Administrator on duty for evenings or weekends) will order Source Patient Panel, which will include
rapid antibody testing for HIV, Hepatitis B surface antigen, and Hepatitis C antibody. Order with a “stat draw” priority.
HIV1 and HIV2 antibody testing will be performed only when the Rapid HIV test is positive. If the hepatitis C antibody is
positive, an HCV-RNA Qualitative PCR will be performed for confirmation.
6.3. Clinical:
6.3.1. If it is not possible to determine the HBV, HCV or HIV status and if information becomes available suggesting that the
source patient is high risk, then note that the source patient is high risk on the BBF Checklist. Use the following criteria
to define high risk:
6.3.1.1. History of recent (within 3 months) possible HBV, HCV, or HIV exposures (e.g., injection-drug use or sexual
contact with a known positive partner).
6.3.1.2. Clinical evidence of AIDs or HIV infection or acute syndrome suggestive of primary HIV infection or
undiagnosed immuno-deficiency disease.
6.4. Unusual Source Situations:
6.4.1. Infant in nursery or NICU:
6.4.1.1. Use baby’s blood instead of mother’s blood.
6.4.1.2. Check with lab to see if cord blood or other blood is available for use. Order venipuncture only if other blood
not available for use.
6.4.1.3. If no blood available on NICU infants, coordinate timing of specimen with RN caring for baby to be drawn the
next time baby is scheduled to have laboratory studies.
6.4.2. Discharged patient (inpatient or outpatient):
6.4.2.1. If blood is available in lab, then place order in computer.
6.4.2.2. If no blood is available in lab:
6.4.2.2.1. Contact source patient at home to ask if they will return to lab for testing. Ask the source patient if
they wish to have the report sent to a healthcare provider and record this information on the “Source
Patient” portion of the BBF Checklist.
6.4.2.2.2. If source patient agrees to return to lab, notify lab of source patient’s expected date and time of
arrival. When patient arrives, have patient sign BBF Source Consent and have lab draw blood for
HIV, Hep C and Hep B antigen.
6.4.2.2.3. If the source patient refuses to submit to blood testing, then explore legal recourse for obtaining
specimen. If this cannot be resolved in a timely fashion, then the source is to be considered “of
unknown HIV status.”
6.4.2.2.4. Lab to send copies of results to HW.
6.4.2.2.5. Employee Health is to send the results to the healthcare provider requested by the source patient,
who will then notify the source patient of the results and provide counseling on results.
6.4.3. Off-site patient:
6.4.3.1. Retesting:
6.4.3.1.1. If initial HIV test of source was “indeterminate”, contact the source patient to arrange for a retest at 6
months and notify the source patient’s healthcare provider.
6.4.3.1.2. Follow the procedure for Discharged patient (inpatient or outpatient) where no blood is available in
lab.
GME Policies
6.4.3.2. Assess Lab Results:
6.4.3.2.1. Lab will send reports to EH.
6.4.3.2.2. EH will document lab reports on BBF Checklist.
6.4.3.2.3. If any source patient results are positive, notify the patient’s physician as soon as possible and
document on BBF Checklist.
6.4.3.3. Entering Data:
6.4.3.3.1. Put injured employee’s information into SYSTOC as usual. However, on the “Patient Summary” of
the employee in the “Use Field”, type in “see F3 Memo”. In the F3 Memo, put the source patient’s
name, SSN and date of exposure.
6.4.3.3.2. Add demographic information on source patient in the Patient Summary tab. In the “User Field”, put
the name of the exposed employee and the date of the exposure. Save the file. This is done so that
the source patient can be cross referenced with the exposed employee.
6.4.3.3.3. On the exposed employee, enter data into the “Exposure” tab to include a brief description of how
the exposure occurred.
6.4.3.4. Near One of the Hospitals:
6.4.3.4.1. This policy applies to Hospice, HomeCare, Center for Pain Management and Baptist Northwest and
all other exposures occurring off-site but near one of the three hospitals.
6.4.3.4.2. All employees are to carry an “Emergency Rinse Kit” with them at all times. These kits are provided
by the home department. Directions for using these kits are on the orange sticker on the outside of
the kit.
6.4.3.4.3. The employee should report to Employee Health, or contact the Administrator on Duty if EH is
closed, immediately after exposure.
6.4.3.4.4. All registered nurses are responsible for carrying a “source patient kit” with them at all times which
includes the following:
6.4.3.4.4.1. Employee Health lab slip marked “source patient” (which requests testing for HIV,
Hepatitis C and Hepatitis B antigen
6.4.3.4.4.2. BBF Source Consent
6.4.3.4.4.3. Two (2) gold top tubes (may use pediatric tubes).
6.4.3.4.5. The nurse will be responsible for obtaining the patient or care giver’s signature on the consent form,
drawing and delivering the blood to the laboratory. DO NOT DELAY GETTING TO HOSPITAL. (If
needed, someone else can get the source patient blood work drawn).
6.4.3.4.6. Source consent is given to EH to be kept with employee record of exposure.
6.4.3.5. Off-site Exposures that Occur Some Distance from the Hospitals:
6.4.3.5.1. Employee carries packet with them and is seen at designated care provider immediately after
exposure.
6.4.3.5.2. Source patient is to sign BBF Source Consent and have blood drawn and run. Employee should not
delay treatment to self to obtain Source blood. Another employee may need to be sent to obtain
source patient’s blood.
6.4.4. Evaluate the Need for Employee Testing and Post-exposure Prophylaxis:
6.4.4.1. Responsibility:
6.4.4.1.1. Employee Health Physicians or Nurse Practitioners are responsible for the decision making process,
assisted by the Occupational Health RN.
6.4.4.2. HIV:
6.4.4.2.1. If source’s Rapid HIV test is negative, there is no need for employee HIV baseline or follow-up testing
and no need for post-exposure prophylaxis (PEP).
6.4.4.2.2. If source patient’s confirmatory HIV test is positive, source is unknown or source HIV status cannot
be determined, then have HIV antibody level drawn on employee at baseline, 6 weeks, 12 weeks
and 6 months. If the source is co-infected with HCV and HIV and the employee becomes infected
with HCV, extended HIV testing at 12 months is indicated.
6.4.4.2.3. In general, the decision to start PEP is made on the basis of a positive Rapid HIV test result with the
decision to continue based on the results of the confirmatory test.
6.4.4.2.4. If the employee consents to baseline blood collection, but does not give consent at that time for
HIV serologic testing, the sample shall be preserved for at least 90 days. If, within 90 days of the
exposure incident, the employee elects to have the baseline sample tested, such testing shall be
done as soon as feasible (OSHA 1910.1030 – Bloodborne pathogens 1910.1030(f)(3)(iii)(B))..
6.4.4.3. Hepatitis B:
6.4.4.3.1. If source is negative or employee has documentation of immunity, no need for employee Hepatitis B
baseline or follow-up testing and no need for consideration of HBIG or Hepatitis B immunization.
6.4.4.3.2. When HBIG is indicated, it should be administered as soon as possible after exposure (preferably
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within 24 hours). The effectiveness of HBIG when administered >7 days after exposure is unknown.
When hepatitis B vaccine is indicated, it should also be administered as soon as possible (preferably
within 24 hours) and can be administered simultaneously with HBIG at a separate site (vaccine
should always be administered in the deltoid muscle).
6.4.4.3.3. For exposed employees who are in the process of being vaccinated but have not completed the
vaccination series, vaccination should be completed as scheduled, and HBIG should be added as
indicated (Table 3).
6.4.4.3.4. For exposed employees who require HBIG and/or additional vaccination, the exposed employee
should be tested for Hepatitis B surface antigen, Hepatitis B surface antibody, and Hepatitis B core
antibody upon completion of their Hepatitis B immunization series to confirm the positive Hepatitis B
surface antibody is secondary to the immunization and not Hepatitis B seroconversion.
6.4.4.3.5. When HBIG is indicated, the HW NP/PA/MD can immediately refer the patient to the USC
Department of Infectious Disease (803) 540-1008 or 540-1000 – please inform the Receptionist
this is an urgent call. The HW NP/PA/MD MUST ALWAYS speak directly to the Infectious Disease
Specialist – (see HIV Post Exposure Prophylaxis box below for details regarding STAT referrals).
6.4.4.3.6. Otherwise, follow the recommendations in the Hepatitis B section of the Employee Health
Immunizations policy.
6.4.4.4. Hepatitis C:
6.4.4.4.1. If source is antibody negative, no need for employee Hepatitis C baseline or follow-up testing.
6.4.4.4.2. If the source is antibody positive and HCV-RNA Qualitative PCR positive, employee will be tested
for HCV antibody and ALT at baseline then HCV-RNA Qual PCR at 4 - 6 weeks to make the earliest
possible diagnosis (1 test). If the employee’s HCV-RNA Qual PCR is positive. They must be referred
to USC Department of Infectious Disease (803) 540-1008 or 540-1000 for further evaluation and
management. If the employee’s HCV-RNA Qual PCR is negative at least 1 month after exposure,
then no additional testing is needed.
6.4.4.4.3. If the source’s hepatitis C antibody is positive, but the HCV-RNA Qual PCR is negative, the source is
not considered infectious and no need for employee Hepatitis C baseline or follow-up testing7.
6.4.4.4.4. Post-exposure prophylaxis for hepatitis C is not available.
6.4.4.4.5. Any employee exposed to hepatitis C can be referred to the USC Department of Infectious Disease
(803) 540-1008 or 540-1000 for a
6.4.4.5. Recommendations and Counseling:
6.4.4.5.1. Using the above guidelines, complete the BBF Employee Education and Consent.
6.4.4.5.2. Counsel the employee.
6.4.5. HIV Post Exposure Prophylaxis:
6.4.5.1. Overview:
6.4.5.1.1. EH NP/ MD will evaluate employees to determine if PEP is warranted. If so warranted, then the
employee will be started on PEP. During normal business hours, EH NP/ MD can immediately refer
the patient to the USC Department of Infectious Disease (803) 540-1008 or 540-1000 – please
inform the Receptionist this is an urgent call. The EH NP/ MD MUST ALWAYS speak directly to the
Infectious Disease Specialist – (SEE NEXT FOUR SECTIONS for details).
6.4.5.1.2. If the Infectious Disease Specialist agrees, they will assume immediate management of the
employee including the determination of whether PEP is to be offered, which PEP drugs should be
utilized, which labs should be ordered and when employee needs to follow-up with them.
6.4.5.1.3. If there is uncertainty regarding the management of the exposure, complicated co-existing factors
(such as pregnancy, renal or liver disease) or appears to be a problem with PEP due to adverse
effects, then EH NP/ MD can immediately refer the employee to the USC Department of Infectious
Disease as detailed above.
6.4.5.1.4. In these cases, the EH NP/ MD should ALWAYS speak directly to the Infectious Disease Specialist
who, if they are unable to immediately see the patient, will instruct the EH NP/ MD which
medications to prescribe and which labs to draw and when the employee is to follow-up directly
with them.
6.4.5.1.5. The EH NP/ MD will only prescribe the doses of PEP necessary to cover the employee until they can
be seen by infectious disease (i.e.
6.4.5.1.6. 1-2 days’ supply of PEP).
6.4.5.1.7. Medications to relieve the adverse effects may also be written if indicated.
6.4.5.1.8. The dosing schedule may be changed as well to avoid adverse effects, but the PEP cannot be
stopped unless the Employee Health Physician orders it and an Infectious Disease Consult is
arranged.
6.4.5.1.9. In all cases, a complete list of current employee medications must be
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6.4.5.1.10.obtained since drug interactions are common and may be serious.
6.4.5.1.11.In all cases, regardless of whether the EH NP/PA/MD or USC Department of Infectious Disease is
managing the employee, they are to be monitored for the full 28 days of therapy.
6.4.5.2. CDC Recommendations for Postexposure Prophylaxis:
6.4.5.2.1. The BBF HIV PEP Recommendations are based on the updated CDC guidelines and by
recommendations from Drs. Charles Bryan and Helmut Albrecht, Infectious Disease Specialists. By
knowing the exposure type and the HIV infection status of the source, these guidelines determine
the PEP recommendation. In all cases except those in which the employee has known renal failure
(do not delay PEP to test renal function), the protocol requires both Truvada (Tenovir, a Nucleotide
analogue reverse transcriptase inhibitor) and Kaletra (2 Protease inhibitors) to be given for 28 days.
6.4.5.2.2. If the employee has known renal failure, use Combivir (2 Nucleoside transcriptase inhibitors) and
Kaletra in place of Truvada and Kaletra.
6.4.5.2.3. Truvada is generally better tolerated than Combivir but can not be given in a worker with renal
disease.
6.4.5.2.4. Initially only prescribe 1-3 days of PEP necessary to cover the employee until they can be seen in
follow-up to ensure they are able to tolerate these medications. If they have demonstrated tolerance
and the decision is made to continue, then prescribe the remaining supply of PEP to complete a 28
day course of treatment.
6.4.5.3. Counseling:
6.4.5.3.1. The employee has the option of accepting or rejecting the recommendation to take PEP.
6.4.5.3.2. Accepting the recommendation:
6.4.5.3.2.1. Males: Sign the BBF PEP Consent.
6.4.5.3.2.2. Females:
6.4.5.3.2.2.1. Ask the following questions and record on the “Additional History”
section of the BBF Checklist:
6.4.5.3.2.2.1.1. Is she known to be pregnant or think that she might
be pregnant?
6.4.5.3.2.2.1.2. First day of last menstrual period.
6.4.5.3.2.2.1.3. Has the patient had a sterilization procedure?
6.4.5.3.2.2.2. If there is any question of pregnancy, obtain a stat urinary or blood
pregnancy test.
6.4.5.3.2.2.3. If the worker is not pregnant, have her sign the BBF PEP Consent and
the pregnancy waiver.
6.4.5.3.2.2.4. If the worker is pregnant and still elects to take PEP, have her sign the
BBF PEP Consent and the pregnancy waiver for women known to be
pregnant.
6.4.5.3.2.3. If the worker is pregnant and decides not to take PEP, have her sign
the declination.
6.4.5.3.3.
Rejecting the recommendation:
6.4.5.3.3.1. Males and females are to sign the declination statement
6.4.5.3.3.2. In this case, no prescriptions are given however baseline HIV Ab, HBsAb, HBsAg,
HCV Ab on employee should be drawn to determine if the patient is already infected
at the time of the exposure. If the employee consents to baseline blood collection,
but does not give consent at that time for HIV serologic testing, the sample shall
be preserved for at least 90 days. If, within 90 days of the exposure incident, the
employee elects to have the baseline sample tested, such testing shall be done as
soon as feasible.
6.4.5.3.4. The employee should be referred to the USC Department of Infectious Disease (803) 540-1008 or
540-1000 for a one-time consultation.
6.4.5.4. Referrals to the USC Dept of Infectious Disease (803) 540-1008 or 540-1000:
6.4.5.4.1. When HIV PEP or HBIG is indicated.
6.4.5.4.2. When an employee has been exposed to hepatitis C, they can be referred to the USC Department
of Infectious Disease (803) 540-1008 or 540-1000 for a one-time consultation, if they desire.
6.4.5.4.3. If there is uncertainty regarding the management of the exposure, complicated co-existing factors
(such as pregnancy, renal or liver disease) or appears to be a problem with PEP due to adverse
effects, then will an infectious diseases consult should be obtained to determine if PEP should be
continued. In these cases, only prescribe the doses of PEP necessary to cover the worker until they
can be seen by infectious disease (i.e. 1-3 days supply of PEP).
6.4.5.4.4. See Box 4 for additional details regarding referrals.
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6.4.5.4.5. In the cases described above, the worker will be scheduled to see the infectious disease consultant
as soon as possible.
6.4.5.4.6. For details regarding making a STAT referral, see HIV Post Exposure Prophylaxis above. Please
note, in these cases, the HW NP/PA/MD MUST ALWAYS speak directly to the Infectious Disease
Specialist.
6.4.5.4.7. Once a referral to USC Department of Infectious Disease has been made, they will assume all
management of the case, as in any other workers’ compensation case, including the ordering of any
additional testing needed and/or medications. The exposed worker will follow-up with them based
on their recommendations. They will send copies of their notes to our case management division
as a means of transmitting updates on the status of the exposure and for appropriate workers’
compensation record keeping.
6.4.5.4.8. Case Management Divisions: PHR 434-2877 (fax 434-3587); PHB 298-5873 (fax 296-2217); PHBE
864-442-7824 (fax 864-442-7787)
6.4.6. Healthcare Professionals Written Evaluation:
6.4.6.1. EH nurse, in consultation with MD or NP fills out BBF Checklist, which serves as the health care professional’s
written opinion. This is signed by the MD or NP.
6.4.6.2. Employee is provided with a copy of this health care professional’s written opinion within 15 days of the
completion of the evaluation.
6.4.7. Employee Follow-up Testing:
6.4.7.1. Terminated Employees:
6.4.7.1.1. If a employee is due follow-up studies after they are terminated, they will be notified by certified mail
(BBF T Employee Follow-up Letter). If the employee does not come in for testing, the follow-up is
discontinued.
6.4.7.2. Interpretation of Baseline Results:
6.4.7.2.1. If baseline blood was drawn within a short time of the exposure, and the results are abnormal, then
the employee needs to be informed and documented on the BBF Checklist that this is not due to
the current blood or body fluid exposure. Consult the medical director if there are any questions.
6.4.7.2.2. Offer counseling and support.
6.4.7.2.3. Refer to personal physician
6.4.7.3. Reminders:
6.4.7.3.1. The employee was given follow-up schedule when initially seen.
6.4.7.3.2. If employee does not come to EH for follow-up testing, call his department or send the BBF Followup Letter and document on the BBF Employee Education and Consent in the comment section.
6.4.7.3.3. If no response to the above reminder, then send the BBF Past-due Letter by certified letter and
document on the BBF Employee Education and Consent.
6.4.7.3.4. If there is no immediate response, then close the record and document on the BBF Employee
Education and Consent.
6.4.7.4. Completion of Follow-Up:
6.4.7.4.1. When follow-up is finished, complete the BBF Post Exposure Follow-up place exposure follow-up
chart in employee’s health record.
6.4.7.5. Additional Resources:
6.4.7.5.1. National Clinicians’ PEP Hotline (PEPline) 1-888-448-4911; www.ucsf.edu/hivcntr
6.4.7.5.2. Needlestick! www.needlestick.mednet.ucla.edu
6.4.7.5.3. Hepatitis Hotline 1-888-443-7232; www.cdc.gov/hepatitis
6.4.8. Emergency Department Procedure:
6.4.8.1. When EH is closed and a blood/body fluid exposure occurs, the employee will be seen, evaluated, and
treated by Administrator on call. She may determine to send employee to Emergency Department. The
employee will be seen on an urgent care basis and will be referred to EH to be seen the next time the office is
open.
6.4.9. Physician Exposure:
6.4.9.1. Physician will report blood/body fluid exposure to Employee Health.
6.4.9.2. Physician may choose if he/she wants to be tested or just test source.
6.4.9.3. An EOR must be completed on employee-physicians only.
REFERENCES:
1.
2.
3.
4.
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29 CFR 1910.1030.
66FR 5325 Jan. 18, 2001.
Public Law 106-430.
Centers for Disease Control and Prevention. Updated U.S. Public Health Service Guidelines for the Management of Occupational
GME Policies
Exposures to HBV, HCV, and HIV and Recommendations for Post-exposure Prophylaxis. MMWR 2001; 50 (No. RR-11):1-52.
5. South Carolina statute #44-29-230 amended 7/94.
6. Centers for Disease Control and Prevention. Updated U.S. Public Health Service Guidelines for the Management of Occupational
Exposures to HIV and Recommendations for Post-exposure Prophylaxis. MMWR 09/30/2005; 54 (No. RR-9).
7. Information provided by National Clinicians’ PEP Hotline.
APPENDIX
Table 1: Factors to consider in assessing the need for follow-up of occupational exposures
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Table 2. recommended postexposure prophylaxis for exposure to hepatitis b virus
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Table 3. Situations for which expert* consultation for HIV postexposure prophylaxis is advised
*Local experts and/or the National Clinicians’ Post-Exposure Prophylaxis
Hotline (pepline) - (888) 448-4911
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EMPLOYEE HEALTH
Informed Consent
Post-Exposure Hiv Prophylaxis
This consent form is used to facilitate the prompt administration of post-exposure prophylaxis (PEP) medications after exposure to blood
or body fluids of HIV positive persons. Persons consenting to begin prophylaxis MUST have continuing medical follow-up.
Employee
I have been exposed to blood or body fluids which may contain the human immunodeficiency virus (HIV). It has been explained to me that:
I have been advised to take the following PEP drugs (check those that apply):
Truvada & Kaletra
- OR Combivir & Kaletra
The PEP medications that I have been advised to take may be of benefit to me if taken promptly. There is no guarantee that this will
prevent infection after exposure to the virus, but it is recommended that treatment with these drugs be started as soon as possible after
exposure to HIV-positive blood or body fluids.
I have been provided with an information sheet (BBF_PEP_Information) on the medications that I have been given. I am aware of the
potential side effects (adverse effects) of these medications and I have been given an opportunity to ask questions. Medical follow-up will
be necessary to interpret the results of my laboratory tests and provide clinical evaluation while I am taking these medications.
I will be given more detailed information about these medications and the results of my baseline blood work when I am seen by the
infectious disease physician. After being seen by this physician, I will be given the opportunity to decide whether or not to complete the full
28 day course that is recommended for prophylaxis.
While taking medications on this protocol, I will not use any of the medications listed on the handout I received without consulting a
physician.
CONSENT TO TAKE THE INITIAL DOSES:
Signature
Date
PREGNANCY WAIVER (MUST BE SIGNED BY ALL WOMEN)
I am currently not pregnant, to the very best of my knowledge. While I am taking the PEP medications listed above and for one month
after completing this course of treatment, I shall take all precautions necessary to keep from becoming pregnant. I fully understand that
these drugs might be harmful to the fetus. Should pregnancy be suspected during the course of my therapy, I shall contact my physician
immediately.
Signature
Date
Witness
Date
BLOOD TESTING CONSENT
I consent to have blood drawn and tested for a pregnancy test and other necessary STAT PEP testing.
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Signature
Date
Witness
Date
GME Policies
PREGNANCY WAIVER (MUST BE SIGNED BY ALL WOMEN WHO ARE KNOWN TO BE PREGNANT
AND WHO CHOOSE TO TAKE THE DRUGS).
I am pregnant, and while understanding the potential effects to myself and my unborn child, I elect to take the PEP medications listed
above. I do not hold Palmetto Health or any of its agents or employees responsible for the effects to me or my unborn child. I understand
that I need to report the incident, and my taking of the medication(s) to my personal physician immediately, and that my personal physician
shall be responsible for my continued care while on this medication. I further understand that the designated ID physician may be available
to my physician to assist as consultant if my physician so chooses.
Signature
Date
Witness
Date
DECLINATION (DECISION NOT TO TAKE PROPHYLACTIC DRUGS LISTED ABOVE)
Understanding the implications involved, I choose not to take the post-exposure prophylactic medications listed above. I will not hold
Palmetto Health, its agents or employees responsible for any consequences which occur from my decision.
Signature
Date
Witness
Date
POST-EXPOSURE HIV PROPHYLAXIS
Information for the individual who may have been exposed to HIV
Since you have been exposed to someone’s blood or body fluids, you have been given a supply of medications to reduce the risk of
getting HIV (human immunodeficiency virus), the virus that causes AIDS. This preventative therapy is called post-exposure prophylaxis
(PEP). Studies have been conducted on health care workers who may have been exposed to HIV through needle sticks, blood splashes,
and other ways of exposure.
A study done by the Centers for Disease Control and Prevention (CDC) showed that the infection risk among health care workers who
took an anti-HIV medication after exposure, was about 80% lower than the risk of those workers who did not receive treatment. Truvada,
Combivir and Kaletra, used in the treatment of HIV, are also commonly used as PEP medications. They will not always prevent infection
or the spread of infection with HIV. It is best to use a condom during sex and to protect others from your blood and body fluids, basically
treat your self as if you were infected until all of your follow-up tests are negative which takes 3-6months.
PEP MEDICATIONS:
Truvada = Emtricitabine/Tenofovir Disoproxil Fumarate
Combivir = Zidovudine (AZT) /Lamivudine (3TC)
Kaletra = Lopinavir /Ritonavir
You will be given two of the three above PEP Medications as follows:
Either 0 Truvada & Kaletra - OR- 0 Combivir & Kaletra
PREGNANCY:
While you are taking the PEP medications listed above and for one month after completing this course of treatment, you should take all
precautions necessary to keep from becoming pregnant. The effects of PEP in humans during the early weeks of pregnancy are unknown.
These drugs might be harmful to the fetus. Should pregnancy be suspected during the course of this therapy, contact your physician
immediately to discuss continued use of PEP. Please see attached handouts on your specific PEP medication for more information.
BREAST FEEDING:
If you are currently breast-feeding, you should change to bottle-feeding while taking these medications.
ADVERSE EFFECTS:
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As with all medications, the PEP protocol may cause side effects. The following are only some of the adverse effects of the PEP
medications. For additional information, please see the attached handouts specific to your medications.
Some of the less serious effects PEP may cause include the following:
muscle aching headache trouble sleeping dizziness loss of appetite nausea stomach pain diarrhea abnormal bowel movements skin rash body fat changes
runny nose, nasal stuffiness or cough
fatigue
vomiting
unusual or bad taste in mouth
asthenia – loss of muscle strength
If you are a diabetic, let your doctor know and be sure to monitor your blood sugars routinely as prescribed. The PEP medications may
make your diabetes more difficult to control. If you have any other side effects that you think are caused by these medications, tell your
doctor.
ADVERSE EFFECTS THAT YOU SHOULD REPORT TO YOUR DOCTOR:
In very rare cases, medications may cause serious adverse effects that should be brought to your doctor’s attention immediately. Usually
these effects are reversible if they are treated right away. It is very important that you come to your scheduled appointments so your
progress can be checked over the next few months. Your blood may be taken to test for HIV, Hepatitis, and signs of severe adverse
effects from taking PEP.
All of these medication(s) may cause anemia (lowered amount of red blood cells). All may cause other changes in the blood cells (e.g.
granulocytopenia). In additions, they may also cause changes in liver and pancreas functions, increase bleeding, develop or exacerbate
diabetes mellitus, increase cholesterol and triglycerides.
Symptoms of a serious effect from PEP include the following:
itching, redness and/or rash
fever, chills or sore throat
shortness of breath or chest tightness
extreme nausea and vomiting
extreme muscle pain
yellowing of your skin, eyes
very dark brown urine
severe abdominal pain
extreme tiredness or weakness
bloody urine
sharp mid-back or side pain
Your doctor will decide the best way to manage your care, and whether you should continue the PEP protocol, decrease medication
doses or discontinue the PEP protocol. Do not stop taking any medication in the PEP protocol unless you are told to stop by your doctor.
INTERACTIONS WITH OTHER MEDICATIONS:
PEP may interact with other medications. It is best to check with your doctor or pharmacist before taking other medications while you are
taking the PEP protocol. The following are some of the possible interactions, which can occur.
Kaletra (Lopinavir/Ritonavir)
1. Dihydroergotamine, ergonovine, ergotamine and methylerogonorine such as Cafergot, Migranol D.H.E. 45, Ergotomine Maleate,
Methergine and others. Halcion (triazolam), Hismanal (astemizole), Orop (pimozide), Propulsid (cisapride), Seldane (tertradine) and
Versed (midazolam) may cause serious problems or death.
2. Rifampin – lowers the amount of Kaletra in your blood and makes it less effective.
3. St. John’s Wort – decreases Kaletra levels and leads to increased viral load and possible resistance to Kaletra or cross-resistance to
other anti-HIV medicines.
4. Cholesterol lowering medications – possible serious reactions.
5. Oral contraceptives – Kaletra reduces the effectiveness of oral contraceptives.
6. Sustiva/Viramune/Viracept/Agenerase – lowers the amount of Kaletra in the blood.
7. Mycobutin, Phenobarbital, Phenytoin, and Carbamezopine- lower the amount of Kaletra.
8. Metronazole/disulfiram – causes severe nausea and vomiting.
9. Sildenafil – may cause hypotension, syncope, visual change and prolonged erection.
Truvada (Emtricitabine/Tenofovir)
See attached handout.
Combivir
1. Acyclovir: may cause profound drowsiness/lethargy - also may potentiate effects of zidovudine.
2. Cancer medications (e.g. methotrexate, cyclophosphamide or Cytoxan® and others): may result in increased anemia and blood cell
toxicity.
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3.
4.
5.
6.
7.
8.
9.
Dapsone:may result in increased anemia and blood cell toxicity.
Ganciclovir: may result in increased anemia and blood cell toxicity.
Fluconazole: may interfere with metabolism & clearance of zidovudine, increasing zidovudine effects.
Probenecid: may cause higher & prolonged serum concentrations of zidovudine.
Acetaminophen or indomethacinmay potentiate the toxicity of either drug-use with caution.
Phenytoin: may decrease the plasma concentration of zidovudine and lamivudine.
Trimethoprim/sulfamethoxazole): may cause increased serum concentrations of lamivudine.
TAKING PEP:
Take all medications exactly as prescribed and do not miss a dose. These medications work best when there is a constant amount in the
blood. To help keep the blood level constant, do not miss any doses. If you do miss a dose, and you realize it before your next dose is
due, take the missed dose. If you do not realize that you missed a dose until it is time for your next dose, do not take the missed dose.
Return to your normal dosing schedule. The normal dosing schedules are:
»» 0 Truvada – one tablet once a day
»» 0 Kaletra – two tablets twice a day
»» 0 Combivir - one tablet twice a day
HBIG CONSENT AND RECORD OF ADMINISTRATION
As a result of the needlestick/splash/mucus membrane exposure I sustained on , I understand the
source patient is:
known Hepatitis B surface antigen positive.
has been tested for Hepatitis B surface antigen and test results are positive.
I hereby elect to receive Hepatitis B Immune Globulin, at no charge to me.
I hereby elect NOT to have Hepatitis B Immune Globulin prophylaxis.
Signature
SSN
Date
Body Weight: pounds kilograms Emergency Department Physician: Dosage: (given at.06 ml per kg)
First Dose:
Manufacturer Name & Lot #
Date Given
Dosage
Site
Nurse
R.N.
Second Dose:
Manufacturer Name & Lot #
Date Given
Dosage
Site
Nurse
R.N.
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Business Courtesies, Gifts And Vendor Interactions
Palmetto Health workforce members should use this policy as a guide when business courtesies, gifts or charitable
contributions are offered to individuals or departments. These guidelines govern activities with those outside of
Palmetto Health and do not pertain to actions between the organization and its workforce nor among Palmetto
Health’s workforce members (refer to Human Resources’ Solicitation policy). Requesting or otherwise soliciting
business courtesies, gifts, charitable contributions and the like violates Corporate Compliance’s Code of Conduct.
It is the purpose of Palmetto Health’s Foundations to conduct such activities on the organization’s behalf. All
other requests are inappropriate (see Corporate Compliance Charitable Contributions policy). Acceptance of
meals, entertainment and routine marketing materials is permissible as described below. Workforce members are
cautioned to use good judgment when determining those items falling into this category and should seek guidance
from management or Corporate Compliance as necessary.
DEFINITIONS:
1. Business Courtesies/Gifts: for purposes of this policy, refers to funds, gratuities, sponsorship, meals, products, gifts, travel,
entertainment, recreation, benefits and other courtesies provided by another individual, patient, company or organization (vendor) in
the context of business-related discussions.
2. Routine Marketing Materials: for purposes of this policy, refer to pens, cups, notepads and other small-dollar items provided by an
individual, company or organization as a means of marketing.
3. Family Member: as an individual who is the spouse, parent, brother, sister, child, mother-in-law, father-in-law, son-in-law, daughter-inlaw, grandparent or grandchild or a member of the individual’s immediate family.
4. Vendor: Any entity doing or seeking to do business with Palmetto Health.
5. Workforce Members: for purposes of all policies contained in the Compliance Manual, refers to employees, independent contractors,
volunteers, students, trainees, medical residents/fellows, and other persons whose conduct in the performance of work for Palmetto
Health is under the control of the organization.
GUIDANCE:
1. Workforce members or their families shall not accept or shall not request, coerce or in any way solicit vendors, potential vendors or
others to provide business courtesies, gifts or charitable contributions to Palmetto Health, its for-profit or not-for-profit subsidiaries or
for personal use.
In an effort to prevent the appearance of special consideration, business courtesies should not be provided to family members of
workforce members.
2. Workforce members or their family should not solicit or accept business courtesies or donations that are then directed to the
Palmetto Health Foundation. It is the responsibility of the Foundation to conduct all solicitation activities on behalf of Palmetto Health.
3. Meals, entertainment and routine marketing materials are often provided during in-services, at educational conferences and in other
situations. These items, of nominal value, are permissible to accept. Frequency should be a consideration when evaluating these
situations.
Should a routine marketing item be of significant value, it should not be accepted.
4. Door prizes awarded at educational conferences or meetings that are not specifically targeted by the contributing organization are
permissible.
5. Training and educational opportunities, including meals or other refreshments, are permissible as long as the education is directly
relevant to the department’s job duties and the training is directly related to products or services beneficial to Palmetto Health.
5.1. Workforce members may not accept industry-sponsored training and educational opportunities that include paid registration,
travel and/or accommodations. This includes traveling with a company representative in his/her vehicle or other mode of
transportation.
5.2. Educational grants for conferences and other educational activities sponsored by professional societies and other
organizations may be accepted upon approval of the area Vice President.
6. Gifts from Patients
6.1. In accordance with the Human Resources Gratuities policy, Palmetto Health believes that every patient, regardless of
economic circumstances, is entitled to the best services possible. For this reason, no workforce member is permitted to
solicit or accept gifts or gratuities from patients, their families or friends for any services rendered. Anyone wishing to make a
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donation or gift to Palmetto Health should be referred to the one of the Foundations.
6.1.1. Consumable gifts (e.g. cookies, popcorn tins, etc.) that can be shared with all staff members are acceptable.
7. Pharmaceutical Companies
7.1. The Pharmaceutical Research and Manufacturers of America (PhRMA) represents research-based pharmaceutical and
biotechnology companies. Ethical relationships with healthcare professionals are critical to their mission of helping patients
through the development and marketing of new medicines. In an effort to avoid the perception of inappropriate interactions,
they have developed the PhRMA Code on Interactions with Healthcare Professionals that dictates how company sales
representatives should interact with healthcare professionals.
7.2. Participation in the PhRMA Code is voluntary; however, most reputable companies are represented. The list of companies can
be found at http://www.phrma.org/code_on_interactions_with_healthcare_professionals/ .
7.3. The PhRMA Code addresses interactions with respect to marketed products and related pre-launch activities. Examples of
activities that are not allowed include, but are not limited to:
7.3.1. Prohibiting the distribution of non-educational items (such as pens, mugs and other “reminder” objects typically
adorned with a company or product logo) to healthcare providers and their staff. The PhRMA Code acknowledges
that such items, even though of minimal value, may foster misperceptions that company interactions with healthcare
professionals are not based on informing them about medical and scientific issues.
7.3.2. Prohibiting company sales representatives from providing restaurant meals to healthcare professionals. Occasional
meals in healthcare professionals’ offices may be provided in conjunction with informational presentations.
7.3.3. Companies should not provide any entertainment or recreational benefits to healthcare professionals.
REFERENCES:
PHRMA Code on Interactions with Healthcare Professionals www.phrma.org
Federal Health Care Program Anti-kickback Statute
August 10, 2010
February 12, 2013
Signature on File
Signature On File
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Code Of Conduct
Palmetto Health is committed to conducting its business lawfully and ethically; it is a place of business where
an environment of trust, integrity and the highest ethical standards are maintained at all levels of the system. To
protect Palmetto Health’s vision and reputation and to assure uniformity in standards of conduct, Palmetto Health
has established this Code of Conduct (Code) as part of its Corporate Compliance Program (Program). Compliance
Officers have been appointed to ensure compliance with the Program, to serve as contacts for workforce members
to report any potential violations and to take appropriate action against violators when appropriate.
This Code establishes the general policy and procedure that all workforce members must comply with as a
condition of employment with Palmetto Health. This Code exists to ensure that workforce members’ conduct
conforms to the highest ethical standards and is in accordance with all applicable laws, rules and regulations.
This policy is not meant to cover all situations. Any doubts whatsoever as to the propriety of a particular situation,
whether or not the situation is within this Code, should be submitted either to an immediate supervisor or to one
of Palmetto Health’s Compliance Officers. The intent of the Program is to safeguard Palmetto Health’s tradition of
strong moral, ethical and legal standards of conduct.
DEFINITIONS:
1. Anti-trust Laws: for the purposes of all policies contained in the Compliance Manual, refer to laws that prohibit competitors from
entering into agreements to fix prices or to reduce price competition. In general, the Anti-trust laws benefit consumers by protecting
competition.
2. Anti-kickback Laws: for the purposes of all policies contained in the Compliance Manual, refer to laws that prohibit the offer or
receipt of certain compensation in return for referrals for or recommending purchase of supplies and services reimbursable under
government health care programs.
3. Family Member: an individual who is the spouse, parent, brother, sister, child, mother-in-law, father-in-law, son-in-law, daughter-in-law,
grandparent or grandchild or a member of the individual’s immediate family.
4. Workforce Members: for purposes of all policies contained in the Compliance Manual, refers to employees, independent contractors,
volunteers, students, trainees, medical residents, fellows and other persons whose conduct in the performance of work for Palmetto
Health is under the control of the organization.
POLICY SPECIFICATIONS:
1. Every Palmetto Health workforce member is required to understand and fully comply with the principles of the rules and approved
procedures established by this Code.
1.1. The standards of conduct that govern Palmetto Health’s relationship with the government are applicable to all workforce
members whether or not the member is directly engaged in performing activities relevant to any federal, state or private
contracts.
1.2 Decisions regarding requests for interpretation of or exception to this Code may be made only by the Chief Compliance
Officer. Any workforce member violating any provision of this Code will be subject to disciplinary action, up to and including
discharge from employment, in accordance with Human Resources’ Disciplinary Action policy.
1.3 Promotion of and adherence to this Code and to the Program will be one criteria used in evaluating the performance of
personnel.
1.4 Any additional policies set forth in any other Palmetto Health manual should be consistent with this Code. In the event any
inconsistency is discovered, the provisions of this Code will govern.
2. These guidelines are designed to assist workforce members in making the right choices. We clearly understand that the responsibility
for ethical behavior rests with each of us through the judgments we make and the actions we take. We are all expected to recognize
and avoid activities and relationships that involve, or might appear to involve, conflicts of interest or behavior that may cause
embarrassment to the organization or compromise its integrity.
Workforce Members
1. Palmetto Health workforce members must comply with all applicable federal, state and local laws and government regulations. Any
actual or perceived violation of this Code or the Program must be immediately and directly reported to a Palmetto Health Compliance
Officer.
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2. Workforce members must comply with all policies and procedures in this and all other Palmetto Health manuals.
3. All Palmetto Health workforce members must exercise absolute candor in providing facts and information requested by a Compliance
Officer, other Palmetto Health personnel or other external personnel with authority to investigate any suspected violation of any law,
regulation or this Code.
4. All patients are to be treated properly, respectfully, with dignity and as described in the Patients’ Bill of Rights.
5. All Palmetto Health workforce members must comply with all policies governing patient care including, but not limited to patient
confidentiality, continuity of care and one level of care for all patients.
Dealing Honestly With Customers, Suppliers And Consultants
1. Palmetto Health envisions a healthcare system where quality service for patients and their physicians is relentlessly pursued, and
there is a continuous effort to strengthen quality and improve cost effectiveness. Palmetto Health is committed to providing services
that meet all contractual obligations and quality standards.
2. All data delivered by Palmetto Health to a government or commercial provider will be accurate, complete and current to the best
belief of the workforce member involved in its preparation.
3. Palmetto Health will not distort the truth or make false claims when conducting marketing and advertising activities.
Anti-trust Activity
4. Anti-trust laws prohibit competitors from entering into agreements to fix prices or to reduce price competition. Price fixing has been
interpreted broadly to include any type of joint action between two competitors which influences the price of products or services that
the competitors sell either directly or indirectly.
4.1 Because it is often difficult to determine what activities may result in price fixing, Palmetto Health workforce members should
adhere to the following principles:
4.1.1 Workforce members should not provide Palmetto Health business information to a competitor, unless the provision
of this information is necessary to consummate a bona fide customer/supplier relationship or to serve particular
customers jointly or unless Palmetto Health has already disclosed this information to the general public. Workforce
members may supply pricing information to customers even though a competitor may obtain this information through
the customer. However, workforce members should limit the pricing information provided to customers to only that
information which is necessary for the particular customer.
4.1.2 Workforce members should not obtain information about a competitor’s business directly from the competitor unless
the provision of this information is necessary to consummate a bona fide customer/supplier relationship or to serve
particular customers jointly. Workforce members will not obtain such information directly from a competitor in order to
perform market analyses. However, workforce members may obtain information from public sources or other parties.
4.2 Anti-trust laws apply to commercial transactions by Palmetto Health, and they are designed to ensure that competition exists
and to preserve the free enterprise system. In general, the Anti-trust laws benefit the consumer by protecting competition. As
these laws can be very technical and are applied in a highly complex area, this Code cannot cover all situations in which Antitrust laws may apply. Workforce members should take special care in this area and promptly refer any questions to the Chief
Compliance Officer who will consult legal counsel as appropriate. Anti-trust issues that a workforce member may encounter
include the areas of pricing, boycotts and trade association activity.
4.3 The following examples of actions that violate the Anti-trust law and are absolutely prohibited, under any circumstance, include
entering into or negotiating an agreement with one or more competitors to:
4.3.1 fix prices at any level or to fix other terms of service;
4.3.2 allocate customers or markets; or
4.3.3 boycott a supplier or customer.
4.4 Workforce members must refrain from engaging in unfair practices that might restrict competition. For example, workforce
members should refrain from any discussion of pricing schemes or market divisions with competitors to avoid violating these
prohibitions. Also, workforce members must refrain from reciprocal agreements and must not require purchasers to buy from
Palmetto Health under any kind of coercion, expressed or implied.
Anti-kickback Activity
5. Federal and state laws prohibit Palmetto Health and its workforce members from offering a kickback to any entity or person to induce
customers or potential customers to purchase services from or refer a patient to Palmetto Health. Federal and state laws prohibit
accepting a kickback and prohibit the filing of false claims. As this is a highly complex area of law, this policy cannot list all situations
in which the anti-kickback or false claims act may apply. Therefore, workforce members must take special care in this area, and
promptly refer any questions to a Compliance Officer who may refer the question to legal counsel if appropriate.
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5.1
5.2
Examples of the types of actions that could violate the Medicare/Medicaid anti-kickback statute and similar state laws include
the following:
5.1.1 offering or paying anything of value to induce someone to refer a patient to use Palmetto Health’s services;
5.1.2 offering or paying anything of value to anyone (patient or referral source) in marketing Palmetto Health;
5.1.3 soliciting or receiving anything of value for the referral of Palmetto Health patients to others; or
5.1.4 receiving free goods, other than pursuant to volume purchase discounts, samples and other normal marketing material
of minimal value when purchasing products.
Palmetto Health has adopted various policies designed to ensure compliance with federal and state anti-kickback laws.
Examples of the types of actions that could violate the Federal False Claims Act (see the Corporate Compliance Detecting and
Preventing Fraud, Waste and Abuse PGR) and other federal false billing laws include:
5.2.1 Filing a false claim for services that were not rendered at all or that were not rendered as described on the claim form;
5.2.2 Filing a claim for services that were rendered but were known to be medically unnecessary;
5.2.3 Submitting a claim containing information you know to be false; or
5.2.4 Misusing Social Security or Medicare symbols, emblems or names in marketing.
Billing and Finance
5.3 Patient Financial Services (PFS) personnel must comply with Palmetto Health’s Billing and Reimbursement PGR; this PGR
should be referred to for further guidance when questions arise.
5.3.1 Workforce members reporting data used for billing purposes will report such data accurately and in accordance with
applicable guidelines and regulations.
6. Palmetto Health strives to ensure billing and reimbursement practices comply with all federal and state laws, regulations, guidelines
and policies and that bills are accurate and reflect current payment methodologies.
6.1 Efforts will be made to distribute bills timely and answer subsequent questions.
6.2 All billing departments will maintain current billing and reimbursement policies and procedures.
6.3 Appropriate and accurate documentation of physicians’ orders is required in accordance with approved billing and
reimbursement practices.
7. Workforce members are required to review their timesheets for accuracy and report any errors to their immediate supervisor.
7.1 Workforce members must be particularly careful that hours worked and costs incurred are applied to the department or
account for which the effort was required.
7.2 Timesheets must be submitted in a complete, accurate and timely manner.
7.3 The supervisor’s signature/approval on a timesheet or expense report signifies his/her review and verification of the validity and
appropriate allocation of the hours and expenses reported.
Emergency & General Patient Care
8. Palmetto Health will provide treatment to all individuals who have an emergency medical condition (see Corporate Compliance
Emergency Care PGR).
8.1 Palmetto Health may not delay the treatment or provision of appropriate medical screening in order to inquire about the
individual’s method of payment or insurance coverage.
8.2 Palmetto Health will comply with all federal and state laws, rules and regulations pertaining to the transfer of patients to
another facility.
8.3 Patients needing admission will be admitted without discrimination because of age, sex, race, religion, handicap, or national
origin.
8.4 All patients will be treated without discrimination in regard to charges and medical care.
8.5 Workforce members will comply with all Palmetto Health policies and procedures and federal and state regulations governing
advance directives and right to die issues.
Using Palmetto Health’s Resources Properly
1. Workforce members may not contribute or donate Palmetto Health’s funds, products, services or any other resource to any political
cause, party or candidate without the advance written approval of the Chief Compliance Officer (CCO) and Chief Executive Officer
(CEO).
1.1 Workforce members may make voluntary personal contributions to any lawful political cause, party or candidate as long as the
workforce member does not represent that the contribution comes from Palmetto Health and as long as the individual does
not get the money for the contribution from Palmetto Health for the sole purpose of making such a contribution.
Business Courtesies & Gifts
2. Palmetto Health’s success results from providing quality services at competitive prices. Palmetto Health will not seek to gain an
advantage by improperly offering business courtesies such as entertainment, meals, transportation or lodging to referral sources or
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purchasers of Palmetto Health’s services. To avoid even the appearance of impropriety, workforce members must not provide any
referral source or purchaser with gifts or promotional items of value.
2.1 Except for additional restrictions that apply in the federal or state government area and are noted below, workforce members
may pay for reasonable meal, refreshment and/or entertainment expenses for referral sources and purchasers of Palmetto
Health services which occur only occasionally, are not requested or solicited by the recipient, and are not intended to or likely
to affect the recipient’s business decisions with respect to Palmetto Health.
2.2 Workforce members may provide or pay travel or lodging expenses of a customer or source of customers only with the
advance approval of the vice president or corporate officer responsible for the department and a Compliance Officer if the
travel or lodging is not for a business-related purpose.
2.3 Reasonable meals and/or refreshments may be provided to appropriate community groups by Palmetto Health only with advance
approval of a vice president or corporate officer responsible for the department. The fact that the group may include actual
or potential referral sources or purchasers of Palmetto Health services will not prohibit Palmetto Health from providing such
courtesies, as long as the person receives the same treatment as all other participants in such group functions.
3. All payments, benefits or gifts provided to any member of Palmetto Health’s workforce or his/her family member must comply with the
Potential Conflicts of Interest, Business Courtesies and Gifts and Charitable Contributions policies.
3.1 Workforce members will not request, coerce or in any way solicit vendors or others to make gifts or charitable contributions to
Palmetto Health or its for-profit or not-for-profit subsidiaries.
3.1.1 All unsolicited charitable contributions received must be processed through a Palmetto Health Foundation and must
directly benefit Palmetto Health, its for-profit or not-for-profit subsidiaries.
3.1.2 A check may not be made payable to an individual at Palmetto Health or its for-profit or not-for-profit subsidiaries.
3.1.3 Donations will not be accepted if Palmetto Health, its for-profit or not-for-profit subsidiaries are required to purchase
supplies from the contributing vendor.
3.1.4 Donations will not be accepted if they are tied in any way to marketing activities initiated by the vendor.
3.2 Palmetto Health workforce members will not receive any financial subsidies for educational activities that create the
appearance of impropriety or conflict with Corporate Compliance’s Business Courtesies and Gifts PGR.
Research
3.3 Palmetto Health will ensure any funds provided to support healthcare research or consulting agreements are provided in a
manner clearly separating such payments from referrals.
3.3.1 All research awards from sponsors must be reported and approved by the Vice-President and/or Department Head
and must be for legitimate, bona fide research.
3.3.2 All research conducted must meet the criteria outlined in institutional and federal guidelines, which can be found on the
Palmetto Health website.
Billing & Finance
4. Palmetto Health is a party to numerous government contracts or subcontracts with various governmental agencies. Examples include
provider contracts wherein Palmetto Health supplies services to or on behalf of Medicare/Medicaid programs, either directly or as a
subcontractor to a Medicare/Medicaid contractor. It is essential that workforce members are knowledgeable of, and comply with, all
of the applicable laws, rules and regulations of all such governmental agencies and their contractors.
4.1 Billing Personnel must comply with the Corporate Compliance Billing and Reimbursement PGR.
4.2 Any workforce member with a concern or question concerning compliance with any standard of care or services,
governmental contract or subcontract should contact his/her supervisor or a Compliance Officer.
5. All Palmetto Health payments and other transactions must be properly authorized, accurate and completely recorded in accordance
with generally accepted accounting principles and established corporate accounting policies. No false, incomplete corporate entries
may be made. No undisclosed or unrecorded corporate funds will be established for any purpose, nor will Palmetto Health’s funds
be placed in any personal or non-corporate accounts. All corporate assets must be properly protected and asset records must be
regularly compared to actual assets with proper action taken to reconcile any variances.
Avoiding Abuses Of Trust
Potential Conflicts of Interest
1. Palmetto Health workforce members must not engage in any activity that interferes or appears to interfere with his/her judgment
in situations where the employee’s personal interest might detract from or conflict with the best interest of Palmetto Health, its
customers and/or suppliers.
1.1 Workforce members will not use his/her position, or any knowledge gained from his/her position, in such a way that a
conflict of interest, the appearance of impropriety or personal gain might arise between the interest of Palmetto Health, the
interest of the workforce member, members of the workforce member’s family, individuals with whom the workforce member
is associated and/or businesses with which the workforce member is associated. Outside employment is included in this
definition.
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1.2
1.1.1 Workforce members will disclose any situation where a potential conflict of interest might arise. Examples include but
are not limited to moonlighting, second businesses, and family/friend/employment/ownership with a competitor, vendor
and/or government agency.
1.1.2 Workforce members will not in any way attempt to use his/her employment to influence a Palmetto Health decision in
which the workforce member, a member of his/her family, an individual with whom he/she is associated or a business
with which he/she is associated or has an economic interest in or where the workforce member may experience
personal gain. For Richland Memorial Hospital workforce members leased to Palmetto Health, these terms are defined
in the State Ethics Act. A copy of the State Ethics Act is available in the Office of the General Counsel, the Human
Resource office and the office of the Chief Compliance Officer.
1.1.3 Should a situation arise wherein any of the above scenarios exist, full disclosure to a vice president, corporate officer or
Compliance Officer is required in addition to disclosure on the Potential Conflict of Interest form, see Potential Conflict
of Interest PGR.
Palmetto Health workforce members will not trade in the securities of any company, or buy and/or sell any property or assets,
on the basis of information acquired through his/her employment, whether such information comes from Palmetto Health or a
company with which Palmetto Health has a confidential relationship.
Confidentiality
2. The dissemination of Palmetto Health’s proprietary information is closely controlled. Except as specifically authorized by management
pursuant to established policy or procedure, workforce members should not disclose to any outside party any non-public business,
financial, personnel, commercial or technological information, plans or data acquired during employment at Palmetto Health.
2.1 Palmetto Health workforce members should disseminate these types of information only to individuals with a “need to know”
and should protect such information from access by unauthorized personnel.
2.2 Upon termination of employment, an individual may not copy, take or retain any documents containing Palmetto Health’s
restricted information. The prohibition against disclosing Palmetto Health’s restricted information extends beyond the period
of employment as long as the information is not in the public domain. An individual’s agreement to continue to protect
the confidentiality of such information after the term of employment ends is considered an important part of that person’s
obligation to Palmetto Health.
2.3 Workforce members must strictly safeguard all confidential information with which they are entrusted and must never discuss
such information outside the normal and necessary course of Palmetto Health’s business.
2.4 All workforce members must protect the confidentiality of all patient records and the information contained therein. Records
containing documentation related to sensitive information like alcohol abuse, drug abuse, psychiatry, HIV status, etc. are to be
kept extremely confidential.
2.5 Workforce members must also respect and protect the confidential nature of personnel and employee health records.
2.6 Those associated with Palmetto Health shall not seek, use, or disseminate information for which they do not have a need or
right to know to perform their direct responsibilities. This also applies to employees accessing their own personal information.
2.7 Workforce members agree to abide by Palmetto Health policies regarding confidentiality of information as well as federal and/
or state law including the Health Insurance Portability and Accountability Act known as HIPAA.
2.8 Palmetto Health does not solicit any sensitive proprietary internal government information, including budgetary, program or
source selection information before it is available through normal processes.
Substance Abuse
3. Palmetto Health provides its workforce members and customers with an environment that is free of abuse of controlled substances
and alcohol. As a part of this commitment, Palmetto Health has an established Human Resource Substance Abuse policy that
workforce members should abide by.
Implementation Of Palmetto Health’s Code Of Conduct
1. Upon initial adoption by the Board, a copy of this Code was provided to all workforce members. Thereafter, workforce members will
sign a Statement of Understanding (Exhibit A) both at the time of employment and on an annual basis thereafter.
1.1 Signing of this Statement will be done in conjunction with the training requirements set forth in the Corporate Compliance
Compliance Education & Training PGR and in accordance with Organizational Development education requirements.
1.2 New workforce members will sign the Statement within (30) days of initial employment and then on an annual basis in
conjunction with the training requirements set forth in the Program.
1.3 All signed original Statements will be included in the workforce member’s Human Resources personnel file.
Training
1. In consultation and coordination with Palmetto Health’s Chief Compliance Officer, the Senior Vice President of Human Resources will
ensure all workforce members participate in annual compliance training dealing with laws, the Program and/or this Code.
2. The Compliance Officer for Human Resources will establish other training or dissemination of information to all workforce members
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concerning the necessity to comply with all applicable laws and with this Code, including the continuation of existing compliance
programs such as Medicare/Medicaid billing compliance.
3. Individual departments will provide department-specific training to workforce members as appropriate.
Report To The Board Of Directors
1. At least annually, the Chief Compliance Officer or his/her designee will report to the Board concerning:
1.1 Palmetto Health’s adherence to the standards of legal and ethical conduct contained in this Code; and
1.2 the Program, in general.
Reporting Violations And Discipline
1. Strict adherence to this Code is vital. Supervisors are responsible for ensuring workforce members are aware of and adhere to its
provisions. For clarification or guidance on any point in the Code, consult a Compliance Officer.
2. Workforce members must report any suspected violations of the Code or other irregularities to their supervisor or a Compliance
Officer.
2.1 If the workforce member wishes to remain completely anonymous, that workforce member may submit his/her report through
the Compliance Hotline ((1-888-398-2633 or http://palmettohealth.silentwhistle.com). The number and website address have
been posted throughout Palmetto Health and have been communicated to workforce members through various Palmetto
Health publications. All reports must contain sufficient information for the Chief Compliance Officer to investigate the concerns
raised.
3. No adverse action or retribution of any kind will be taken by Palmetto Health against any workforce member because he/she reports
in good faith a potential violation of this Code or other irregularity.
4. Palmetto Health will treat such reports confidentially and protect the identity of the workforce member who has made a report to the
maximum extent consistent with fair and rigorous enforcement of the Code unless state and/or federal law require they be divulged.
5. Upon receipt of one or more credible reports of potential violations or irregularities, the Chief Compliance Officer will investigate and
implement corrective action where appropriate.
6. Violations of the Code may result in discipline ranging from warnings and reprimand to discharge or, where appropriate, the filing of
a civil or criminal complaint. Disciplinary decisions will be made according to Human Resources policy, and may be reviewed by the
Chief Compliance Officer. Workforce members will be informed of the charges against them.
7. Management may be sanctioned for failure to adequately instruct their subordinates or for failing to detect non-compliance with
applicable policies and legal requirements, where reasonable diligence on their part would have led to the discovery of any problems
or violations and given Palmetto Health the opportunity to correct them earlier.
Reservations of Rights
1. Palmetto Health reserves the right to amend the Code, in whole or in part, at any time and solely at its discretion.
Signature on File
Jerome D. Odom, PhD
Chairman of the Board
Signature On File
Effective March 5, 1998
Revised December 1, 2011
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EXHIBIT A
Corporate Compliance Program
December 1, 2011
STATEMENT OF UNDERSTANDING OF AND COMPLIANCE WITH PALMETTO HEALTH CODE OF
CONDUCT
I have attended Palmetto Health’s Corporate Compliance Program training and agree to abide by its policies and procedures during the
entire term of my employment. I acknowledge that I have been provided a copy of the Code of Conduct and have a duty to report any
alleged or suspected violation of this Code of Conduct or the Corporate Compliance Program to a Compliance Officer. Unless otherwise
noted below under Comments, I am not aware of any possible violation of the Code of Conduct or the Corporate Compliance Program.
I will report any potential violation of which I become aware promptly to a Compliance Officer. I understand that any violation of the
Corporate Compliance Program, the Code of Conduct or any other corporate compliance policy or procedure is grounds for disciplinary
action, up to and including discharge from employment.
I also certify that I have not been convicted of, or charged with, a criminal offense related to healthcare nor have I been listed by a federal
agency as debarred, excluded, or otherwise ineligible for participation in federally funded healthcare programs.
Comments: Please check the appropriate box:
I certify that this is my first review of this Code of Conduct Policy and Corporate Compliance Program following either initial adoption
of this Policy or my initial employment.
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I certify that this is my annual review of this Code of Conduct Policy and Corporate Compliance Program.
Signature
Date
Printed Name
Department
Campus
I.D. Number
GME Policies
Confidentiality
Palmetto Health recognizes that patients expect and deserve that all information pertaining to them be strictly limited only to those
who need to know that information. Palmetto Health considers a breach of confidentiality to be a serious event and considers any
inappropriate disclosure of patient or business information a violation of trust that jeopardizes the mission and survival of the organization.
GUIDANCE:
1. Those associated with Palmetto Health shall not seek, use, or disseminate information for which they do not have a need or right
to know to perform their direct responsibilities. This also applies to employees accessing their own personal information. Refer to
“Accessing PHI” policy in Compliance Manual.
2. Those who have access to patient and business information must protect and utilize this information with the greatest level of care.
Failure to protect confidential information will result in disciplinary action up to and including discharge.
3. Confidential patient and business information is produced, transmitted, and displayed through a variety of media and methods. These
methods include but are not limited to: person to person conversations, electronic mail, computer display screens, printed reports
and documents, telephone (land line) and cell phone (radio transmission) conversations, fax machines, copy machines, computer
disks, etc. Employees must at all times take precautions to prevent inadvertent disclosure of confidential information, including
information that is being shred or destroyed.
4. Those who do not need access to patient or business information but gain access willfully, and as a result, breach either the integrity
of patient care or the business operations of the organization, will be disciplined up to and including discharge.
5. Those who gain access to patient information inadvertently, whether within the organization or outside it, have a responsibility to
protect the confidentiality of patient and business information and to take action to stop the further dissemination of confidential
information.
6. The degree to which the integrity of this policy is breached will determine the level of discipline.
7. Statements of confidentiality will be provided and acknowledged by all associated with Palmetto Health.
8. Requests for references, addresses, telephone numbers, etc pertaining to employees of Palmetto Health are to be referred to Human
Resources for appropriate action. Health information maintained by Employee Health on employees is confidential and may not be
accessed by anyone other than the Employee Health staff.
9. Requests for medical information about patients or requests for copies of patient records are to be referred to the Health Information
Management department. Refer to the Palmetto Health Compliance Manual, Accessing PHI Policy.
10. ALL INQUIRIES by the news media, law enforcement agencies, etc, for interviews, patient condition status reports, or any other
coverage involving the hospital, employees, patients, or visitors shall be referred to Corporate Communications or its designate as
appropriate. When Corporate Communications is closed, these requests should be referred to the administrative representative oncall at the appropriate facility. Refer to Palmetto Health Media/Public Requests for Patient Information Policy.
Signature on File
Gwen Hill
Signature On File
Effective August 1, 2007
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Conflict Of Interest (Potential)
Facility: Palmetto Health
Effective: July 17, 2000
Revised: August 10, 2004; October 1, 2007; October 1, 2008; October 1, 2009; December 1, 2010; December 1, 2011
Name of Associated Policy: Code of Conduct
DEFINITIONS:
1. Potential Conflict(s) of Interest: any circumstance in which a workforce member’s activities, financial interests, positions or
associations outside of Palmetto Health potentially conflict with his/her professional responsibilities. Such circumstances may be
created through business, financial or investment activities of the workforce member, his/her family members and/or close relations.
Potential conflicts occur when the above named parties:
1.1. have a present or potential ownership, investment or compensation arrangement in any entity providing or receiving goods or
services from Palmetto Health;
1.2. serve as a member, shareholder, trustee, owner, partner, director, officer, workforce member or volunteer of any organization
that competes or has the potential to compete with Palmetto Health;
1.3. serve as a member, shareholder, trustee, owner, partner, director, officer, workforce member or volunteer of any organization
currently or likely to become involved in litigation or other adversarial proceeding with Palmetto Health; or
1.4. provide regulatory, inspection, supervision, accreditation or other oversight to Palmetto Health.
Potential conflicts of interest include but are not limited to moonlighting, second businesses, and relative/friend employment/
ownership with a competitor, vendor and/or government agency.
2. Family Member: an individual who is the spouse, parent, brother, sister, child, mother-in-law, father-in-law, son-in-law, daughter-inlaw, grandparent or grandchild or a member of the individual’s immediate family.
3. Hatch Act: The Hatch Act is the 1939 law that regulates the political activities of federal employees and some state and local
government workers. It applies to those who are principally employed in connection with programs financed in whole or in part by
loans or grants made by the United States or a federal agency. Employees of private nonprofit organizations are covered by the Hatch
Act if the statute through which the organization receives its federal funds contains language that states the organization shall fall
under the guidelines of the Hatch Act.
4. Workforce Members: for purposes of all policies contained in the Compliance Manual, refers to employees, independent
contractor, volunteers, students, trainees, medical residents, fellows and other persons whose conduct in the performance of work
for Palmetto Health is under the control of the organization.
Workforce Members
EQUIPMENT NEE DED: N/A
1. Workforce members shall disclose any situation wherein a potential conflict of interest might arise via the Conflict of Interest form.
1.1 Potential conflicts of interest will be evaluated on a case by case basis.
2. Workforce members will not use their position, or any knowledge gained from it in such a way that a conflict of interest, the
appearance of impropriety or personal gain might arise between the interests of the system, the interests of the workforce member
or volunteer, members of the workforce member’s or volunteer’s immediate family, individuals with whom the workforce member or
volunteer is associated, and/or businesses with which the workforce member or volunteer is associated. Outside employment is
included in this definition.
3. No workforce member may participate in making a system decision or in any way attempt to use his/her employment or association
to influence a system decision in which he/she, a member of his/her immediate family, an individual with whom he/she is associated
or a business with which he/she is associated has an economic interest or where the workforce member or volunteer may experience
personal gain.
4. Workforce members subject to the Hatch Act may not
4.1. be candidates for public office in a partisan election;
4.2. may not use official authority or influence to interfere with or affect the results of an election or nomination; or
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4.3.
directly or indirectly coerce contributions from subordinates in support of a political party or candidate.
5. Disclosure of Potential Conflicts of Interest:
5.1. Workforce members will complete and sign a potential conflict of interest disclosure statement accurately reflecting potential
conflicts during the following times:
5.1.1. within 30 days of employment/association with Palmetto Health (during new workforce member in-processing);
5.1.2. annually; and
5.1.3. at any time between reviews if a workforce member’s situation changes.
5.2. If a potential conflict is reported, the form must be sent to Corporate Compliance for review. These forms will be sent to
Human Resources and included in the workforce member’s personnel file.
5.3. Any disclosed potential or actual conflict of interest must be reviewed by a vice president, corporate officer, compliance officer,
management representative or his/her designee.
6. Non-Compliance:
6.1 Failure to comply with this PGR may result in disciplinary action up to and including discharge.
7. Retention:
7.1 The Conflict of Interest Disclosure Statement will become a permanent part of the workforce member’s personnel file and will
be maintained in the appropriate area.
REFERENCES:
Hatch Act 5 §§U.S.C. 1501-1508
Sponsoring Department: Corporate Compliance (803) 296-5044
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GME Policies
Corporate Compliance Program
Corporate Compliance
December 1, 2011
Part I
POTENTIAL CONFLICT OF INTEREST PGR ACKNOWLEDGEMENT FORM
I hereby acknowledge that I have received a copy of the Potential Conflict of Interest procedure. I have read and understand the
procedure. I hereby agree to be legally bound by and comply with the Potential Conflict of Interest procedure as a condition of my
continued employment with Palmetto Health. I have made all disclosures required by the Potential Conflict of Interest procedure. Failure to
comply may result in disciplinary action up to and including discharge.
Date
Campus
Department
Print Name
Signature
ID Number
Part II
POTENTIAL CONFLICT OF INTEREST DISCLOSURE STATEMENT
I hereby certify that either I or my relative (s) have interests, as defined in the Corporate Compliance Program’s Potential Conflict of Interest
procedure in the organization(s) listed below that are currently conducting business with Palmetto Health or are in competition with
Palmetto Health now or in the future. I will not use my position for personal gain or to influence a decision concerning these organization(s).
Examples are not inclusive: moonlighting, second businesses, and relative/friend employment/ownership with a competitor, vendor and/or
government agency.
Relationship to Employee
Organization Name
128
Date
Campus
Department
Describe the Relationship
with the Organization
Print Name
Signature
ID Number
GME Policies
Disciplinary Action
Employees and Residents are expected to observe basic rules of good conduct and perform their roles in an
efficient and productive manner. Rules for the acceptable conduct and performance of employees and residents
are necessary for the orderly operation of Palmetto Health and protection of the rights and safety of all residents,
employees and patients. It is for those few incidents when conduct or performance is unsatisfactory that policies
on discipline are established. Disciplinary action will be taken for the purpose of developing or maintaining
orderly conduct. It is expected that willful or inexcusable breaches of rules or regulations will be dealt with firmly
throughout Palmetto Health. Most of the actions listed within this policy will be confined to negative actions which
will be invoked in the event of unacceptable conduct or performance.
GUIDANCE:
1. Program Directors should promptly counsel residents for unsatisfactory performance and acts that are not in keeping with the
standards, rules, and regulations of Palmetto Health.
2. All disciplinary actions must be documented in writing by the Program Director. The Program Director must include specific
information regarding the event and specific corrective action to be taken, or that has been taken. It should be discussed with and
signed by the resident to indicate that he/she has read and received a copy of the action. (Signing the document does not necessarily
mean the resident agrees with the action.) If he/she desires to write a rebuttal, he/she should be permitted to do so and it will
become a part of the record. Copies of the document are to be distributed to those concerned, and the original will be retained in the
resident’s permanent file.
3. It is not possible to list all acts or omissions which might result in disciplinary action or even in dismissal. Included in the following list
are examples of unacceptable conduct that may lead to discipline, up to and/or including termination. If any question exists regarding
the proper approach to take on a disciplinary matter, the DIO is to be contacted. Human Resources may also be consulted.
OFFENSES AND DEFICIENCIES:
»» Absent without authorization
»» Accepting Gratuities
»» Alcohol abuse
»» Breach of confidence
»» Breach of trust
»» Breach of Palmetto Health Standards of Behavior
»» Creating a hostile environment
»» Drug abuse
»» Excessive absenteeism
»» Excessive tardiness
»» Fighting on hospital premises
»» Failure to attend mandatory training
»» Failure to report illness/injury or infectious/contagious disease
»» Fraud
»» Gambling on hospital premises
»» Harassment of any type on the basis of race, sex, age, religion
or handicap
»» Having unauthorized visitors while on duty
»» HIPAA Violation
»» Insubordination
»» Lying
»» Misuse of Internet/Intranet
»» Mistreatment of patients
»» Negligence
»» Repeated personal financial obligations that involve the hospital
in wage attachment, correspondence, phone calls, etc.
»» Smoking in unauthorized areas
»» Theft
»» Unauthorized distribution of written material of any description
»» Unauthorized and/or illegal possession of firearms, weapons,
or explosives inside any owned/leased facility
»» Unauthorized solicitation on premises
»» Use of malicious or profane language
»» Violation of municipal, state or federal statute or regulation
»» Violation of Palmetto Health parking or traffic rules
»» Violation of Safety Code policies
»» Violation of non-discrimination policies
»» Willful destruction or misuse of hospital property or equipment
»» Willful falsification of records
»» Willful mistreatment of patients
»» Willful negligence
February 24, 2010
February 12, 2013
Signature on File
Signature On File
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GME Policies
Dismissal Of Residents
A resident may be dismissed “for just cause.” In all cases, however, the resident has the right to appeal the decision
in accordance with the resident Grievance and Due Process Policy.
PROCEDURES:
1. A resident may be dismissed “for just cause”. Causes for dismissal include, but are not limited to, the following:
1.1 Incapacitating illness, which in the judgment of the resident’s Program Director precludes the resident from participation in the
graduate medical education program and patient care activities.
1.2 Failure by the resident to abide by policies of Palmetto Health’s teaching hospitals, GMEC policies, departmental policies, and
resident-related provisions of the Medical and Dental Staff Bylaws/Rules and Regulations of the teaching hospitals.
1.3 Failure by the resident to demonstrate, meet, or maintain satisfactory levels of academic, professional, and/or clinical
performance required by the residency programs .
1.4 Failure by the resident to comply with licensure, registration, or certification requirements and/or failure by the Resident to
maintain authorization for employment in the United States.
1.5 Actions which directly violate any of the terms of the resident agreement of appointment.
1.6 Willful or inexcusable breaches of Palmetto Health’s rules or regulations (see Disciplinary Action policy).
1.7 Unprofessional conduct or behavior by the resident which in the opinion of the Program Director and Palmetto Health,
interferes with the performance of the activities provided for under the resident agreement of appointment and/or which are
determined by the Program Director and the Hospital to be unsatisfactory for members of Palmetto Health’s House Staff. (See
Disruptive Conduct Policy)
2. The Program Director will present the recommendation for dismissal to the GMEC.
3. The GMEC will officially act on the recommendation.
4. The GMEC Executive Subcommittee may impose temporary action (e.g., suspension) until the GMEC meets.
5. The Program Director will notify the resident/fellow of dismissal decision and will collect identification badges, keys, and any other
facility and records access items.
6. DIO will notify GME officials and direct them to notify appropriate parties to ensure that resident/fellow access to electronic medical
records and other privileged residency systems is terminated.
7. In the event of dismissal, the resident has the right to appeal the decision in accordance with the Resident Grievance and Due
Process Policy.
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December 7, 1993
February 12, 2013
Signature on File
Signature On File
GME Policies
Disruptive Behavior
The purpose of this policy is to:
• create and maintain an environment free from intimidating, disruptive, threatening or violent behavior;
• establish a policy regarding disruptive resident behavior that ensures residents conduct themselves in a
professional, cooperative manner while providing services as members of the patient care team;
• encourage the prompt identification and resolution of alleged disruptive behavior by all involved or affected
persons through information, collaborative efforts at counseling and rehabilitation;
• coincide with the existing Palmetto Health Medical Staff Disruptive Conduct policy in MEC Bylaws.
DEFINITION:
Disruptive behavior includes verbal or physical attacks, and inappropriate comments. Disruptive behavior is any conduct of behavior
included but not limited to:
»» Use of language that is profane, vulgar, sexually suggestive or explicit
»» Degrading racial, ethnic, or religious slurring in any professional setting related to the care of patients
»» Unwanted touching, sexually-oriented or degrading jokes or comments
»» Obscene gestures or throwing objects
»» Oral or written threats to a person or property, whether in person or o via email or other means of communication
»» Making inappropriate comments about each other or patients that jeopardize or interfere with quality patient care or ability for others
to provide quality patient care
»» Unethical behavior
»» Physical or verbal abuse of others involved with providing patient care and/or educational instruction
»» Inappropriate conduct that reflects in a negative way on the Hospital or University
»» Some behaviors which may be disruptive are UNLAWFUL as well (discrimination, sexual harassment, retaliation)
1. It is the expectation that residents behave in a professional, courteous, and cooperative manner.
Residents are expected to:
»» Address dissatisfaction through appropriate channels provided
»» Accept and incorporate feedback in a thoughtful and non-defensive manner
»» Cooperate and communicate with all Hospital and University staff with respect and displaying regard for their dignity
»» Be truthful in all written and verbal communications
2. Disruptive behavior by residents, or refusal to cooperate with procedures described in this policy, may result in disciplinary action. This
will enable the necessary actions to ensure a safe working environment or to prevent unlawful conduct. Individuals who violate this
policy may be subject to disciplinary action according to the level of severity. Residents identified as demonstrating disruptive behavior
may be subject to:
»» Counseling/Written warning, probation, suspension or termination.
3. Classification of severity:
Level 1: Physical violence or other physical abuse including sexual harassment involving physical contact.
Level 2: Verbal abuse such as unwarranted yelling, swearing, or cursing; threatening, humiliating, sexual or otherwise inappropriate
comments directed at a person or physical violence or abuse directed in anger at an inanimate object.
Level 3: Verbal abuse that is directed at-large, but has been reasonably perceived and witnessed to be disruptive behavior as
defined above.
4. The training programs and clinical services shall promote continued awareness of these issues in the following ways:
»» Sponsoring educational programs on disruptive behavior for residents and faculty
»» Dissemination of this policy to educate current residents and faculty of its adoption
»» Requiring that E-Care be accessed to assist a resident who exhibits disruptive behavior to obtain education, behavior modification
and treatment to prevent further violations.
February 24, 2010
February 12, 2013
Signature on File
Signature On File
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GME Policies
Disruptive Behavior Procedure
PROCEDURE:
Complaints about a resident regarding alleged disruptive behavior must be written, signed and directed to the resident’s Program Director
(see attached Confidential report of Incident of Disruptive behavior form).
Level 1: The Program Director or designee, with the advice of GME/legal counsel:
Interviews the complainant and any witnesses within one business day of receiving the complaint. The resident is given the opportunity to
respond in writing. The Program Director may:
1. determine that no action is warranted
2. issue a warning
3. require a written apology to the complainant
4. refer resident to E-Care
5. initiate disciplinary action pursuant to GME Resident policies/procedures
Level 2: The Program Director or designee:
Interviews the complainant and any witnesses within 5 business days of receiving complaint and interviews the resident within 5 business
days. He/she provides an opportunity for the resident to respond in writing. The Program Director may:
2. issue a warning
Level 3: The Program Director or designee:
Interviews the complainant and any witnesses within 10 business days of receiving the complaint. The resident is provided the opportunity
to respond in writing. The Program Director may:
2. issue a warning
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GME Policies
Disruptive Behavior
Incident Reporting Form For Residents
TO: Program Director
Date, time and location of incident:
Date: Time: Location: Description of Incident:
Please describe the behavior observed as factually and objectively as possible. Include the behavior and all relevant details (use a separate
sheet if necessary)
Others Present: Did the behavior affect or involve a patient: Yes
No
If yes, provide the patient’s name: Describe the effect the resident’s/fellow’s behavior had on patient care or Hospital operations:
Action Taken:
Was a supervisor, attending (clinical dept chief), chief resident, management, or any other entity notified of the incident?
Yes
No
Name of Person Notified: Was any further action taken? If yes, please provide date, time and description of action taken:
Name of Person Reporting: Position: Date Form Completed: Reviewed February 14, 2012
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GME Policies
Dress Code And Personal Appearance
Professionalism in dress reinforces Palmetto Health’s quality reputation. Our appearance communicates how we
feel about our organization and the work we do. Residents are expected to maintain an appearance that is neat,
clean and professional as determined by the requirements of the area in which the resident is working and the
nature of the work being performed.
PROCEDURES:
1. FRAGRANCES (perfumes, colognes, after shaves, etc.): Fragrances will not be worn while on duty as it may cause potentially
harmful allergic reactions to patients or coworkers.
2. JEWELRY/MAKE-UP: Jewelry and make-up should be worn conservatively and appropriately. Any visible piercing is limited to ears
only.
3. FINGERNAILS: In clinical areas, as determined by each campus, natural fingernails should be kept clean, well manicured, and less
than ¼ inches long, and nail polish must not be chipped or cracked. Artificial fingernails or extenders including nail wraps, overlays,
and nail jewelry are also not to be worn in those clinical areas.
4. HAIR: The length, cleanliness and styling of hair, including facial hair, shall conform to generally accepted business and professional
standards. Hair color must be limited to colors that occur naturally (i.e. pink, green, etc., are not naturally occurring hair colors). When
involved in direct patient care, hair must be worn off the shoulders, pulled back away from the face, and secured.
5. TATTOOS: All visible tattoos must be covered.
6. EMPLOYEE ID BADGE: The ID Badge is part of each resident’s official attire and must be worn at all times. The ID Badge should
be clearly visible and worn above the waist, preferably on the lapel area. The ID Badge must remain in the forward facing position at
all times.
7. IN TRANSIT TO AND FROM WORK: Because residents represent the organization both on duty and off duty they must be
dressed appropriately when coming to work and when leaving work.
8. INAPPROPRIATE APPAREL: All apparel must be worn conservatively (i.e. no bare midriffs or low cut shirts/blouses). Shorts, denim
jeans and t-shirts are prohibited, unless exceptions to this rule are made by the individual’s department head for special occasions.
9. SOCKS/HOSIERY: Hosiery or socks should be worn, as appropriate.
10. SHOES: Shoes should be clean and polished. Excessively high heels and open toed shoe are not permitted where safety or health is
a concern. Beach sandals or flip flops are inappropriate in a professional setting and shall not be worn.
11. DRESSES/SKIRTS: Dress, skirt and pants’ hem lines must be maintained at an appropriate length.
12. LAB COATS: Lab coats are provided and should be worn in all patient care settings.
13. SCRUB SUITS: Hospital owned scrub suit attire is provided in certain special treatment areas. If residents do not change out of
scrubs when leaving these scrub specialty areas, lab coats must be worn over scrubs. Shoe and head covers must be removed and
appropriately disposed of.
14. Appropriateness of grooming and dress is a highly subjective matter; therefore, Program Directors are responsible for ensuring
compliance with the dress code. Any resident who is in violation of the standards above may be sent home to change and return to
duty. For repeated offenses residents may be subject to disciplinary action.
134
February 10, 2004
February 12, 2013
Signature on File
Signature On File
GME Policies
Duty Hours
The provision of safe, high quality patient care guides all decisions regarding resident duty hours. Learning
objectives of the residency program must not be compromised by excessive reliance on residents to fulfill service
obligations.
DEFINITION:
Duty hours are defined as all clinical and academic activities related to the residency program, i.e., patient care (both inpatient and
outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house during call activities,
including short call, home call, night float, day float, and scheduled academic activities such as conferences. Duty hours do not include
reading and preparation time spent away from the duty site.
PROCEDURES:
1. All programs will comply with the Common Program Requirements with regard to duty hours. Areas of non-compliance will be
addressed in a timely manner. In addition, residency programs must also comply with their own RRC specialty requirements with
regard to duty hours. These will adhere to the following principles:
1.1 All duty hours must reflect the concept of safe, quality patient care.
1.2 Duty hours must be limited to 80 hours per week, averaged over a four-week period. All in-house call activities, including time
spent in the hospital when taking call from home, are included. All internal and external moonlighting hours are included. PGY1 residents are not permitted to moonlight.
1.3 The resident must be scheduled for a minimum of one day free of duty every week (when averaged over 4 weeks). At home
call will not be assigned on these free days.
1.4 Duty periods of PGY-1 residents must not exceed 16 hours in duration.
1.5 Duty periods of PGY-2 residents and above may be scheduled to a maximum of 24 hours of continuous duty in the hospital.
1.5.1 Programs must encourage residents to use alertness management strategies in the context of patient care
responsibilities. Strategic napping, especially after 16 hours of continuous duty and between the hours of 10:00 p.m.
and 8:00 a.m., is strongly suggested.
1.5.2 Residents may remain onsite for effective transitions in care; however this period of time must be no longer than an
additional 4 hours.
1.5.3 Residents must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty.
1.5.4 In unusual circumstances, residents on their own initiative may remain beyond their scheduled period of duty to
continue to provide care to a single patient. Justifications for such extensions of duty are limited to reasons of required
continuity for a severely ill or unstable patient, academic importance of the events transpiring, or humanistic attention
to the needs of a patient or family. Documentation of the reason for remaining to care for the patient in question must
be submitted to the program director, who must review and track individual resident and program wide episodes of
additional duty.
1.6 PGY-1 residents should have ten hours, and must have 8, free of duty between scheduled duty periods.
1.7 Intermediate-level residents (as defined by RRCs) should have ten hours, and must have 8, free of duty between scheduled
duty periods. They must have at least 14 hours free of duty after 24 hours of in-house duty.
1.8 Residents in their final years of education (as defined by RRCs) should have 8 hours free of duty between scheduled
duty periods. Residents in their final years may stay on duty or return to the hospital with fewer than 8 hours free of duty.
Circumstances of return to hospital activities with fewer than 8 hours away must be monitored by the program director.
1.9 Residents must not be scheduled for more than 6 consecutive nights of night float.
1.10 PGY-2 residents and above must be scheduled for in –house call no more frequently than every 3rd night, when averaged over
a 4 week period.
1.11 Time spent in the hospital by residents on at home call must count toward the 80 hour weekly maximum limit.
1.11.1The frequency of at home call is not subject to the every third night limitation, but must satisfy the requirement for 1 day
in 7 free of duty, when averaged over 4 weeks.
1.11.2Each episode of return to the hospital while on at home call must be included in the 80 hour weekly maximum, but will
not initiate a new off duty period.
2. These policies and procedures will be submitted to the GMEC for approval and annual review.
3. Each resident must honestly and accurately log their duty hours online in New Innovations. This can be done on a daily or weekly
basis.
4. The program director will investigate any exception to duty hour requirements. Duty hour reports are presented to the GMEC for
monitoring.
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GME Policies
5. GMEC will not entertain requests to extend the weekly duty hours limit beyond 80 hours.
136
August 4, 1993
February 12, 2013
Signature on File
Signature On File
GME Policies
Fatigue Management and Mitigation
The ACGME requires all training programs to educate faculty and residents to recognize the signs of fatigue and
sleep deprivation.
PROCEDURES:
1. The Sponsoring Institution oversees:
a.
Resident/fellow duty hours (See Duty Hours Policy)
b.
systems of care and a learning and working environment that facilitate fatigue management and mitigation for faculty members
and residents/fellows;
c.
educational programs for faculty members, residents and fellows in fatigue management and mitigation.
2. Programs must:
a.
Educate all faculty members and residents to recognize the signs of fatigue and sleep deprivation;
b.
Educate all faculty members and residents in alertness management and fatigue mitigation processes;
c.
Adopt fatigue mitigation processes to manage the potential negative effects of fatigue on patient care and learning, such as
naps or backup call schedules; and
d.
Have a process to ensure continuity of patient care in the event that a resident/fellow may be unable to perform his/her patient
care duties.
3. For residents who are too fatigued to safely return home, several options are available through the Office of Graduate Medical
Education including:
a.
Call Room Space is available on an as needed basis for residents who are too fatigued to safely return home.
b.
If a call room is unavailable, residents may utilize a taxi service to return home safely and submit the bill to the GME office for
reimbursement.
4. Each program must develop a contingency plan to manage the transfer of clinical care responsibilities from a fatigued resident. (See
Transitions of Care Policy)
February 14, 2012
February 12, 2013
Signature on File
Signature On File
137
GME Policies
Grievance And Due Process
Residents are provided a process for resolving academic and job-related complaints. This includes grievances
related to evaluations or disciplinary actions which could result in probation, suspension, dismissal, non-renewal
of a resident/fellow’s agreement of appointment, non-promotion to the next level of training, or other actions that
could significantly threaten a resident/fellow’s intended career development, as well as complaints and grievances
related to the work environment or issues related to the program or faculty.
PROCEDURES:
1. Grievance Steps:
1.1 A resident who has a dispute or grievance must discuss this with his/her Program Director who will make every effort to
resolve the matter within seven (7) calendar days from the date the discussion was held.
1.2 If the response is unsatisfactory to the resident, the resident must discuss the complaint or grievance with his/her Chair/
Director of Education, who will make every effort to resolve the matter within seven (7) calendar days from the date the
discussion was held. (If the Program Director is also the Chair/Director of Education, this step is skipped).
1.3 If the response is unsatisfactory to the resident, the resident must immediately request a meeting with the DIO. The request
must be made within seven (7) calendar days of the Chair/Director of Education’s response. The meeting with the DIO will be
conducted no more than ten (10) calendar days from the date of the request. The DIO will investigate and review the resident’s
grievance and will respond with a decision in writing to the resident within ten (10) calendar days from the date the meeting
was held.
1.4 If the response is unsatisfactory to the resident, the resident may appeal through Palmetto Health Human Resources to a
Dispute Resolution Committee by contacting the Senior Vice President for Human Resources within ten (10) calendar days
from the decision of the DIO.
1.5 If requested, Human Resources will assist the resident in preparing his/her grievance. No attorneys will be present during any
of the proceedings.
2. Dispute Resolution Committee:
2.1 The Dispute Resolution Committee proceeding should be held within twenty (20) calendar days of receipt of the request to
the Senior Vice President for Human Resources. If circumstances do not allow and the resident/fellow is fully informed of the
circumstances. The proceeding may be delayed beyond twenty (20) calendar days, but must be held within thirty (30) calendar
days of the request.
2.2 The Senior Vice President for Human Resources or his/her designee will select members of the Dispute Resolution
Committee, which will be composed of two residents and three faculty members, all of whom will be selected from a
program(s) other than the one from which the grievance is originating. The Senior Vice President for Human Resources will
chair the committee but will not vote on the outcome.
2.3 In addition to the above, the Chair/Director of Education and/or the Program Director of the aggrieved resident, the DIO, the
resident filing the grievance, the Human Resources employee assisting the resident in filing the grievance, if requested, and a
secretary for the purpose of taking minutes will be in attendance. The CMO may also be in attendance.
2.4 Witnesses, other employees, written materials, or other information beneficial to either party may be requested and considered
by the Committee. All hearings will be held in executive session and will be conducted under Palmetto Health rules for
resolving disputes. The tape recording and minutes of the proceedings will be subjected to the control and disposition of the
Senior Vice President for Human Resources.
2.5 All parties, except the Committee and the secretary, will be dismissed after the hearing is completed and before deliberations
begin. The Committee deliberations will not be taped. Voting will be by secret ballot. The decision of the Committee will be
communicated to the resident immediately following the hearing through the Senior Vice President for Human Resources. A
synopsis of the committee’s findings will be distributed in writing within seven (7) calendar days of the hearing to the resident,
Chair/Director of Education, Program Director, DIO, CMO, Senior Vice President for Human Resources or his/her designee,
and the CEO.
2.6 If the resident or the DIO is not satisfied with the decision of the Dispute Resolution Committee, within ten (10) calendar days
of receiving the committee’s written synopsis, either may request in writing through the Senior Vice President for Human
Resources that the dispute be submitted to the Chief Executive Officer. The Chief Executive Officer will respond within ten
(10) calendar days in writing, providing copies to the employee, Human Resources, DIO, and CMO. The decision of the Chief
Executive Officer will be final.
3. Grievance Timelines:
3.1. Failure to meet timelines or receive approval for extension of timelines will result in forfeiture of grievance rights under this
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3.2.
policy.
Requests to extend any deadlines in this process will only be considered based on extenuating circumstances:
3.2.1. Extensions will be considered only when requested in advance of deadlines.
3.2.2. The decision to extend a deadline will be made by the Senior Vice President for Human Resources (or his/her
designee).
3.2.3. Approvals for a delay will be documented and communicated to the parties involved by e-mail or letter.
June 30, 1989
February 12, 2013
Signature on File
Signature On File
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GME Policies
Harassment
Palmetto Health is committed to offering employment opportunity based on ability and performance in a productive
climate free of discrimination and unlawful harassment or retaliation. Accordingly, workplace harassment of any
kind by managers, supervisors, co-workers and non-employees (including temporary workers, customers, vendors,
visitors or independent contractors) will not be tolerated.
GUIDANCE:
1. In general, ethnic or racial slurs and other verbal or physical conduct relating to a person’s race, color, age, religion, gender, sex,
disability or national origin constitute harassment when they unreasonably interfere with the person’s work performance or create an
intimidating work environment.
2. Sexual harassment is a form of sex discrimination. It can consist of unwelcome sexual advances, requests for sexual favors, offensive
literature or pictures or other physical and verbal conduct of a sexual nature by managers, supervisors, co-workers and nonemployees in the workplace.
2.1. Sexual harassment exists when submission to unwelcome sexual advances, requests for sexual favors or verbal or physical
conduct of a sexual nature are made either an explicit or implicit basis for an employment decision (including hiring,
compensation, promotion or retention).
2.2. Sexual harassment may also exist when workplace conduct by any employee or non-employee creates an intimidating, hostile
or offensive work environment, unreasonably interferes with an individual’s work performance or otherwise adversely affects an
individual’s employment opportunities.
3. Although gender harassment may not be conduct of a sexual nature, it is equally unlawful and will not be tolerated by Palmetto
Health.
4. Any employee who feels that he or she has suffered any form of harassment from a supervisor, a co-worker, a physician, a patient,
a member of the general public, or a non-employee (including a temporary worker, customer, vendor, visitor or independent
contractor) MUST immediately report the alleged conduct to the employee’s supervisor or to Human Resources so that a confidential
investigation of the complaint can be undertaken. Complaints regarding physicians may be forwarded to the facility Chief Operating
Officer and/or the Medical Executive Committee. This investigation does not fall under the purview of a grievance. Accordingly, a
formal dispute resolution process will not be conducted.
5. All complaints of harassment will be treated as confidentially as possible and will be investigated as discreetly, promptly and
thoroughly as possible.
6. Any employee found by Palmetto Health to have harassed another employee will be subject to appropriate disciplinary action, up to
and including termination.
7. In addition, retaliation or discrimination against an employee for reporting or complaining about harassment is prohibited.
Signature on File
Gwen Hill
Signature On File
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GME Policies
Health Information Management (Medical Records) For
Inpatients
The resident is responsible for the preparation of a complete, legible, and current medical record for each patient.
PROCEDURES:
1. The resident will dictate or document via PowerNote all appropriate operative notes and discharge summaries and will sign all verbal
orders and progress notes during the patient stay and within timelines specified in medical staff policies. The resident will forward all
dictated H&Ps, Consults, procedure notes, transfer summaries, discharge/death summaries to the attending for signature. Failure to
do so will cause the document to be held as unauthenticated which requires manual intervention for release. Additionally, if a patient is
discharged within 48 hrs the resident must document the following in the final note:
a.
Final diagnosis and procedures performed
b.
Reason for hospitalization
c.
Care, significant findings, treatment, and services rendered
d.
Condition of patient on discharge
e.
Instructions to patient/family on physical activity, diet, medication and follow-up care
2. All PowerNotes must be named/titled appropriately i.e, History & Physical, progress note etc.
3. After a patient is discharged and all essential reports are received and placed on the record, the resident shall complete the medical
record within fifteen (15) days of discharge. If it is still incomplete at the end of this period, the attending physician will be assigned,
along with the resident/fellow, for completion. The record will be considered delinquent at this point.
4. The ability to admit and treat patients under the supervision of the attending may be suspended upon the above notification.
Suspension will be automatically rescinded upon completion of the delinquent medical records.
5. A resident on the delinquent list six (6) times during the academic year could have his/her ability to admit and treat patients under the
supervision of the attending suspended, and must submit a written justification for these delinquencies to the appropriate Director of
Education, the DIO, the Director of Health Information Management, and the Chief of Staff.
6. Further delinquency will result in the revocation of moonlighting privileges, probation, or suspension. In addition, a notation concerning
the above will go into the resident’s permanent record and will be referred to in correspondence requested by other organizations
and/or employers.
7. It is the responsibility of the resident to notify the Health Information Management Department upon completion of any delinquent
charts.
8. Any resident who cannot complete his/her medical records (due to vacation, long-term illness, or educational leave) must notify the
Health Information Management Department and the appropriate Director of Education.
9. Medical records not completed by the resident for any reason will be the responsibility of the resident’s attending physician at the time
of patient discharge.
October 6, 1992
February 12, 2013
Signature on File
Signature On File
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GME Policies
Health Information Management (Medical Records) For
Teaching Clinics
The attending and resident are responsible for documenting and signing each patient encounter. Documentation
shall be completed as quickly as possible to ensure continuity of patient care. The medical record will be delinquent
if not completed within 16 days from the date of service.
PROCEDURES:
1. Whether a paper or electronic medical record system is used in the clinic, the nurse, medical student and/or resident portion of the
clinic record must be completed timely and signed within 8 days of the service date. After signature by the resident, the record must
then be forwarded to the attending who was supervising in the clinic on the service date.
2. The attending must review the nurse, medical student, and/or resident entries in the patient’s record for accuracy and completeness,
and sign the resident’s record. When a separate attending note is required, the attending must complete their entry in the patient’s
record and sign it. The patient’s record must be completed within 16 days of the service date.
3. The resident entry and signature in patient records and the subsequent attending entry (when required) and signature in patient
records will be monitored for delinquent medical records. See the Delinquent Medical Records policy in the appropriate manual/
bylaws.
4. Medical records not completed by the resident for any reason will be the responsibility of the resident’s attending physician at the time
of patient encounter.
ADDITIONAL PROCEDURES FOR AN ELECTRONIC MEDICAL RECORD (EMR) SYSTEM:
1. For clinics with an EMR system, all providers (attendings, residents, medical students, nurses, etc.) practicing in a clinic are assigned
a personal login and must create a personal secure password for use with the EMR system. Each provider’s password must be kept
secure and confidential.
2. Each provider is then assigned or creates a unique electronic signature code that is linked to their login. This personal signature code
must be kept confidential and secure to ensure the integrity of the EMR system.
3. The unique signature code is entered to electronically sign a patient’s medical encounter. The chart is annotated with the phrase
“electronically signed by” along with the provider name, date and time.
4. When an EMR terminal is not in use, the terminal must be logged out or “parked” to protect patient confidentiality.
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February 5, 2002
February 12, 2013
Signature on File
Signature On File
GME Policies
Illness/Injury Reporting
Human Resources
Policy No. #125
Supervisors/employees must immediately report employee illness/injury to Employee Health if employee is out with
illness/injury or has a contagious/infectious disease process. A physician return-to-work statement is required for
hospitalization, surgery, contagious disease or worker’s compensation episode before employee returns to work.
Supervisors or Human Resources may require a physician return-to-work statement for an absence due to illness/
injury of any length.
GUIDANCE:
1. Supervisors/employees immediately report employee injury/illness or contagious/infectious disease process to Employee Health.
Injuries may be reported via myPal (no blood and body fluid exposures) or in-person.
2. Supervisors/employees report employee illness/injury to Human Resources if employee is out of work four days or longer, is
hospitalized, has outpatient surgery, or an absence due to a chronic health condition.
3. Absences shall be noted on the Bi-weekly Time and Attendance Report by the supervisor or department head.
Signature on File
Gwen Hill
Signature On File
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GME Policies
Impairment
The graduate medical education process provides for progressive authority and responsibility, conditional
independence and supervisory roles in patient care to be delegated to residents. Palmetto Health recognizes that a
variety of impairments, including substance abuse, may appear during residency training. Palmetto Health provides
appropriate and confidential support and counseling services for individuals so affected, and does so in a nonpunitive fashion.
PROCEDURES:
1. An educational overview of physician impairment is provided to all incoming residents during orientation. This topic is also covered in
each residency program’s didactic lecture series.
2. When resident impairment is suspected, the Program Director conducts a confidential internal investigation.
3. If after the above, resident impairment seems a possibility, the DIO is notified.
4. The DIO investigates the matter and, if necessary, consults expert and legal opinions.
5. The Department of Medical Education arranges appropriate counseling and support services for the impaired resident in a confidential
and non-punitive fashion.
6. Palmetto Health also provides confidential support and counseling services to residents and their spouses through the Palmetto
Health E-Care program. The first five (5) visits each year are provided as a free benefit. The DIO or the Director of Resident and
Student Services can facilitate confidential access to these services.
Note: See Substance Abuse Policy and “Substance Use and Dependency among Resident Physicians” article in Section A.
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June 27, 1995
February 12, 2013
Signature on File
Signature On File
GME Policies
Lewis Blackman Patient Safety Act
Palmetto Health will meet the requirements of the Lewis Blackman Hospital Patient Safety Act, which requires
the hospital to identify for patients the role of the attending physician and to provide a mechanism for patients to
access the attending physician. The Act also requires hospitals to have their clinical employees wear name badges
with their names, using at a minimum either first or last names with appropriate initials, department, job or trainee
title. Palmetto Health will meet the South Carolina law as interpreted and enforced by DHEC.
GUIDANCE:
In compliance with the Lewis Blackman Hospital Patient Safety Act, Palmetto Health has adopted the following policies.
1. Name Badges. All clinical staff, clinical trainees, medical students, interns, and resident physicians will wear badges clearly stating
their names, using at a minimum either first or last names with appropriate initials, their departments, and their job or trainee titles.
Clinical trainees, medical students, interns, and resident physicians will be clearly identified as such in terms or abbreviations
reasonably understandable to the average person.
2. Written Information Provided to Inpatients and Outpatient Surgery Patients. Prior to or upon admission, the hospital admission staff
will provide each patient with written information identifying the role of the attending physician and explaining that clinical trainees
may participate in their care. The written information will be provided to all persons admitted to the hospital, registered in outpatient
surgery and the emergency department. In all cases, the information will be provided in a document that is separate from the general
consent for treatment. The acknowledgement of the receipt of the Lewis Blackman Hospital Patient Safety Act Letter will be included
as part of the General Consent for Treatment form. The patient or their designee (Power of Attorney or Representative) will be asked
to initial the Lewis Blackman Hospital Patient Safety Act portion of the General Consent form. During admission assessment, nursing
will include the written information regarding the Lewis Blackman Hospital Patient Safety Act as part of orientation.
2.1. The written information must:
2.1.1. Explain that the patient’s attending physician is the person primarily responsible for the patient’s care;
2.1.2. Explain that the patient’s attending physician may change during hospitalization as their condition changes;
2.1.3. Explain that the patient’s nurse will help the patient contact the attending physician if the patient requests assistance;
2.1.4. Explain that the hospital has established a patient assistance system to help resolve any concerns that may not require
the attention of the attending physician; and
2.1.5. Instruct the patient how to access the patient assistance system.
2.2 When the hospital employs clinical trainees, the language below will apply. The written information will also include:
2.2.1 An explanation of the roles of clinical trainees, medical students, interns, and resident physicians in patient care; and
2.2.2 Notification that medical students, interns, or resident physicians may be participating in the patient’s care (by making
treatment decisions or by assisting or performing surgery on the patient).
3. Contacting the Patient’s Attending Physician. If at any time a patient requests that a nurse call his or her attending physician regarding
the patient’s personal medical care, the nurse will place a call to the attending physician or his or her “physician-on-call” to inform
him or her of the patient’s concern. If the patient is able to communicate with and desires to call his or her attending physician or
“physician-on-call”, upon the patient’s request, the nurse must provide the patient with the telephone number and assist the patient in
placing the call. The “physician-on-call” does not include a resident. A nurse or other clinical staff to whom such a request is made or
who receives multiple requests may notify his or her immediate supervisor for assistance.
3.1. If assistance is needed to get the attending physician or physician-on-call to respond timely, workforce members should
escalate the issue following the campus-specific Chain of Command policy.
4. Patient Assistance System. Palmetto Health will maintain a patient assistance system designed to help patients resolve their personal
medical care concerns in a prompt manner. A mechanism (telephone number, beeper number, etc.) will be established that allows the
patient to independently access the patient assistance system, and this mechanism may not require the patient to request assistance
in order to access the system. However, a clinical staff member or clinical trainee must promptly access the system on behalf of a
patient if the patient requests assistance. A representative of the hospital’s administrative or supervisory clinical staff must be available
at all times to respond to patient concerns. Once the patient assistance system has been contacted, the administrative or supervisory
clinical staff representative shall promptly assess (or cause to be assessed) the patient’s concern and provide appropriate follow up.
5. Documentation. Palmetto Health will document when a patient receives the written information and when a patient requests to speak
to the attending physician.
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REFERENCES:
S.C. Code of Laws, Article 27, Section 44-7-3410, Lewis Blackman Hospital Patient Safety Act.
S. C. Code of Laws, Article 27, Section 44-7-3430 of the 1976 Code, as added by Act 146 or 2005, Lewis Blackman Hospital Patient
Safety Act.
Effective June 8, 2005
Sponsoring Department: Corporate Compliance (803) 296-5044.
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GME Policies
Moonlighting And Other Professional Activities
Residency training is a full-time educational endeavor. Residents are not required to engage in moonlighting
or other professional activities outside the program. When residents are allowed to engage in extramural paid
activities, these activities must not interfere with the resident’s educational performance; nor must these activities
interfere with the resident’s opportunities for rest, relaxation and independent study.
PROCEDURES:
1. Each residency program maintains written policies and procedures concerning moonlighting and other professional activities outside
the program. These are submitted to the GMEC for annual review and approval.
2. In programs where these activities are allowed, the resident must complete the Palmetto Health moonlighting request form to request
approval. The form must be submitted to the Program Director and the DIO prior to arranging any moonlighting/other professional
activities. (Generally, the approval process requires two weeks.) This written request must include the number of moonlighting/other
professional hours per week requested. This information is made part of the resident’s file.
3. The number of hours that a resident is allowed to moonlight is determined by the Program Director with the concurrence of the DIO.
4. When residents and fellows participate in moonlighting, these moonlighting hours are counted toward the 80 hour work week limit.
5. PGY-1 residents are not eligible to moonlight.
6. Based on the U.S. Code of Federal Regulation and the United States Immigration and Naturalization Service, residents/fellows on J-1
visas are not permitted to moonlight under any circumstances.
7. It is the responsibility of the resident who plans to moonlight to obtain licensure for independent, unsupervised medical practice in the
state where moonlighting will be done and to provide proof of such licensure to the Administrative Director of Resident and Student
Services prior to arranging any moonlighting/other professional activities.
8. It is the responsibility of the resident to obtain and provide professional liability insurance (malpractice) coverage for all moonlighting/
other professional activities which are not an official part of the resident’s training program and to provide proof of such coverage to
the Administrative Director of Resident and Student Services prior to arranging any moonlighting/other professional activities.
9. It is the responsibility of the resident to negotiate directly with potential employers regarding moonlighting/other professional
opportunities.
10. If allowed by the residency/fellowship program, Palmetto Health permits residents/fellows who are Board certified or Board eligible to
moonlight at its facilities under certain conditions. Such moonlighting must be in the resident’s initial Board eligibility specialty; it may
not be in the specialty in which the resident is currently training. However, fellows on J-1 visas are never eligible to moonlight.
11. If allowed by the residency program, Palmetto Health permits residents to moonlight at its Palmetto Health Baptist Parkridge facility
under certain conditions.
12. Moonlighting privileges may be curtailed or suspended by the Program Director and the DIO on the following grounds:
a.
determination that such activities interfere with the resident’s patient care responsibilities and educational performance or if
such activities adversely impact the professional reputation of the resident and/or Palmetto Health;
b.
limitation is required by the appropriate organization(s) responsible for the accreditation/certification of graduate medical
education programs;
c.
the resident is placed on academic remediation or employee disciplinary action; or
d.
if the resident fails to abide by the residency program’s moonlighting procedures or the procedures outlined herein.
13. Adverse effects may lead to withdrawal of permission to moonlight.
September 1, 1992
February 12, 2013
Signature on File
Signature On File
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Moonlighting/Other Professional Activities Request Form
Date: To Dr. :
(Director of Education or Designee for residency program)
In accordance with the Palmetto Health Graduate Medical Education (GME) “Moonlighting and Other Professional Activities Policy,” please
accept this letter as my request for written approval to participate in a paid position for the period of:
(Start Date) to (End Date) at (Institution), with maximum number of hours per week requested. I understand and will abide by all procedures and requirements as outlined in the
aforementioned moonlighting and other professional activities policy and will seek approval in advance of scheduling such activities. I also
agree to report actual hours worked. I understand that moonlighting that occurs at any of my residency program’s affiliated institutions is
considered moonlighting and counts toward the 80-hour work week limit.
I further understand that it is my responsibility and requirement to obtain a permanently endorsed license for unsupervised medical
practice in the state where moonlighting will be done. I further understand that the educational liability coverage provided by Palmetto
Health does not cover moonlighting activities. I also agree to provide proof of permanently endorsed licensure and proof of professional
liability (malpractice) insurance coverage to the Administrative Director for Resident and Student Services in the Department of Medical
Education at least thirty (30) days in advance of an approved moonlighting/other professional activity start date.
I also attest that I am not a PGY -1 resident or a resident/fellow on a J-1 Visa (J-1Visa status limits resident/fellow activities to educational
experiences only; no external paid activities are allowed).
Respectfully requested,
Resident’s Signature
Resident’s Name (printed):
Permanent Medical License No.
Approvals:
Director of Education or Program Director
DIO
_____Approved or _____Disapproved
_____Approved or _____Disapproved
Date
cc: Administrative Director, Resident & Student Services
Revised February 14, 2012
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Date
GME Policies
Off-Campus Elective Rotations Policy
Palmetto Health shares responsibility with each Program Director for providing its residents with the educational
opportunities required by accrediting organizations. On occasion, special off-campus elective rotations may be
arranged to meet these educational needs. Except under unusual circumstances, residents are not eligible for more
than three months of off-campus elective rotations during their training program. These rotations must provide a
unique educational opportunity not available within the Palmetto Health System. Residents are prohibited from
accepting any financial assistance provided by foundations or companies that have direct ties with pharmaceutical,
biomedical, or similar commercial companies. These rotations are a privilege available only to residents who have
demonstrated appropriate progress towards achieving competence in all required areas.
PROCEDURES:
1. Planning for off-campus elective rotations should begin a year in advance, especially for International elective rotation requests.
Program coordinators can provide assistance and detailed resource checklist. Generally, notice is required at least six months in
advance of the requested rotation date, at which time the resident must initiate the “Off-Campus Elective Rotation” form (attached)
and submit to the Program Director. The Program Director must review and complete the form giving his/her tentative approval
before the resident can forward the form and documentation to the DIO. The resident requesting this elective rotation is ultimately
responsible for ensuring that all steps and required forms/documents/approvals are obtained and submitted within described
timelines. Failure to follow timelines or provide any of the required documentation in satisfactory form may result in terminating
consideration of the request. The resident should seek the assistance of his/her residency program coordinator throughout the
process.
2. The educational need of the proposed rotation must be justified by the resident. The justification must include:
a.
the unique educational opportunity that the elective off-site rotation provides;
b.
the educational objectives (in detail) for the rotation;
c.
a description of whom and how the resident’s activities will be supervised and the qualifications of the supervisor; and
d.
a description of how the resident will be evaluated using core ACGME competencies with goals and objectives for the rotation.
3. The DIO will deny or give tentative approval within 30 days of receiving the “Off-Campus Elective Rotation” form.
4. After tentative approval, the program coordinator will initiate the process of obtaining an executed letter of agreement between
Palmetto Health and the participating site.
5. At least 45 days in advance of the rotation, the resident (with assistance from the Program Coordinator) will obtain and submit the
following to the GME office:
a.
An executed letter of agreement between Palmetto Health and the participating site.
b.
confirmation (copy of) malpractice coverage;
c.
confirmation (copy of) medical licensure for out- of-state (if applicable); and
d.
a copy of any required application from this elective site.
6. Within 15 days of receiving above agreement and documentation, the DIO will issue final approval or disapproval. The decision of the
DIO is final.
7. One week prior to beginning the rotation the resident must provide Medical Record clearance from Palmetto Health to the
Administrative Director for Resident and Student Services.
8. All expenses related to the off-campus rotation will be the responsibility of the resident and/or the corresponding residency program,
although the individual’s Palmetto Health salary will continue to be paid during approved off-campus rotations.
9. At conclusion of the rotation, the resident must evaluate the rotation and provide a copy to the Program Director.
If the off-campus elective rotation requested is in an international location, additional considerations and requirements apply (See
additional details below).
September 1, 1992
February 12, 2013
Signature on File
Signature On File
System Vice President, Medical Education & Research and DIOChief Medical Officer
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Page 1 of 3
Off-Campus Elective Rotation Request / Authorization Form
Submit to DIO via Medical Education’s Administrative Director, Resident/Student Services
Date of Request:
Resident Name:
Resident E-mail Address:
Residency Program:
Location of Off-Site Request:
Start and End Dates:
If this is an international elective rotation request, see additional information and additional form to be completed and
submitted with this request.
In accordance with the Palmetto Health Graduate Medical Education (GME) “Off-Campus Elective Rotations” policy, this is to request
written approval to participate in the off-campus elective rotation noted above.
Include with initial request 6 months in advance of requested rotation:
A written justification of the educational need and or unique opportunity of the proposed rotation is attached for your
review and approval.
The educational goals and objectives, in detail, of the rotation are attached for your review and approval.
A description of whom and how the resident’s activities will be supervised and the qualifications of the supervisor are
attached for your review and approval.
A description of how the resident will be evaluated is attached for your review and approval.
Program Director:
Rotation meets RRC requirements for credit: Program Director Signature / Date: Request meets PH GME policy
TENTATIVE APPROVAL: Approved
YES NO
Not Approved
Submit this page to GME office as soon as above items/tentative approval obtained (6 months in advance of rotation)
Date received in GME office: GME office staff initial: TENTATIVE APPROVAL: Approved
Not Approved
Date
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Page 2 of 3
RESIDENT’S/FELLOW’S NAME: At least 45 days in advance of the requested rotation, submit:
»» Executed letter of agreement
»» Confirmation malpractice coverage copy
»» Confirmation medical licensure for out-of-state copy.
»» Copy of any required application from this elective site.
Date received in GME office: GME office staff initial: FINAL APPROVAL: Approved
Not Approved
Date
One week prior to this elective rotation, the resident must obtain Medical Records clearance and submit to Administrative Director for
Resident and Student Services, Medical Education (failure to complete clearance will void final approval).
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Page 3 of 3
HEALTH INFORMATION MANAGEMENT (MEDICAL RECORDS)
Palmetto Health Richland, 2nd Floor
RESIDENT’S/FELLOW’S NAME: All (Clinic or In-House) medical charts and other records (have / have not) been completed through (date) Authorized Signature
Date
All Outpatient Centers’ medical charts (have / have not) been completed through (date) Authorized Signature
Date received in GME office: Revised February 12, 2013
152
.
Date
GME office staff initial: .
GME Policies
Off Campus- Elective Rotations (International)
Additional considerations and requirements
In addition to considerations and requirements for off-campus elective rotations described above, residents are prohibited from:
1. Visiting any country with a U.S. State Department “Travel Warning” http://travel.state.gov/travel/cis_pa_tw/tw/tw_1764.html
2. Engaging in any activities that have direct political, military, or religious implications on foreign soil while training as a Palmetto Health
resident on an international rotation.
3. Practicing any medical procedures or treatments that clearly contradict the standards of ethical practice in the U.S. or the program or
institution, or that contradict cultural values of the international location.
Residents must obtain international insurance to cover Emergency Medical Evacuation, Security Extraction, Travel assistance, Repatriation
of Remains and Personal effects in addition to the standard Accidental Death and Dismemberment coverage. Proof of these items must
be submitted to the GME office prior to departure. Failure to provide proof may result in denial of approval, denial of credit, and denial of
salary. Residents are also responsible for obtaining travel immunizations, medications, visas, passports and other administrative travel
requirements. Residents should provide the Program Coordinator with an emergency contact in the U.S. and a means to contact you
while you are out of the country. Proof of these items must be submitted to the GME office prior to your departure. Failure to provide proof
may result in denial of approval, denial of credit, and denial of salary.
Residents must complete and submit the following additional agreement, and assumption of risk and release form along with the initial
“OFF-CAMPUS ELECTIVE ROTATION REQUEST AND AUTHORIZATION (FORM) for review by the residents’ Program Director and the
DIO.
Resident/Fellow’s Name: Date: International Elective Rotation to (name of country) Please initial each statement:
I have verified this country is not on the U.S. State Department “Travel Warning.”
I understand that I must obtain international insurance to cover Emergency Medical Evacuation, Security Extraction, Travel
assistance, Repatriation of Remains and Personal effects in addition to the standard Accidental Death and Dismemberment coverage.
I understand that I am responsible for obtaining travel immunizations, medications, visas, passports and other administrative
travel requirements.
I will provide the Program Coordinator with an emergency contact in the U.S. and a means to contact me while I am out of the
country.
I understand that trip-related expenses are my responsibility.
I am attaching documentation that describes the requirement/no requirement for Medical Licensure for visiting U.S. Physicians
to this country.
I understand that if this country requires medical licensure, I will have obtained and provided a copy of such license to the GME
office prior to my travel.
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Assumption of Risk and Release
Name of Applicant: International Elective Rotation Site: International Elective rotations provide unique opportunities for academic achievement and personal growth. These rotations may also
entail special risks. This release form specifies certain areas of risk that you should be aware of before you decide to participate in an
international elective rotation.
I hereby agree as follows:
l. RISKS OF INTERNATIONAL ELECTIVE ROTATION: I understand that participation in the above stated international elective rotation
may involve risks not found in training at Palmetto Health. These risks include, but are not limited to, those risks involved in traveling to
and within, and return from, one or more foreign countries; foreign political, legal, social, religious, and economic conditions; different
standards of design, safety and maintenance of buildings, public places and conveyances; local medical and weather conditions;
and other matters. I understand that Palmetto Health will not provide liability insurance while I am on this international elective. I will be
responsible for any and all claims resulting due to my negligence or inability to provide proper and accepted care in the host country. I
have made my own investigation and am willing to accept these risks.
2. INSTITUTIONAL ARRANGEMENTS: I understand that Palmetto Health does not represent or act as an agent for, and cannot control
the acts or omissions of, any host institution, host family, transportation carrier, hotel, tour organizer or other provider of goods or
services involved with the international elective rotation.
3. LIMITS OF PALMETTO HEALTH RESPONSIBILITY: I am undertaking this international Elective Rotation voluntarily and I understand
that Palmetto Health:
a.
cannot guarantee the safety of participants or eliminate risk from the international elective rotation environment.
b.
cannot monitor or control all the daily personal decisions, choices, and activities of individual participants.
c.
cannot prevent participants from engaging in illegal, dangerous or unwise activities.
d.
cannot assure that the U.S. standards of due process apply or provide or pay for legal representation for participants.
e.
cannot assume responsibility for the actions of persons not employed or otherwise engaged by Palmetto Health, for events
that are beyond the control of Palmetto Health and its subcontractors, or for situation which arise from the failure of a
participant to disclose pertinent information.
f.
cannot assure that home-country cultural values will apply on the rotation when these differ from those of the host country.
g.
cannot be responsible for any injury or loss suffered either to myself or others when traveling independently or otherwise
separated or absent from any Palmetto Health supervised activities.
4. HEALTH AND SAFETY:
a.
I have consulted with a medical doctor with regard to my personal medical needs. There are no health-related reasons or
problems that preclude my participation in this international elective rotation.
b.
I understand that Palmetto Health does not provide medical insurance coverage for any expense caused by war (declared
or undeclared) or any act of war, or for any treatment outside the United States except in the case of injury or medical
emergency. I will have arranged, through insurance or otherwise, to meet any and all needs for payment of medical costs
not covered by Palmetto Health Medical/Health insurance coverage while I participate in this international elective rotation.
I recognize that Palmetto Health is not obligated to attend to any of my medical or medication needs, and I assume all risk
and responsibility. If I require medical treatment or hospital care in a foreign country during the rotation, Palmetto Health is not
responsible for the cost or quality of such treatment of care.
c.
I agree to promptly express any health or safety concerns to the program staff or other appropriate individuals.
d.
Palmetto Health may, but is not obligated to, take any actions it considers to be warranted under the circumstances regarding
my health and safety. I agree to pay all expenses relating thereto and release Palmetto Health from any liability for any actions.
5. STANDARDS OF CONDUCT:
a.
I understand that each foreign country has its own laws and standards of acceptable conduct, including dress, manners,
morals, politics, drug use , alcohol use, and behavior. I recognize that behavior which violates those laws or standards could
harm Palmetto Health relations with those countries and the institutions therein, as well as my own health and safety. I will
become informed of, and will abide by, all such laws and standards for each country to, or through which, I will travel during
the international elective rotation.
b.
I will also comply with Palmetto Health and GME rules, standards and instructions for resident behavior.
c.
I agree that Palmetto Health has the right to enforce the standards of conduct described above, in its sole judgment, and that
it will impose sanctions, up to and including termination from the Program, for violating these standards or for any behavior
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d.
detrimental to or incompatible with the interest, harmony, and welfare of the Program and other participants. I recognize
that due to the circumstances of foreign study programs, procedures for notice, hearing and appeal applicable to residency
disciplinary proceedings at Palmetto Health do not apply. If I am terminated from the Program, I consent to being sent home at
my own expense with no refund of fees or program costs.
I will attend to any legal problems I encounter with any foreign nationals or government of the host country. Palmetto Health is not
responsible for providing any assistance under such circumstances. I assume all expenses and costs on my own.
6. PROGRAM CHANGES: Palmetto Health has the right to make cancellations, substitutions or changes in case of emergency or
changed conditions or in the interest of the Program. I accept all responsibility for loss of additional expenses due to delays or
other changes in the means of transportation, other services, or sickness, weather, strikes, or other unforeseen causes. If I become
detached from the group, fail to meet a departure bus, airplane, train, or other means of transportation, or become sick or injured, I
will at my own expense seek out, contact, and reach the group at its next available destination.
7. ASSUMPTION OF RISK AND RELEASE OF CLAIMS: Knowing the risks described above and in consideration of being permitted
to participate in the Program, I agree, on behalf of my family, heirs, and personal representatives(s), to assume all the risks and
responsibilities surrounding my request for participation in the international elective rotation. I hereby agree to release, hold harmless
and indemnify the Board of Directors of Palmetto Health, a not for profit corporation, its officers, employees, and agents and the
individual members of the Board of Directors, from and against any present or future claim, loss or liability for injury to person or
property which I may suffer, or for which I may be liable to any other person, during my participation in the Program (including period
in transit to or from any country where the rotation is being conducted).
I have carefully read and have the capacity to and do understand this Release Form before signing it. No representations, statements
or inducements, oral or written, apart from the foregoing written statement, have been made. I am voluntarily signing this release and
fully assuming the obligation of my own volition. This agreement shall define my responsibilities relating to the international elective
rotation for which I have applied.
In case of emergency, Palmetto Health or my Program may contact the individual listed below and discuss relevant
information as medically or otherwise needed:
Name
Phone Number
Street Address
Contact’s E-mail address
Signature of applicant
Date
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Professionalism
Residents are responsible for demonstrating a commitment to carry out professional responsibilities and an
adherence to ethical principles in order to meet the obligations of his or her patients, communities, and the
profession. This policy serves as a written guidance to outline professional expectations and the potential
disciplinary consequences of failing to adhere to the expectations.
Residents are expected to demonstrate:
»» Compassion, integrity, honesty, and respect for others (including colleagues, faculty, students, patients, families, staff and guests);
»» Altruism and empathy;
»» Responsiveness to patient needs that supersedes self-interest
»» Respect for patient privacy and autonomy;
»» Accountability to patients, society and the profession;
»» Sensitivity to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and
sexual orientation;
»» A continuing commitment to excellence.
Examples of behaviors which constitute professional expectations (including but not limited to):
»» Clearly identifies oneself to patient and staff
»» Maintains a clean, neat appearance
»» Maintains composure
»» Ensures patient safety
»» Treats patients with dignity and respect
»» Collaborates with other members of the healthcare team and treats them with respect
»» Answers questions and explains the patient’s treatment plan to patient and family (with patient’s permission) and health care team
members
»» Answers phone calls and pages in a timely and courteous manner
»» Is truthful in verbal and written communications
»» Is on time for meetings and appointments
Examples of behaviors which constitute unprofessional conduct (included but not limited to):
»» Plagiarism
»» Fraud
»» Forgery
»» Lying
»» Cheating on academic activities;
»» Alcoholism and/or substance abuse;
»» Harassment or discrimination of any kind;
»» Threatening or abusive (demeaning, berating, rude) language, profanity
»» Work place violence or aggression;
»» Falsification of information (personnel, medical, other official documents)
Related Policies:
Grievance and Due Process; Disciplinary Action; Disruptive Behavior; Impairment
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GME Policies
Remediation Policies
Each residency program is responsible for assessing and monitoring each resident’s academic and professional
progress including specific knowledge, skills, attitudes, and educational experiences required for residents to
achieve competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal
and communication skills, professionalism, and systems-based practice, as well as adherence to departmental
policies concerning resident education and the hospital’s graduate medical education policies. Failure to
demonstrate adequate fund of knowledge or professional decorum adequately in any of these areas may result in
remediation or more stringent disciplinary and corrective action if deemed appropriate.
GUIDANCE:
This policy has been developed in accordance with ACGME guidelines to provide fair and formative remedy – with due process – for
residents failing to meet expectation in the core competencies. The objective of this policy is to provide constructive feedback and
encouragement to overcome deficiencies. In the event that a deficiency is persistent and inconsistent with the practice of medicine, this
policy also provides guidance for the due process leading to adverse actions such as extension of training, probation, or dismissal from
the program. If a resident physician commits an egregious act apart from this policy, he or she may be dismissed from direct patient care
or from the program.
Oral/Written Counseling
If a resident is identified as failing to meet the minimum requirements for progression in the program in any core competency, faculty
or residents will notify the Program Director and disclose the details of the concern. The Program Director will meet with the resident
to discuss the concern. If the Program Director determines that no further action is warranted, no documentation will be placed in the
resident’s file. If the Program Director determines that the concern is sufficient to warrant documentation, the concern and the plan for
remedy will be placed in the resident’s file. If remediation is successful, the documentation will be removed from the resident’s file until
graduation. If no further action is necessary the documentation will be destroyed after graduation. If remediation is not successful, further
action will be taken. In any case, the documentation produced in this portion of the process is NOT reportable for future licensure and
credentialing purposes.
Formal Counseling (Level I Remediation)
If a resident has previously received oral/written counseling regarding a deficiency in meeting a core competency and a similar concern
is again raised, the Program Director will document the details of the concern using the GMEC approved template for formal counseling,
including his or her recommendations and conclusions prescribed to the resident, along with the resident’s remediation plan. The Program
Director should inform the DIO of formal counseling action plans. The Program Director will then meet with the resident to discuss the
action. The resident will be required to sign the formal counseling document and note any disagreement with the concern and/or plan.
A copy of the letter will be forwarded to the department Chair for review and additional recommendations, if any. Once the Chair has
reviewed the letter, it will be placed in the resident’s file until the completion of residency. The status of the resident in correcting the
deficiency will be reevaluated at a time commensurate with the severity of the deficiency, usually between four weeks and three months
after the counseling session.
Formal Counseling Reevaluation
When the resident meets for reevaluation with the Program Director, the resident’s progress will be reviewed. Comments about progress
may be solicited from previously involved individuals and compiled into an addendum counseling letter. If a deficiency has not been
corrected satisfactorily, the resident will be placed on formal remediation. This action will be documented in the addendum counseling
letter, along with the prescribed corrective action. If it is unclear whether a deficiency has been corrected, the counselor may set another
interval reevaluation session. If the deficiency has been corrected, documentation of this will be placed in an addendum counseling
letter, which will be maintained in the residents file until graduation. If no further action is necessary, these letters will be destroyed after
graduation. A corrected counseling letter is NOT considered an adverse disciplinary action for future licensure and credentialing purposes.
Formal Remediation (Level II Remediation)
If, during reevaluation of formal counseling, it is found that a deficiency has not been corrected satisfactorily, the resident will be placed
on formal remediation, (hereinafter “remediation”). Curriculum credit may be withheld pending the outcome of formal remediation.
Moonlighting privileges, if previously granted, will be suspended. During this process, the resident is given a final opportunity to correct
a recognized deficiency in a core competency before incurring an adverse, or reportable, action. The Program Director must inform
the DIO of formal remediation action plans. The recommendation for remediation, along with the prescribed corrective action, will be
documented in an addendum to the original letter of counseling. The status of the resident’s correction of the deficiency will be reevaluated
at a time commensurate with the severity of the deficiency, usually between four weeks and three months after this counseling session.
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Comments may be solicited from involved individuals and compiled – along with other evidence of successful remediation – into a
reevaluation addendum to the letter of counseling. Once the resident physician has successfully demonstrated adequate correction of the
documented deficiency(-ies), this reevaluation letter will state that remediation was successful and will be maintained in the resident’s file
until graduation. After graduation, the letter and addendum will be destroyed permanently if no further action was necessary. A corrected
remediation letter IS NOT considered an adverse disciplinary action for future licensure and credentialing purposes.
If the resident physician has failed to demonstrate resolution of the documented deficiency(-ies), or if the problem recurs after apparently
successful remediation, he or she will be placed on formal probation. In this case, a reevaluation addendum to the original counseling letter
will state that probation is recommended, and a letter recommending probation will be prepared. Formal probation is reportable for future
licensure and credentialing purposes.
Formal Probation (Level III Remediation)
If a resident physician fails to successfully remediate a documented deficiency in a core competency(-ies), he or she will be placed on
probation (“probation”). The Program Director will compile a letter of recommendation for probation that includes:
1. the nature of the deficiency(-ies);
2. a summary of due process and remedation opportunities (i.e., verbal counseling, formal counseling and program level remediation);
3. statement of failure to successfully remediate the deficiency(-ies);
4. final recommendations for corrective action that must be met within the probationary period in order to avoid prolongation of training,
inability to sit for boards, dismissal from the program or other adverse action;
5. a prescribed date of reevaluation for final disposition;
6/ a statement that failure to meet recommendations for corrective action in three months will result in permanent dismissal from the
program if this is intended;
7. a statement that probation is reportable on all future state licensing and credentialing forms in most states; and
8. signature blocks for the Program Director, the resident and the Chair. The resident’s signature box will be placed below a checkbox
stating, “I accept the terms of probation as outlined in this letter.”
The Program Director will present his or her recommendation for probation to the GMEC for formal action prior to implementation.
If the resident refuses to sign and/or accept the terms of probation, the terms will go into effect from the date that the Program Director’s
signature is placed on the letter. The resident may choose to appeal the recommendation for probation by initiating the formal resident
grievance process.
If the terms and conditions of formal probation are met, the resident will be retained by the program and, if no further adverse events
transpire, will be allowed to graduate from the program. However, probation is reportable for all future licensure and credentialing
purposes, and could adversely affect future employability.
If the terms and conditions of probation are not met, the Program Director will recommend to the department Chair that the resident be
subject to additional adverse actions, such as extension of training, inability to sit for boards, or termination from the program. The resident
may appeal this decision by initiating the formal resident grievance process.
If the resident’s deficiency is believed by the Program Director to potentially compromise patient safety, the resident will be removed
from direct patient care responsibilities and placed on administrative leave for the duration of the appeal. Should a recommendation for
dismissal be overturned after a successful appeal, the resident, following administrative leave, will be responsible for completing any
additional training time lost during the appeal process with additional training in order to fulfill board requirements for length of training to
sit for boards. In the case of successful appeal, the DIO, in consultation with the CMO and Dean, will determine whether the department’s
recommendation for probation or additional length of training is reportable for future licensure and credentialing purposes. If it is
determined that such recommendation is not reportable, documentation will be removed from the resident physician’s file and destroyed
at the time of graduation from the program.
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GME Policies
Social Networking Policy
All residents, fellows and residency programs are guided by Palmetto Health’s Social Media policy and procedure,
guidelines, and rules (see PH Social Media policy/PGR. Social networking websites and applications (e.g., Blogs,
Facebook, LinkedIn, MySpace, YouTube, and Twitter) are important forms of communication. However, residents
who use these websites and applications should be aware of the importance of privatizing their websites so that
only trustworthy “friends” have access to the websites/applications. Posting of certain information is illegal and
could lead to adverse academic outcomes in regards to professionalism.
PROCEDURES:
1. When using social networking websites/applications, residents are strongly encouraged to use a personal e-mail address, rather than
their Palmetto Health address, as their primary means of identification.
2. Residents must make every effort to present themselves in a mature, responsible, and professional manner.
3. Discourse must always be civil and respectful.
4. No privatization measure is exact and undesignated persons may still gain access to your to your networking site. A site such as
YouTube is completely open to the public. Future employers (residency program directors, fellowship program directors, department
chairs, private practice partners, etc.) review these network sites when considering potential candidates for employment.
5. Think carefully before you post any information on a website or application; be respectful and professional. Posted information can be
removed from the original social networking site, but exported information cannot be recovered.
PROHIBITED BEHAVIORS:
1. In your role as a care-giver, you must not present the personal health information of other individuals. Removal of an individual’s
names does not constitute de-identification of protected health information. Inclusion of biographical information, date of evaluation
or type of treatment or the use of highly specific medical photography (e.g., before/after photo of pt having surgery) may still allow the
reader to recognize the individual.
2. You must not report private (protected) academic information of another student or trainee. This could include but is not limited to
clerkship grades, narrative evaluations, exam scores, or adverse academic actions.
3. In posting information on social networking sites, you must not present yourself as an official representative or spokesperson for
Palmetto Health or University of SC School of Medicine.
4. You must not represent yourself as another person.
5. You must not utilize websites and/or applications in a manner that interferes with or delays your academic/work commitments.
UNPROFESSIONAL BEHAVIORS THAT MAY RESULTS IN DISCIPLINARY ACTION:
1. Display of vulgar language or photos that disrespect other individuals.
2. Display of language or photographs that imply disrespect for any individual or group because of age, race, gender, ethnicity, or sexual
orientation.
3. Posting of inflammatory or unflattering material on another individual’s website.
February 8, 2011
February 12, 2013
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Solicitation
Human Resources
Policy No. #195
Palmetto Health governs the solicitation of and by employees or the distribution of literature to employees on
Palmetto Health property.
GUIDANCE:
Solicitation and distribution are governed by the following rules:
1. Solicitation or distribution of literature by employees during work time is prohibited.
2. Distribution of literature by employees in work areas is prohibited.
3. Solicitation or distribution of literature by employees in immediate patient care areas, patient care corridors and patient floor sitting
rooms is prohibited.
4. Solicitation or distribution of literature by non-employees on premises is prohibited.
5. Distribution of literature by employees on property in non-work areas during working time is prohibited. For the purpose of these rules,
work time is defined as those periods which are designated for assigned job tasks by the employee. If either the employee soliciting
or distributing materials or the employee being given the materials or being solicited is on work time, these rules shall apply.
6. Solicitation on behalf of the Palmetto Health Foundation and the United Way will be allowed. Employees wishing to solicit for other
charities must clear it through their vice president with final approval by the office of the Senior Vice President of Human Resources.
Employees may only solicit for non-profit, charities (American Cancer Society, MS Society, Girl Scouts, etc., or other organizations
congruent with the Palmetto Health mission) and form teams in their immediate work areas or service lines to participate in walks.
7. Other fund raising activities may be considered as long as those activities are conducted off-site or in non-work areas (break rooms,
locker rooms, dining rooms, main lobbies) during non-work time. Any organization that competes with or is perceived to compete
with Palmetto Health or the Palmetto Health Foundation will not be allowed to raise funds or solicit.
Signature on File
Gwen Hill
Revised March 31, 2011
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GME Policies
Subpoenas To Employees
When local law enforcement agencies or officers of an appropriate court subpoena employees, Palmetto Health will
cooperate with the subpoena authority and attempt to forward the subpoena to the appropriate employee.
GUIDANCE:
1. Law enforcement agencies or other agencies empowered with subpoena authority will deliver all subpoenas to Security.
2. Security will deliver the subpoena to the appropriate department.
3. Department management will locate the subpoenaed employee whether on or off duty and notify the employee that the subpoena is
waiting. The employee will respond within 24 hours of being notified by his department.
4. If an employee is out of contact with Palmetto Health, i.e., vacation, leave of absence, etc., department management will return the
subpoena to Human Resources.
5. Human Resources will then notify the issuing office that the employee has not received the subpoena.
6. Human Resources may release home address information of an employee in order to assist the law enforcement agency in carrying
out its duties.
7. During hours when Human Resources would normally be closed, the subpoena authority will deliver a subpoena to the evening/night
supervisor. The supervisor is responsible for following the policy outlined above.
Signature on File
Gwen Hill
Signature On File
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Substance Abuse Policy
As a part of its commitment to provide a safe place for its employees to work and to promote a drug-free
community, Palmetto Health Alliance (hereinafter “alliance”) establishes this policy on the use or abuse of alcohol
and illegal drugs by its employees. Drug and alcohol dependence is recognized as a treatable condition and
Palmetto Health encourages employees to seek help in dealing with these problems. The purpose of this policy is
to set forth the alliance’s Palmetto Health’s guidelines regarding substance abuse.
GUIDANCE:
1. EFFECT:
The information contained in this policy does not create a contract of employment between the alliance Palmetto Health and any
employee or guarantee any benefit, procedure, or period of employment.
2. SCOPE:
All alliance Palmetto Health employees are covered by this policy. Certain employees may be subject to additional requirements under
state and/or federal regulations.
3. DEFINITIONS:
3.1. Illegal Drugs
“Illegal drugs” are drugs or controlled substances which are (1) not legally obtainable or (2) legally obtainable but not obtained
or used in a lawful manner. Examples include cocaine and marijuana, as well as prescription drugs which are not lawfully
obtained or properly utilized. The term “illegal drugs” also refers to mind-altering and/or addictive substances which are not
sold as drugs or medicines but are used for mind- or behavior-altering effect. (ex. Inhalants)
3.2. Legal Drugs
“Legal drugs” are those prescribed or over-the-counter drugs which are legally obtained by the employee and used for the
purpose for which they were prescribed and sold.
3.3. Alliance Palmetto Health Property
The term “alliance Palmetto Health property” includes work sites; parking lots; vehicles; or offices owned, rented, utilized, or
serviced by the alliance Palmetto Health or by any customer of the alliance Palmetto Health; employee-owned or employeerented vehicles on the property of the alliance Palmetto Health or of any customer of the alliance Palmetto Health while on
alliance Palmetto Health business; and locations where the employee represents the alliance Palmetto Health in any capacity.
3.4. On Duty
The term “on duty” includes all working hours as well as meal periods and break periods, regardless of whether on premises,
and all hours when the employee represents the alliance, Palmetto Health, in any capacity.
3.5. Employer Intervention:
3.5.1. The insertion of Palmetto Health into a situation in which an employee is believed to have a substance abuse problem
is considered Employer Intervention. Employer intervention may be accomplished by different options as Palmetto
Health deems appropriate in specific situations.
3.5.2. Methods of intervention may include, but are not limited to, making the employee aware that Palmetto Health is
aware of the substance abuse problem, making the employee aware that he/she MUST seek help for the problem,
and educating the employee as to the use of E-Care in obtaining immediate treatment. As part of the intervention
process, the employee will be required to sign a contract with the appropriate monitoring agency as determined by
Palmetto Health. Palmetto Health retains the right to address each situation through its disciplinary process as it deems
appropriate. Active substance abuse may result in discipline up to and including termination of employment in the initial
instance.
4. E-Care:
4.1 Palmetto Health regards its employees as its most important asset. Accordingly, the Palmetto Health maintains E-CARE which
provides help to employees who suffer from alcohol or drug abuse and other personal or emotional problems. Employees
with such problems should seek professional assistance from E-CARE or other community resources before drug or alcohol
problems lead to employer intervention or disciplinary action, which can include discharge for a first offense. Information about
a self-referred employee’s contact with E-CARE is confidential, within legal limits, and will not be disseminated without the
employee’s permission.
4.2 An employer intervention and/or disciplinary action can occur as a result of self-referral to E-Care treatment if the treatment
team determines that patients or others are at risk as a result of the employee’s substance abuse. An employer intervention
and/or disciplinary action may also occur for a violation of Palmetto Health’s substance abuse policy if such violation comes to
Palmetto Health’s attention through other means, such as direct observations, job performance, drug testing, etc.
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4.3
4.4
In keeping with the need for safety and security, Palmetto Health will determine whether it should grant a leave of absence or
reassign an employee following a positive test or during a period of evaluation, treatment or counseling.
Participation in any evaluation, treatment, or counseling program will be at the employee’s expense unless the employee is
entitled to such benefits under the terms of Palmetto Health’s group health plan or by other available benefits. Time lost from
work for such a program shall be without pay unless the employee is otherwise entitled to pay pursuant to Palmetto Health
policy.
5. ALCOHOL USE PROHIBITIONS:
5.1. The consumption of alcohol on alliance Palmetto Health property or while on duty is prohibited. There may be occasions,
removed from the usual work setting, at which it is permissible to consume alcohol in moderation.
5.2. Off-duty abuse of alcohol which adversely affects an employee’s job performance or adversely affects or threatens to adversely
affect other interests of the alliance Palmetto Health is prohibited.
5.3. The personal possession (i.e., on the person or in a desk or locker) of alcohol on alliance Palmetto Health property or while on
duty is prohibited. However, the possession of alcohol in a personal vehicle is not prohibited provided such possession is in
compliance with this policy, as well as federal, state, and local laws.
5.4. It is against policy to report to work or to work under the influence of alcohol. An employee will be considered under the
influence of alcohol when, in the judgment of the employee’s supervisor or other management official, the employee’s ability to
perform the job safely and effectively is affected by the use of alcohol. An employee who is perceived to be under the influence
of alcohol (to include simply the odor of alcohol on the person) will be removed immediately from the workplace and may be
required to submit to a breath or blood test to measure the blood alcohol concentration. An employee with any measurable
amount of alcohol will be considered to be under the influence of alcohol for purposes of this policy. However, a determination
that an employee is under the influence of alcohol may be made by the alliance Palmetto Health without conducting a test to
determine the employee’s alcohol concentration.
5.5. Employees arrested for an alcohol-related incident must immediately notify their supervisor of the arrest if the incident occurs:
5.5.1. During scheduled working hours;
5.5.2. While operating an alliance Palmetto Health vehicle on alliance Palmetto Health or personal business; or
5.5.3. While operating a personal vehicle on alliance Palmetto Health business.
6. DRUG USE PROHIBITIONS:
6.1. The use, sale, purchase, possession, manufacture, distribution, or dispensation of illegal drugs on alliancePalmetto Health
property or while on duty is against alliancePalmetto Health policy and is cause for immediate employer intervention and/or
disciplinary action including immediate discharge.
6.2. It is also against alliancePalmetto Health policy for an employee to report to work or to work while under the influence of illegal
drugs. An employee will be considered to be under the influence of illegal drugs if the employee tests positive for such drug(s)
(or their metabolites) at or above the cutoff levels established by the alliancePalmetto Health.
6.3. Legal drugs may also affect the safety of the employee or fellow employees or members of the public. Therefore, any
employee who is taking any legal drug which the prescribing physician or pharmacist indicates might adversely affect the
employee’s ability to safely perform the functions of his or her job must advise his or her supervisor before reporting to work
under such medication. If the alliancePalmetto Health determines that such use adversely affects the employee’s ability to
safely perform the functions of his or her job, the alliancePalmetto Health may temporarily reassign the employee, grant a
leave of absence during the period of treatment, or otherwise attempt to accommodate the employee. If the alliancePalmetto
Health determines that such use does not pose a risk, the employee will be permitted to work. Improper use of “legal drugs” is
prohibited and may result in an employer intervention and/or disciplinary action up to and including immediate discharge.
7. DRUG TESTING:
7.1. Testing of Applicants
7.1.1. All applicants considered final candidates for a position will be tested for the presence of illegal drugs as part of the
application process.
7.1.2. If an applicant’s test is positive, the applicant will not be considered for employment at that time.
7.1.3. Any applicant who refuses to submit to or tampers with the pre-employment drug test will not be considered for
employment at that time.
7.2. For-Cause Testing
7.2.1. Employees may be asked to submit to a drug or alcohol test if in the opinion of management there is reason to believe
that their ability to perform work safely or effectively may be impaired.
7.2.2. For-cause testing may be based upon specific, contemporaneous, articulable observations of a management official(s)
concerning the appearance, behavior, speech, body odors or other factors deemed appropriate by management.
7.3. Follow-Up Testing
All employees who have been determined by the alliancePalmetto Health to have used illegal drugs (through a positive drug
test, self-identification, or otherwise) or abused alcohol and who have accepted the opportunity to enter an alcohol or drug
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7.4.
7.5.
counseling or rehabilitation program will be subject to periodic, unannounced follow-up drug tests for a one-year up to a five
year period after returning to work or completion of any rehabilitation program, whichever is later.
Additional Testing
Additional testing may also be conducted as required by applicable state or federal laws, rules, or regulations or as deemed
necessary by the alliance Palmetto Health. Specifically, the alliance Palmetto Health reserves the right to conduct testing on
all employees in a location, department, or on a shift if there is objective evidence of the use, sale, purchase, possession,
manufacture, distribution, or dispensation of illegal drugs on alliancePalmetto Health property that is reasonably related to that
particular location, shift, or department. Additional testing may also be conducted where abuse or theft of alliancePalmetto
Health owned drugs occurs or is believed to have occurred.
Testing Procedure
7.5.1. The alliancePalmetto Health will determine for which drugs testing will be performed and the cutoff levels at or above
which a test result will be considered positive proof of drug and/or alcohol usage.
7.5.2. If an employee refuses to consent to testing, fails to appear for testing, tampers with the test, or otherwise fails to
cooperate with the testing procedure, he or she will be considered to have tested positive.
8. DISCIPLINARY ACTION:
8.1. Generally, a positive test or tampering with a sample may will result in immediate assessment and, if appropriate, referral to
alcohol and drug treatment and may result in discipline up to and including immediate discharge. Theft of drugs will result in a
report to DHEC, possible criminal charges and disciplinary action up to and including immediate discharge. The following will
apply:
8.1.1. If the employee remains employed, the employee will receive a written warning and be referred to E-CARE.
8.1.2. The employee must contact the alliance’s E-CARE. E-Care must be contacted immediately (at a minimum within 24
hours) within 24 hours. As appropriate, the employee must and satisfactorily participate in a professional drug and/or
alcohol evaluation, the Recovering Professionals Program or its equivalent, professional drug and/or alcohol evaluation,
counseling, and/or other rehabilitation programs as prescribed by Palmetto Health and/or E-CARE. The employee
must cooperate with E-CARE staff in carrying out its responsibility to coordinate the evaluation, counseling, treatment,
and follow-up process including signing releases of information that will allow their E-.Care counselor to coordinate their
care.
8.1.3. The employee may require inpatient or outpatient treatment. If inpatient treatment is required, the employee will be
placed on leave status during his or her absence. Normal leave policy will apply.
8.1.4. Any employee referred to E-CARE for drug use must sign an agreement prior to returning to work and agree to submit
to periodic, unannounced follow-up drug testing for a period of up to one five years.
8.1.5. After signing the agreement and before returning to work, the employee must submit to a drug test, and the results of
the test must be negative.
8.1.6. The alliancePalmetto Health may suspend employees with or without pay under this policy pending the results of a
drug test or investigation.
8.2. Employees who (1) do not cooperate with E-CARE, or (2) refuse to participate in or do not satisfactorily complete a prescribed
drug or alcohol abuse assistance, counseling or rehabilitation program, or (3) who subsequently violate this policy will be
subject to employer intervention or discharged. Disciplinary action up to and including termination, whichever Palmetto Health
deems appropriate.
8.3. Any employee determined by the alliancePalmetto Health to be using, selling, purchasing, possessing, distributing, or
dispensing drugs or alcohol on duty or on alliancePalmetto Health property is subject to disciplinary action, up to and including
immediate discharge, without referral to the alliancePalmetto Health’s E-CARE.
8.4. The determination of what employer intervention, clinical intervention and/or disciplinary action is appropriate for a violation
of this policy rests solely with the alliancePalmetto Health. Employer intervention and/or disciplinary action may be based not
only on a violation of this policy, but also on prior poor performance, workplace misconduct, other rule violations, and any
other factors which the alliancePalmetto Health determines to be relevant. Any of the forms of employer intervention and/or
disciplinary action set forth above may be applied or omitted at the alliancePalmetto Health’s discretion. This policy in no way
infers or creates any contractual obligation to follow any particular procedure.
9. INVESTIGATION:
To ensure that illegal drugs and alcohol do not enter or affect the workplace, the alliancePalmetto Health reserves the right to search
all vehicles, containers, lockers, or other items on alliancePalmetto Health property in furtherance of this policy. Individuals may be
requested to display personal property for visual inspection upon alliancePalmetto Health request. Failure to consent to a search or
display personal property for visual inspection will be grounds for discharge or denial of access to alliancePalmetto Health premises.
10. ARREST OR CONVICTION FOR DRUGALCOHOL OR DRUG--RELATED CRIME:
10.1. If an employee is arrested for or convicted of an alcohol or drug-related crime, the alliancePalmetto Health will investigate all of
the circumstances, and alliancePalmetto Health officials may utilize the drug-testing procedure interventions as outlined in this
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GME Policies
policy as appropriate. The following procedures will apply:
10.1.1.During the investigation, an employee may be placed on leave without pay. After the investigation is completed,
the leave may be converted to a suspension or the employee may be reinstated, depending upon the facts and
circumstances employees may be reinstated or may be disciplined up to immediate termination, depending on the
circumstances.
10.1.2.If convicted of a drug and/or alcohol-related crime, an employee will be terminated. Palmetto Health may institute the
employer intervention and/or disciplinary action up to and including immediate termination.
10.1.3.If an employee has been suspended and the case has been dismissed or otherwise disposed of, the alliancePalmetto
Health will make a determination as to whether to authorize the employee’s return to work based on the
alliancePalmetto Health’s own investigation, as well as other factors related to the individual’s employment.
10.1.4.Because of the seriousness of such situations, the alliancePalmetto Health reserves the right to alter or change its
policy or decisions on a given situation depending upon its investigation and the totality of the circumstances.
10.2. As a condition of employment, an employee shall notify the alliancePalmetto Health’s Human Resources Manager of any
criminal drug statute conviction for a violation which occurred on alliancePalmetto Health premises. The employee must give
notice to the alliancePalmetto Health with five (5) days of such conviction.
11. UNITED STATES DEPARTMENT OF TRANSPORTATION REGULATIONS:
Employees subject to the United States Department of Transportation (DOT) regulations may be subject to additional drug and
alcohol-related procedures. You may check with Human Resources if you have any questions about these additional requirements or
obligations.
Signature on File
Gwen Hill
Signature On File
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GME Policies
Supervision Of Medical Students
Medical students shall be supervised by appropriate members of the medical staff and work with assigned
residents in patient care areas as the medical students pursue their education, abiding by Palmetto Health and USC
School of Medicine policies.
POLICY:
1. Assignment to a clinical rotation is processed through the Office of Enrollment Services – Admissions of the University Of South
Carolina School Of Medicine (USC SOM) and the Department Chair/Clerkship Director or the medical staff member.
2. Students may participate only in clinical services where educational objectives have been developed and approved for credit.
3. The primary responsibility for the patient is vested with a teaching attending or medical staff and may not be delegated to a student.
4. Residents or fellows may participate in overseeing the educational process, but any supervising physician must have applicable
credentials, privileges, and authorization in order to oversee each clinical activity or procedure.
5. Students must be clearly identified as such. When being introduced, the phrases “student doctor” or “medical student” are
recommended. A name tag with the student designation will be worn at all times.
6. Utilization of Palmetto Health facilities is dependent upon following the procedures and guidelines as outlined in this policy.
PROCEDURES:
1. M-III and M-IV medical students may record history and physical examinations and progress notes on the patient’s permanent
medical record if clearly identified as “Student”. For electronic medical record entries, this means that the student must be signed
on using their own unique user ID # and password. The student record may not substitute for the required history and physical
examination or progress notes of an attending or resident physician. The history and physical and progress notes recorded by a
student must be co-signed by a faculty member or the attending physician responsible for the patient. The attending physician who
countersigns the student entries verifies the content as being accurate and appropriate and shall sign as verified or the record will be
rewritten or a note made clarifying any areas of question. M-III and M-IV students may scribe a physician order if the order is signed
by the responsible resident or attending physician prior to the order being carried out.
2. All procedures are to be performed under appropriate supervision. The supervising physician must have privileges or authorization to
perform the procedure being supervised. The degree of supervision must take into account the complexity of the procedure, potential
for untoward effects, and the demonstrated competence, maturity and responsibility of each student in order to ensure the safety and
comfort of the patient.
3. Each student will be assigned a unique medical center computer access code. Students MAY access the computer to obtain needed
information on their patients with authorization through Medical Education, but ARE PROHIBITED from entering orders for laboratory
tests, diagnostic tests, diagnostic procedures, x-rays, studies, medications, or diets.
4. Students may not sign as witnesses to authorizations or consents for procedures or surgery on patients cared for by them, or their
team.
5. At the conclusion of each rotation, the supervising physician(s) will complete a written evaluation of the student, in the format provided
by each department, for submission to the department Chair or Clerkship Director and/or designee.
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October 8, 2002
February 12, 2013
Signature on File
Signature On File
GME Policies
Supervision Of Palmetto Health Resident Physicians
In accordance with accreditation, regulatory, and other requirements, all residents will be actively supervised by
independently licensed attending physicians and/or senior level residents, as appropriate.
1.1 Within the scope of the residency training program, all residents will function under the supervision of appropriately credentialed
attending physicians. Every residency program must ensure that adequate supervision is provided for residents at all times. A
responsible attending must be immediately available to the resident in person or by telephone and able to be present within a
reasonable period of time, if needed. Each program will publish and make available in a prominent location, call schedules indicating
the responsible attending(s) to be contacted.
1.2 Each residency program will be structured to encourage and permit residents to assume increasing levels of responsibility
commensurate with their individual progress in the six general competencies, including experience, skill, knowledge, and judgment.
Program Directors will review each resident’s performance and supervise progression from one year of training to the next based on
Accreditation Council for Graduate Medical Education guidelines and program curriculum. As the residents advance, they may be
given increasing responsibilities to conduct clinical activities with limited supervision, to act as teaching assistants for less experienced
residents, and/or to supervise less experienced residents, as appropriate.
1.3 Resident job descriptions (by year of training) and competency checklists are available on the intranet to accurately reflect the
resident’s progression. Competency checklists are updated by the training programs at least annually. (PGY 1 resident competencies
are updated at least twice per year). These competencies reflect the patient care services that may be performed by the resident and
the level of supervision required.
1.4 Throughout all clinic hours, there will be an attending physician present and immediately available to the resident.
ROLES AND RESPONSIBILITIES:
1.1.The Graduate Medical Education Committee (GMEC) is responsible for establishing and monitoring policies and procedures with
respect to the institution’s residency programs.
1.2.Each Program Director is responsible for the quality of overall residency education and for ensuring that the program is in compliance
with the policies of the respective accrediting and certifying bodies. The Program Director defines the levels of responsibility for each
year of training by preparing a description of types of clinical activities residents may perform and those for which residents may act
in a teaching capacity. The Program Director monitors resident progress and ensures that problems, issues, and opportunities to
improve education are addressed.
1.3 The attending physician is responsible for, and is personally involved in, the care provided to individual patients. When a resident
is involved, the attending physician continues to maintain personal involvement in the care of the patient. The attending physician
will direct the care of the patient and provide the appropriate level of supervision based on the nature of the patient’s condition, the
likelihood of major changes in the management plan, the complexity of care, and the experience and judgment of the resident being
supervised. Documentation of involvement includes at a minimum attending physician:
a.
progress notes written at least daily on critically ill patients and those where there is difficulty in diagnosis or management of
the clinical problem, and at least every two (2) days on all other patients;
b.
countersignature on history and physical exams (to include current complaints, assessment of findings, and treatment plans);
c.
countersignature on operative reports; and
d.
countersignature on the discharge summaries.
1.4 Residents must be aware of their limitations and not attempt to provide clinical services or do procedures for which they are not
trained. They must know the graduated level of responsibility described for their level of training and not practice outside of that
scope of service. Failure to function within graduated levels of responsibility, respond appropriately to directions by the attending
physician, or to communicate significant patient care issues to the responsible attending physician may result in remediation actions
and the removal of the resident from patient care activities. Mechanisms are in place by which residents/fellows can report inadequate
supervision in a protected manner that is free from reprisal.
GRADUATED LEVELS OF RESPONSIB ILITY:
1.1 As part of their training program, residents will be given progressive responsibility for the care of the patient. The determination of
a resident’s ability to provide care to patients without a supervisor being physically present, to act in a teaching capacity, and/or to
supervise less experienced residents will be based on documented evaluation of the resident’s level of achievement in the six general
competency areas, including clinical experience, judgment, knowledge, and technical skill. Ultimately, it is the decision of the attending
physician as to which activities the resident will be allowed to perform within the context of the assigned levels of responsibility. The
overriding consideration must be the safe and effective care of the patient.
1.2 To ensure oversight of resident supervision and graded authority and responsibility, programs must use the following classification
of supervision, which must be based on documented evidence (e.g., evaluations by attending physicians and program directors,
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GME Policies
procedure logs, and other clinical practice information reflecting a resident’s knowledge, skill, experience, and judgment):
»» Direct Supervision – the supervising physician is physically present with the resident and patient (Level 1).
»» Indirect Supervision with direct supervision immediately available – the supervising physician is physically within the
hospital or other site of patient care, and is immediately available to provide Direct Supervision (Level 2).
»» Indirect Supervision with direct supervision available – the supervising physician is not physically present within the hospital
or other site of patient care, but is immediately available by means of telephonic and/or electronic modalities, and is available to
provide Direct Supervision (Level 3).
»» Oversight – the supervising physician is available to provide review of procedures/encounters with feedback provided after care is
delivered (Level 4).
1.3 The assignment of graduated levels of responsibility will be made available to other staff who have a need to know through the
residency competency database on the Palmetto Health intranet. Updates are made at least annually.
HOSPITAL MONITORING OF SUPERVISION:
1.1 The DIO is responsible for ensuring that the institution fulfills all responsibilities identified within this section.
1.2 Along with the DIO, each Program Director is responsible for monitoring resident supervision, identifying problems, and devising plans
of action for their remedy.
1.3 At a minimum, the monitoring process includes:
a.
A review of compliance with inpatient and outpatient documentation requirements, as part of medical record reviews;
b.
A review of all incidents and risk events with complications to ensure that the appropriate level of supervision occurred;
c.
A review of all accrediting and certifying bodies’ concerns and follow-up actions;
d.
A review of resident evaluations of their faculty and rotations;
e.
An analysis of events where violations of graduated levels of responsibility may have occurred;
f.
A review of all tort claims involving residents, to determine if there was an appropriate level of supervision.
1.4 Reviews pertaining to monitoring of resident supervision are communicated, at a minimum, on a yearly basis, to the MEC and Board
of Palmetto Health.
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February 5, 2002
February 12, 2013
Signature on File
Signature On File
GME Policies
Tobacco-Free Workplace
In the interest of promoting health and healthy lifestyles, Palmetto Health Richland is a tobacco-free workplace.
Tobacco use by employees, patients, medical staff, volunteers, residents, students, contractors or visitors is not
permitted on the Palmetto Health Richland Campus.
POLICY:
1. The use of all tobacco products is prohibited on the campus of Palmetto Health Richland, including its outpatient facilities, business
entities, private and hospital-owned vehicles, and parking lots/decks.
2. The term “tobacco” includes, but is not limited to cigarettes, cigars, chewing tobacco, snuff and pipe smoking.
3. For buildings/properties that Palmetto Health Richland leases are or owned by more than one company and for buildings/properties
that have common areas, use of tobacco products will be prohibited.
EMPLOYEES:
1. All employees of Palmetto Health are expected to comply with this policy while working, doing business or present on Palmetto
Health Richland property or in a Palmetto Health vehicle. Violation of this policy could subject employees to disciplinary actions as
outlined in the “Disciplinary Action” policy in the Palmetto Health Human Resources Policy manual.
2. Enforcement of the Tobacco-Free policy is the responsibility of every employee. The Security Services department will respond to
requests for assistance from any employee when managing individuals who refuse to comply with this policy.
PATIENTS:
1. Inpatient Assessment/Compliance:
During the pre-admission process or admission assessment, the nurse will determine if the patient is a tobacco user; if so, the nurse
will document such in Cerner and remind patient that Palmetto Health is a tobacco-free environment. For patients who use tobacco
and desire assistance complying with this policy, there will be standing orders for nicotine replacement therapy (NRT) which can be
initiated at the discretion of the admitting physician.
Patients will be advised that leaving the nursing unit and campus to use tobacco product is against policy and will be managed and
documented according to the Against Medical Advice (AMA) policy A-5. If the patient is noncompliant with this policy, the following
steps will be taken:
a.
Staff will re-educate the patient using appropriate scripting on the Tobacco Free Policy and document in the medical record
the education discussion and the alternatives to tobacco products offered to the patient.
b.
Staff will ask the patient to surrender the tobacco products.
c.
Staff will notify the physician as appropriate, who will be asked to discuss health/safety concerns with the patient.
d.
Staff will notify their Nurse Manager/designee and/or Administrator on Duty of patient’s non-compliance with policy.
e.
Security Services will be contacted as appropriate for those patients who are threatening, abusive, disruptive, or presenting a
safety risk.
2. Outpatients:
Outpatients are subject to the same restrictions as other visitors to Palmetto Health properties/facilities.
3. Visitors:
Nicotine Replacement Therapies (NRT) are available for purchase for visitors at any time in the Hospital Gift Shops. An informational
brochure is available to be given to visitors observed smoking. Employees are encouraged to address visitors who may be unfamiliar
with our policy.
a.
If a visitor is non compliant, the staff member should, courteously remind him/her that PHR is a tobacco-free campus and
request that tobacco be safely disposed of or that the visitor move to publicly maintained property in order to use tobacco.
Staff member should walk away without creating a confrontation, and notify Security Services at ext. 7351.
b.
If the visitor becomes threatening, abusive, or disruptive, the staff member should walk away and notify Security Services at
ext.7351 for assistance. A security officer will attempt to locate offender in order to educate offender regarding the Tobacco
Free Policy.
c.
Continued non-compliance may result in the visitor being escorted off the premises.
Signature on File
Marty Bridges
Chief Operating Officer, Palmetto Health
Signature On File
Carolyn Swinton
Chief Nursing Officer, Palmetto Health
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GME Policies
Transitions Of Care
A responsibility of the Institution that sponsors Graduate Medical Education is to ensure and monitor effective,
structured hand-over processes to facilitate both continuity of care and patient safety. The institution must
ensure the programs design clinical assignments in a manner to minimize the number of transitions in patient
care, ensuring that residents are competent in communicating with team members in the hand-over process, and
ensuring the availability of schedules that inform all members of the health care team of attending physicians and
residents currently responsible for each patient’s care.
DEFINITIONS:
Transitions of Care: The transfer of information, authority and responsibility during transitions in care across the continuum for the
purpose of ensuring the continuity and safety of the patient’s care. Hand-off communication is a real-time, active process of passing
patient-specific information from one caregiver to another, generally conducted face-to-face, or from one team of caregivers to another for
the purpose of ensuring the continuity and safety of the patient’s care. Hand-offs occur upon admission, at shift changes, before and after
procedures, upon unit changes, institutional changes, and at discharge.
PROCEDURES:
1. Each program is responsible for ensuring that a standardized approach to hand offs is utilized.
2. Handoffs must:
a.
Be face to face, when possible
b.
give critical data that affects patient care, such as outstanding studies or scheduled labs. Faculty will identify a quiet area to
give report that is conducive to transferring information with few interruptions.
3. The transferring provider will have at hand any supporting documentation or tools used to convey information and immediate access
to the patient’s record.
4. All communication and transfers of information will be provided in a manner consistent with protecting patient confidentiality.
5. Providers will afford each other the opportunity to ask or answer questions and read or repeat back information as needed. If
the contact is not made directly (face-to-face or by telephone), the caregiver must provide documentation of name and contact
information (extension, pager, or email address) to provide opportunity for follow up calls or inquiries.
6. At a minimum, hand-offs should cover the following:
•
the problem;
•
pertinent information to the problem at hand;
•
resident/fellow’s or attending’s assessment; and
•
recommendations for managing potential problems
7. The DIO, GMEC, and working environment committee will review each department’s approach to hand-offs when the department
submits its annual report.
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February 14, 2012
February 12, 2013
Signature on File
Signature On File
Section C
Patient-Related Policies
172
Patient-Related
Policies
Table
Of Contents
Abuse and Neglect of Senile, Developmentally Disabled
Multi-disciplinary Patient and Family Education...................... 253
or Mentally Ill persons................................................................... 175
Notification of Next Kin................................................................ 254
Accessing Protected Health Information.................................... 177
Occurrence Reporting and Follow Up......................................... 256
Autopsy Authorization................................................................. 179
Organ and Tissue Donation ......................................................... 258
Cardiopulmonary Resuscitation (Code 99 or Code 3)............... 180
Pain Management ......................................................................... 260
Care of Discharged Patients Who are Unable
Patient Care Orders ....................................................................... 263
to Leave Hospital............................................................................ 181
Patient Complaint Management ................................................. 265
Chain of Command........................................................................ 182
Patient Identification..................................................................... 267
Child Abuse and Neglect............................................................... 184
Patient Responsibilities ................................................................ 268
Communication Services for Deaf, Hard of Hearing, Visually
Patients’ Bill of Rights.................................................................... 269
Impaired and Non-English-Speaking Patients........................... 186
Pneumococcal and Influenza Vaccine.......................................... 271
Continuity of Care.......................................................................... 188
Private Duty Nursing Assistants ................................................. 272
Coroners’ Case................................................................................ 191
Pronunciation and Certification of Death .................................. 274
Critical Test Results........................................................................ 193
Protected Health Information ..................................................... 276
Discharge or Transfer of Patient in Bed Tracking...................... 194
Rapid Response Team.................................................................... 279
Discharge Planning........................................................................ 195
Red Rules......................................................................................... 281
HIPAA Privacy Policy..................................................................... 197
Reporting Illegal Drug Use During Pregnancy........................... 282
Informed Consent.......................................................................... 202
Restraint Interventions ................................................................ 284
Infusion Management Safety Precautions.................................. 207
Restraint and Seclusion for Violent/Self-Destructive Behavior.... 287
IntraHospital Hospice Transfer Orders....................................... 208
Restricting Uses and Disclosures of Protected Health
Infection Control, Isolation Procedures/Guidelines/Rules....... 209
Information..................................................................................... 291
Latex Allergy/Sensitivity.............................................................. 231
Care of Psychiatric Patients in an Acute Care Environment..... 292
Lewis Blackman Safety Act........................................................... 235
Transporting Patients ................................................................... 294
Media/Public Requests for Patient Info...................................... 237
Verification of Invasive/Surgical Site .......................................... 298
Medical Record Information Release........................................... 239
Visitors for Patients ....................................................................... 300
Medtronic Synchro Med Infusion System/Implantable Pump.....242
Warfarin Monitoring..................................................................... 301
Metformin and Metformin Combination Products Policy....... 244
Withholding or Withdrawing Resuscitative Services ............... 302
Moderate Sedation......................................................................... 245
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Abuse and Neglect of Senile, Developmentally Disabled or
Mentally Ill Persons or Those with Like Incapacities
Patient Care
Policy No. 12, R-5
January 27, 1977
Revised Date: July 20, 1999
Palmetto Richland Memorial Hospital cooperates with South Carolina agencies to ensure that “all practitioners
of the healing arts having reasonable cause to believe that any person who is senile, developmentally disabled,
mentally ill or who has like incapacities (conditions that prevent an individual from caring for him/herself), and has
been subjected to physical abuse, neglect, or exploitation shall report or cause a report to be made.”
GUIDANCE:
1. Senile, developmentally disabled, and/or mentally ill persons or those with like incapacities arriving at the Emergency Room,
Ambulatory Care Center, or inpatients of the Hospital suspected of having been abused or neglected shall be reported to the South
Carolina Department of Social Services.
2. Abuse and Neglect shall be defined for reporting purposes as:
2.1 Physical Abuse – Any injury to the person which is inadequately accounted for shall be evaluated for possible abuse/neglect.
These may include but are not limited to the following:
2.1.1. Bruises, ecchymoses, and/or hematomas
2.1.2. Fractures
2.1.3. Welts
2.1.4. Lacerations
2.1.5. Sprains
2.1.6. Burns, especially multiple
2.1.7. Blunt trauma
2.1.8. Abrasions
2.1.9. Significant signs head trauma
2.1.10.Signs of sexual trauma
2.1.11.Subdural hematoma
2.2 Physical Neglect – Failure to meet the physical wants and needs of the person in relation to food, shelter, clothing, personal
hygiene, medical care or need for supervision. This includes malnutrition or starvation.
2.3 Exploitation – An unjust or improper use of another person for one’s own profits or advantage.
3. Elements in the patient’s medical history indicating a need for evaluation of possible abuse or neglect may include:
3.1 Undue delay between injury and presenting patient for medical care.
3.2 A history that does not explain the injury.
3.3 Reluctance to give information.
3.4 History of repeated fractures or other injuries.
3.5 Impossibility of locating responsible family member or guardian.
3.6 Unusually fearful patient.
3.7 Evidence of overall poor care.
PROCEDURE:
Responsibility
Vice President
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Action
Director of Nursing
1. Ensure implementation of policy in consultation and cooperation with
Hospital, Medical and Dental Staff and House Staff.
2. Ensure implementation by Nursing Staff.
Charge Nurse
Social Work Case Manager
3.
4.
5. 6.
Notify attending physician.
Notify the Hospital Social Work and Discharge Planning Department.
Notify Director of Nursing.
In suspected abuse/neglect cases, notify Adult Protective Services
Director of Social Work and Discharge Planning
Signature on File
John J. Singerling, III
President, Palmetto Health
of the Richland County Department of Social Services. When the
client/patient is currently admitted or committed in the care of
any public or private agency, department, hospital, institution or
facility, the suspected abuse or neglect should be reported to one
of the following: SC Law Enforcement Division, the Nursing home
Ombudsman or the Solicitor.
7. Photographs or causes photographs to be taken of areas or trauma
which show evidence of suspected physical abuse/neglect
8. Ensure proper notation of patient record.
9. Ensure proper continuity among appropriate agencies and PRMH for
abuse/neglect cases.
Signature On File
Carolyn Swinton
Chief Nursing Officer and Vice President,
Patient Care Administration, Palmetto Health Richland
Effective January 27, 1977
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Accessing Protected Health Information
Effective: April 14, 2003
Revised: August 10, 2004; October 1, 2007; May 11, 2010; December 1, 2010; December 1, 2011
Name of Associated Policy: HIPAA Privacy Policy
Responsible Positions: Workforce Members
PROCEDURE STEPS, GUIDELINES, RULES OR REFERENCE:
Access
1. Those associated with Palmetto Health shall not seek, use, or disseminate information for which they do not have a need or right to
know to perform their direct responsibilities. This also applies to employees accessing their own personal information. Employees
who need access to their personal health information must obtain access via Palmetto Health’s approved processes. Please see the
Human Resources Confidentiality Policy.
2. Patients have the right to inspect and receive a copy, at their expense, of the PHI in their designated record set and in accordance
with Palmetto Health’s Medical Record Information Release Policy. All requests to access, inspect and/or obtain a copy of PHI will be
directed to Health Information Management or the specific department maintaining the PHI. Exceptions include:
2.1. Psychotherapy notes unless authorized by physician;
2.2. Information compiled in reasonable anticipation of or for use in a civil, criminal or administrative action or proceeding;
2.3. PHI subject to the Clinical Laboratory Improvements Amendments (CLIA) of 1988;
2.4. PHI exempt from CLIA, pursuant to 42 CFR 493.3(a)(2), i.e. PHI generated by:
2.4.1. facilities or facility components that perform testing for forensic purposes;
2.4.2. research laboratories that test human specimens but do not report patient specific results for diagnosis, prevention,
treatment or the assessment of the health of patients;
2.4.3. laboratories certified by the National Institutes of Drug Abuse (NIDA) in which drug testing is performed that meets
NIDA guidelines and regulations. However, other testing conducted by a NIDA-certified laboratory is not exempt.
3. A patient has the right to inspect or receive copies of their PHI for as long as the PHI is maintained in the designated record set.
4. Patients have a right to obtain, at their expense, a copy of their PHI in an electronic format and, if the patient chooses, to direct
Palmetto Health to transmit the copy directly to an entity or person designated by the patient.
5. If Palmetto Health does not maintain the PHI that is the subject of the patient’s request for access but knows where the information is
maintained, Palmetto Health must inform the patient where to direct the request for access.
6. The patient must make the request in writing using the Palmetto Health Authorization for the Use and Disclosure of PHI form or a valid
authorization form received from another entity.
7. Palmetto Health must act on the patient’s request no later than 30 days after the request is made, or if the request is for PHI that is
not maintained or accessible on-site, no later than 60 days after the request.
7.1. If Palmetto Health is unable to take action on a request for access to PHI within the established time period, Palmetto Health
may extend the required time by no more than 30 days, as long as Palmetto Health provides the individual with a written
explanation for the delay and the date by which the request will be completed.
8. If access is granted in whole or in part, Palmetto Health must:
8.1. provide the patient access to his or her PHI in the designated record sets, including inspection, receiving a copy or both:
8.2. provide the patient with access to PHI in the form or format requested by the patient if it is readily producible in such form or
format; if not, in a readable hard copy form or format agreed to by both parties.
9. Palmetto Health may provide the patient with a summary of PHI requested in lieu of providing access to the PHI or may provide an
explanation of the PHI to which access has been provided if:
9.1. the patient agrees to such a summary or explanation; and
9.2. the patient agrees in advance to the fees imposed, if any, by Palmetto Health for such summary or explanation.
10. Palmetto Health must provide the access requested by the patient in a timely manner, including arranging with the patient for a
convenient time and place to inspect or receive a copy of the PHI or mailing the copy of the PHI at the patient’s request. Palmetto
Health may discuss scope, format and other aspects of the request for access with the patient as necessary to facilitate the timely
provision of access.
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11. If the patient requests to inspect or receive a copy of their PHI while still in the hospital, Palmetto Health requires that there be a
physician’s order stating that the patient may inspect or receive the requested PHI. If the physician denies the patient’s request to
inspect or receive copies of their PHI, the physician must document the reason for refusing access.
12. If the patient requests a copy of the PHI or agrees to a summary or explanation of such information, Palmetto Health may impose a
reasonable, cost-based fee provided that the fee includes only the cost of:
12.1. copying, including the cost of supplies for and labor for copying the PHI requested. The fee schedule for these services is set
by the State of South Carolina and can be obtained from the Health Information Management Department:
12.2. postage if the patient has requested the copy, summary or explanation is mailed. Contact the Health Information Management
Department for the fee schedule for postage:
12.3. preparing an explanation or summary of PHI is agreed to by the patient.
12.4. Under South Carolina law, a health care facility or a health care provider may charge a fee for the search and duplication of a
medical record. The fee may not exceed sixty-five (65) cents per page for the first thirty (30) pages, fifty (50) cents per page for
all other pages and a clerical fee for searching and handling not to exceed fifteen (15) dollars per request plus actual postage
and applicable sales tax. The facility or provider may charge a patient or the patient’s representative no more than the actual
cost of reproduction of an X-ray. Actual cost means the cost of materials and supplies used to duplicate the X-ray and the
labor and overhead costs associated with the duplication.
Denial Of Access
1. Palmetto Health must allow a patient to request access to inspect or receive a copy of PHI maintained in their designated record set.
However, Palmetto Health may deny a patient’s request without providing an opportunity for review when:
1.1. an exception detailed in #1 under ACCESS;
1.2. Palmetto Health is acting under the direction of a correctional institution and the prisoner’s request to obtain a copy of
PHI would jeopardize the patient, other prisoners or the safety of any officer, employee or other person at the correctional
institution, or a person responsible for transporting the prisoner;
1.3. the patient agreed to temporary denial of access when consenting to participate in research that includes treatment, and the
research is not yet complete;
1.4. the records are subject to the Privacy Act of 1974, and the denial of access meets the requirements of that law;
1.5. the PHI was obtained from someone other than Palmetto Health under the promise of confidentiality and access would likely
reveal the source of the information.
2. Palmetto Health may deny a patient access for the following reasons, provided that the patient is given the right to have such denials reviewed.
2.1. A licensed healthcare provider has determined that the access is likely to endanger the life or physical safety of the patient or
another person;
2.2. The PHI makes reference to another person who is not a healthcare provider, and a licensed healthcare professional has
determined that the access requested is likely to cause substantial harm to another person;
2.3. The request for access is made by the patient’s personal representative and a licensed healthcare professional has determined
that the provision of access to the personal representative is reasonably likely to cause substantial harm to the individual or
another person.
3. If access is denied as stated in #2, the patient has the right to have the denial reviewed by a licensed healthcare professional,
designated by Palmetto Health to act as a reviewing official. The reviewing official must not have participated in the original decision to
deny. Palmetto Health must provide or deny access with the determination of the reviewing official.
4. If Palmetto Health denies access (in whole or in part) to the PHI, Palmetto Health must:
4.1. to the extent possible, give the patient access to any other PHI requested, after excluding the PHI to which Palmetto Health
denied access:
4.2. provide a timely, written denial to the patient, in plain language and containing
4.2.1. the basis for denial;
4.2.2. if applicable, a statement of the patient’s review rights, including a description of how the patient may exercise such
review of rights; and
4.2.3. a description of how the patient may complain to Palmetto Health.
REFERENCES:
HIPAA Federal Regulation 45 C.F.R. §164.524
South Carolina Code of Laws 44-115-30
HITECH Act of 2009, Section 13405
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Autopsy Authorization
Palmetto Health Richland provides facilities for performing autopsies by the attending physician upon appropriate
authorization.
GUIDANCE:
1. The attending physician/designee shall obtain the consent for autopsy from the next-of-kin.
2. In Coroner or Solicitor’s cases the specific instructions of the Coroner and/or Solicitor are required for the performance of any autopsy
and authorization by next-of-kin is not required.
3. Consent for a licensed physician to perform an autopsy may be given in writing by the decedent during his/her lifetime.
4. Where no consent was obtained from the decedent during his/her lifetime, consent should be obtained from the next-of-kin. Legal
next-of-kin, in order of precedence is spouse, adult son or daughter, either parent, adult siblings, guardian of deceased at time of
death, grandparents, uncles and aunts and cousins.
4.1 If there is no surviving spouse or relative, consent to an autopsy may be obtained from any person who has obtained custody
of the body for burial.
4.2 In the event consent for an autopsy is given by the next-of-kin, other than the spouse, the autopsy shall not be performed if
any other next-of-kin shall object in writing to the physician who is to perform the autopsy.
5. If all the next-of-kin are minors, the consent of any minor who is at least sixteen years of age will be sufficient.
6. A married minor may consent to an autopsy upon himself/herself, his/ her spouse, or his/her child.
7. When obtaining authorization for autopsy, the Consent Form for Postmortem Examination will be completed by the attending
physician or his/her designee.
7.1 All autopsy authorizations will be in writing (Consent Form for Postmortem Examination).
7.2 Autopsy authorizations will be witnessed and dated.
8. Authorization for autopsy should be obtained as soon as possible after death.
9. Authorization for autopsy of a minor must be signed by both parents.
10. Note on the autopsy authorization form if the patient was on isolation and the type of isolation.
PROCEDURE:
Responsibility
Attending Physician/Designee
Nurse Manager/Designee
Action
1. Obtains consent for autopsy. Upon consent, completes Autopsy
Authorization Form.
2. Documents patient’s chart.
3. Monday-Friday, 07:30-18:00, notify the Pathology Office (6405)
of autopsy authorization. Take consent form and patient’s medical
record to the Pathology Office.
4. From 18:00-07:30, on weekends and holidays, notify the Laboratory
supervisor (7471) of the autopsy authorization. Take the consent
form and patient’s medical record to the Laboratory supervisor.
Signature on File
James E. Lathren
178
Cardiopulmonary Resuscitation
(Code Blue and Code Blue, Jr.)
Patient Care
April 2005
Palmetto Health Richland provides cardiopulmonary resuscitation (CPR) as a means of life support to victims of
sudden, unexpected cardiac and/or pulmonary arrest.
RULES
Those persons trained in CPR and are required by their job description will participate in Code Blue or Code Blue, Jr.
1. Gather equipment:
Code Cart
Monitor/Defibrillator
Emergency Drug Box
2. Procedure:
a.
Initial responder is to make assessment, call for help, and initiate basic rescuer CPR. The initial responder is to note time and
remain with patient until relieved by other members of the code team.
b.
Initial responder or first person available is to call 6222 to notify operator of code or use “code” button on telephone if
available. Identify type of code (Code Blue, Jr for pediatrics and Code Blue for Adults) and location.
The Operator (6222) is to be notified for codes in Medical Park 5, 6 and 7. Codes that occur in any other campus building
need to be called to “911.”
Have unit secretary call attending physician (private) and bring chart to room.
c.
Additional responder(s) is (are) to:
Bring code equipment to bedside
Assist with placement of cardiac board
Connect patient to the monitor
Open emergency cart
Assemble bag-valve mask equipment
Assemble suction set-up
Relieve first responder in performing CPR, if Necessary
Obtain IV access if not already established
d.
Additional responder(s) is (are) to set up for defibrillation.
e.
Additional responder(s) is (are) to administer medications ordered by physician/standing orders. Prepare medication as
needed. Mix drips as directed (see Emergency IV Drip Instructions located with Code Book).
f.
Additional responder(s) is (are) to document events on resuscitation record. Obtain information from other responder(s).
Maintain an ongoing record of code events.
g.
Make arrangements for possible transfer to critical care area. If patient expires, provide post-mortem care.
h.
Upon determination of the need for an infusion pump:
A unit secretary or designee is to call material management services to request a “code infusion” pump.
Material Management services is to bring the infusion pump to the site of the code.
i.
Support and/or notify family of patient’s condition.
j.
Arrange exchange of Code Blue/Blue, Jr. cart with Material Management services and return infusion pump if no longer
needed.
k.
Exchange unit Emergency Drug box with pharmacy.
l.
Document code events on resuscitation record and complete occurrence report. Ensure physician and nurse sign resuscitation record.
m.
The charge nurse should ensure completion of the Code Evaluation Record and the Performance Improvement Tool.
Signature on File
Signature On File
Carolyn Swinton
Effective July 2006
179
Care of Discharged Patients Who Are Unable To Leave
Hospital
Patient Care
October 1, 1976
Policy No. 9, R-5 Revised Date: July 20, 1999
Palmetto Richland Memorial Hospital will provide the appropriate level of care to all discharged patients until the
patient leaves the Hospital premises.
GUIDANCE:
1. When a discharged patient is unable to leave the Hospital because of family circumstances or lack of availability of community
resources, the Nurse Manager or designee will notify the attending physician, the Department of Social Work and Discharge Planning,
Nursing Director, and the Department of Admissions.
2. The Department of Social Work and Discharge Planning will seek means to obtain adequate aftercare for the patient.
3. PRMH personnel will continue to provide the appropriate level of care.
3.1. All physician orders for inpatient treatments and medications should stop at the time the discharge order is written.
3.2. Medications and treatments will be given as ordered in discharge prescriptions.
4. The patient’s chart will remain on the nursing unit until the patient leaves the Hospital. Documentation will include :
4.1. Condition of the patient.
4.2. Care given.
4.3. Measures taken to obtain adequate aftercare.
PROCEDURE:
ResponsibilityAction
Nurse Manager or Designee
1. Notifies attending physician, Department of Social Work and
Discharge Planning, Nursing Director, and Admission Office that
patient is unable to leave the Hospital.
2. Ensures that the appropriate level of care is provided.
3. Ensures that treatments and medications are given as ordered on
discharge.
4. Retains patient chart and documents care.
Department of Social Work and Discharge Planning
5. Seeks means to obtain aftercare.
Department of Admissions
6. Assists patient with financial arrangement as appropriate.
Signature on File
Effective October 1, 1976
180
Signature On File
Carolyn Swinton
Chain of Command
Lewis Blackman Policy
Reviewed:
March 2005
January 3, 2006
The Chain of Command Policy has been designed to provide professional nursing staff and physicians with
appropriate direction for the prompt handling of patient care issues. This policy makes available a formal line of
communication for staff members who have concerns that a prescribed treatment plan ( or the lack thereof), a
medical decision, or other medical act might adversely affect the welfare of a patient or that of the hospital.
DEFINITIONS
1. The ‘Practice of Professional Nursing” means the performance of those acts requiring substantial specialized knowledge, judgment,
and nursing skill based upon applied principles of psychology, biological, physical, and social sciences which shall include, but not be
limited to:
•
The observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care, health teaching and counseling
of the ill, injured, or infirm; and the promotion of wellness, maintenance of health, and prevention of illness of others.
2. Duty of Care Owed by Nurse: In general, a professional nurse has the duty to exercise the degree of care and skill ordinarily
employed, under same or similar circumstances by the members of her/his profession in good standing in the same or similar
community or locality, and to use reasonable care and diligence, along with the exercise of professional judgment.
3. Chain of Command: The lines of authority and responsibility within the hospital administration and the medical staff governing body
through which to channel communication from the staff employee or the attending physician to the appropriate administrative and/or
medical leader to facilitate resolution of a patient care or hospital issue.
POLICY
1. The Nursing Staff and the Medical Staff have the responsibility to cooperate in their mutual efforts to assure delivery of patient care of
the highest quality in accordance with the established policies, procedures, and standards of the hospital.
•
The Nursing Staff will adhere to the following procedure for problem resolution involving Nursing staff and Medical staff related
to patient care concerns and problems.
2. Patient care concerns/problems include, but are not limited to the following: Life-threatening concerns to patients; potential for
complications jeopardizing the safety of patients, family or employees; acts that might constitute the unauthorized practice of
medicine; falsification of records, incorrect orders, transfers to/from other facilities; physician inattention to deteriorating patient
condition; inability to reach the attending physician, etc. Questions involving such issues as billing practices or charges should go
directly to the Risk Manager, Director, or VP for resolution according to Administrative Policies and Procedures and Medical Staff
Bylaws.
3. The Nursing staff, Hospital Administration and Medical staff will follow all requirements under the Lewis Blackman act. A patient or
patient representative may independently access the patient assistance system through the customer service line at 434-7777,
24 hours a day seven days a week. This service is managed by the Patient Relations Department Monday through Friday 8:00am
-8:30pm, Saturday through Sunday 10:00am through 6:30pm. The Administrator on duty will respond to all concerns from this line
at other times. The Customer Service Line is listed in the Patient Guide which is found in each patient room and on a sticker in the
patient’s room.
PROCEDURE
1. The nurse shall contact the attending physician when patient management issues emerge as a result of evaluation of the patient
and the prescribed treatment regimen. When the Nurse-Physician discussion fails to resolve the concerns of adverse effects, noncompliance with established policies and procedures or the unavailability of the physician, the Nurse shall:
• Document the time, name of Attending Physician, summary and outcome of the discussion
in the nurse’s notes of patient’s chart.
• Notify the Charge Nurse or Nurse Manager and their Director /Administrator on Duty of the
situation. Document the date, time, person notified, summary and outcome of the discussion in the
patient’s chart.
•
Retain accountability for the patient, continue to monitor the patient’s status and perform actions necessary to provide for the
patient’s well being.
181
2. Following a thorough investigation the Charge Nurse or Nurse Manager and Director/Administrator on Duty will call the Attending
Physician to resolve the issue or problem.
3. When efforts of the Department Director/Administrator on Duty fail immediate resolution of concerns, the Department Director/
Administrator on Duty contacts the Chief of the Department or Medical Department Director of the unit as appropriate.
•
The nurse shall complete an Occurrence Report regarding the situation and forward the report to Department Director. The
Department Director will forward report to Risk Management.
•
Risk Management shall forward the Occurrence Report to the VP of Medical Affairs (VPMA).
•
The VPMA forwards details of the occurrence to the Chief of Staff (COS).
4. Attending Physician:
•
When efforts of the Chief of the Department (COD) or MD fail immediate resolution of concerns, the Chief of Staff (COS) shall
be notified.
5. When the emergent situation does not provide for the initiation of the chain of command process the Charge Nurse may notify the
Attending Physician (if a resident is involved in the care) and/or the Chief of Department in question. If this effort produces no action,
the Nurse may contact the Chief of Staff and ask him/her to come into the hospital to evaluate the situation. At the same time, the
Nurse Manager of the Unit, the Administrator on Duty, and the Director of the Service should be notified of the actions taken.
ACCOUNTABILITY
1. All Nurses who are responsible for the delivery of patient care must ensure that the well being of each patient is of the highest priority.
Nursing Staff are expected to take whatever action is necessary and appro-priate to ensure that quality of care is being provided at all
times.
2
Nurses and Physicians are encouraged to resolve issues on a one-to-one basis at the level closest to the bedside care.
3. All incidents that involve patient care concerns are to be reported to the Director of Risk Management according to the Risk
Management Policies and Procedures.
4. The Risk Manager is responsible for notifying the VP of Medical Affairs of the action taken on behalf of the patient.
5. The Risk Manager will monitor referrals to identify trends and opportunities for Performance Improvement and make
recommendations to appropriate committees.
6. An Ethics Committee Consultation may be requested, if needed, to facilitate communication and discussion among the members of
the health care team.
Signature on File
182
Signature On File
Carolyn Swinton
Child Abuse and Neglect
Patient Care
January 27, 1977
Policy No. 11, R-6Revised Date: July 20, 1999
Palmetto Richland Memorial Hospital cooperates with South Carolina state agencies to ensure that “all
practitioners of the healing arts and any other person having reasonable cause to believe that a child under the age
of eighteen years has been subjected to abuse or neglect shall report or cause a report to be made.”
GUIDANCE:
1. Child abuse and neglect shall be defined for reporting purposes as including:
1.1 Physical Neglect – Failure to meet the physical wants and needs of the child in relation to food, shelter, clothing, personal hygiene,
or need for supervision. This includes malnutrition.
1.2 Medical Neglect – Failure to provide for the child necessary diagnosis and/or treatment of medical condition whether physical
or psychological.
1.3 Physical Abuse – Any injury to the child which is not accidental, to include beatings, welts, lacerations, burns, broken bones,
hematomas, sprains, etc.
1.4 Abandonment – The factual situation of a parent leaving a child unattended or leaving a child in someone else’s care with no
intent of return to assume care and responsibility for the child.
1.5 Sexual Abuse – Subjecting a child to sexual exploitation or activity.
1.6 Emotional Neglect - Failure to provide for the child the emotional nurturing or emotional support necessary for the
development of a sound personality. Results in perceivable behavior problems for the child.
1.7 Threat of Harm – Perception that child is subject to a substantial risk of harm.
1.8 Illegal Drug Use During Pregnancy – Use of illegal drugs by a pregnant woman of 24 weeks qestation (see policy “Reporting of
Illegal Drug Use During Pregnancy).
2. Symptoms indicating the need for evaluation of possible abuse or neglect may include:
2.1 Bruises and/or ecchymoses.
2.2 Fractures
2.3 Burns
2.4 Blunt Trauma
2.5 Abrasions
2.6 Subdural hematoma
2.7 Severe neglect and/or starvation
2.8 Failure to thrive
2.9 Signs of sexual trauma or activity
2.10 Emotional disturbance
3. Elements in the child’s medical history indication a need for evaluation of possible abuse or neglect may include:
3.1 Undue delay between injury and presenting child for medical care.
3.2 A history that does not explain the injury
3.3 History of repeated fractures or other injuries
3.4 Reluctance to give information
3.5 Projection of responsibility for injury onto a sibling or third party
3.6 Impossibility of locating a parent or guardian
3.7 Parents show inappropriate concern and/or anger
3.8 History of recurrent ingestions
4. Elements in a child’s physical examination indicating a need for evaluation of possible abuse or neglect may include:
4.1 Injury not mentioned in history
4.2 Unexplained injury
4.3 Evidence of overall poor care
4.4 Evidence of repeated injury – especially fractures and ingestions
4.5 Dress inappropriate for degree or type of injury
4.6 Unusually fearful
4.7 Unusual location or type of burn
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PROCEDURE:
Vice President
1. Ensure implementation of policy in consultation and cooperation with
Hospital Medical and Dental Staff and House Staff.
Director of Nursing
2. Ensure implementation by Nursing staff.
Charge Nurse (where suspicion first noted)
3. Notify family physician or Pediatric resident.
4. Notify Hospital Social Worker.
5. Contract the Sheriff’s Department or the Police Department and
contacts Protective Services when parents or guardians demand the
release of a child who the physician feels should remain for treatment
or observation.
6. Ensure proper notation of patient’s medical record.
Hospital Social Worker
Signature on File
184
7. Notify Protective Services of County Department of Social Services
and complete DSS Form 3006. Ensure that a written report follows
the phone report within 72 hours.
8. Forward one (1) copy of DSS Form 3006 to the county DSS Office
and two (2) copies to the Hospital Department of Social Work and
Discharge Planning.
9. Photographs or causes photographs to be taken of area (s) of
trauma visible on the child.
10. Ensure proper documentation in the patient’s medical record.
11. Ensure continuity between DSS and PRMH for Child Abuse/Neglect
cases.
Signature On File
Carolyn Swinton
Communication Services for Deaf, Hard of Hearing, Visually
Impaired and Non-English Speaking Patients
Multi-Disciplinary Patient Care
Policy No. 3
August 1, 1999
Palmetto Health Richland is committed to ensuring that its services are accessible to all persons and to providing
effective communication with those patients who are deaf, hard of hearing, visually impaired or non-English
speaking. Special communication services needed to facilitate effective communication are provided at no cost to
the patient.
RULES:
Identification of Patients with Special Communication Needs
Identification of patients having special communication needs should be made by first contact employee(s) when patient is admitted or
receives services at an outpatient area.
First contact employee(s) will determine if foreign language/hearing impairment/vision impairment is a barrier to effective communication.
First contact employee(s) will determine patient’s need for assistive devices and other resources and will notify Patient Relations/Nursing
staff as appropriate.
Unit/Dept Assessment and Documentation
Special communication needs of patient will be evaluated. Determine any special equipment needs [TTY machine/amplified phone
handset/writing pad and pen]. The TTY machines are obtained by beeping the maintenance worker or on-call maintenance supervisor.
Amplified handsets are obtained from Telecommunications during normal working hours (7:30am to 5pm) and from the hospital operator
after hours and on week-ends/holidays. At discharge, notify Telecommunications via the HelpDesk (434-4357) to remove amplified
handsets and the maintenance worker to remove the TTY machine.
Any written materials requiring informed consent, signature/verbal authorization or other patient acknowledgement of receipt will be read
to the visually impaired person by the staff. Documentation will be made that the material was read to the patient and accompanied by the
patient’s signature or a statement that patient gives verbal consent. There will be signatures of two witnesses.
Label the patient’s chart on chart back spine and arm band with the appropriate identification sticker.
Communication Resources
Palmetto Health Richland provides sign language interpreters and foreign language interpreters for those patients who are deaf or nonEnglish speaking at no cost to our patients. [An interpreter is defined as an individual who is fluent in English and the necessary second
language or a person who can accurately sign and read sign language.]
Paid and qualified Spanish Interpreters are available to Hispanic patients 24 hours a day, 7 days a week for inpatients, outpatient centers,
and PHR-owned practices and entities.
A list of hospital staff volunteers with multi-lingual fluency, including staff who can accurately sign and read sign language, will be
maintained by the Patient Relations office. This list will be made available to the Administrators on Duty (AOD).
The office of Patient Relations coordinates the procurement all language interpreters Mon-Fri, 8:30am-5:00pm at 434-7777. The AOD will
make arrangements at all other times.
Paid interpreters are to be utilized for limited periods of time, when there is a definite need for clear communication regarding medical
treatment. As such, these resources are to be used efficiently to minimize repeat calls. Such occasions when an interpreter must be used
are, but are not limited to:
»» history and physical
»» explaining tests and procedures
»» explaining diagnoses, treatment options/treatment plans/discharge plans and instructions.
185
Language Line
For languages other than Spanish, if an interpreter cannot be found from the list of employee and community volunteers, then staff may
request use of the Language Line. Call Patient Relations weekdays, 8:30am – 5:00pm at 434-7777. After 5pm weekdays, on weekends,
and holidays contact the AOD on duty.
Inform Patient Relations/AOD re:
»» Patient name and location
»» Language patient speaks
»» General description of patient situation
Closed-captioned televisions are available in all non-critical care inpatient rooms.
Paid Sign Language Interpreters For Deaf Employees
Department Director or designee determines need and requests interpreter through Patient Relations Office. Employees’ department is
responsible for all charges. Invoices will be forwarded to department from Patient Relations Office.
PROCEDURES:
ResponsibilityAction:
Admissions/Registration Personnel
1. Identifies communications needs of incoming patients.
2. Notifies Patient Relations office/Nursing Director/Unit/Dept. regarding
inpatient admissions.
Nurse Manager or designee
3. Notifies Patient Relations or evening/night/weekend AOD when sign
language or foreign language interpreters are needed.
Department Director of designee
4. Makes requests for sign language interpreters through Patient
Relations office for employees for department-related issues.
5. Assesses patient’s communication impairment and special needs.
6. Implements identification system.
7. Requests appropriate equipment.
Department
8. Pays for sign language interpreters used by department employees
for employment related issues.
Telecommunications and
Engineering Department
9. Stores/distributes equipment to patient/family.
10. Maintains equipment.
Patient Relations
11. Coordinates requests and makes arrangements for sign language
interpreters, Non-English speaking language interpreters and/or use
of language line.
12. Updates and distributes list of Sign Language and language
interpreters.
13. Budgets for and pays costs of paid interpreters.
Signature on File
186
Signature On File
Carolyn Swinton
Continuity of Care
Patient Care
January 10, 1978
Policy No. 16, R-6Revised Date: November, 1999
Palmetto Richland Memorial Hospital (PRMH) assures that patients being relocated for admission elsewhere or for
therapeutic or diagnostic services are afforded appropriate levels of professional care and equipment during transport
and rendering of the services.
GUIDANCE:
A. Movement Within PRMH
1.
Patients requiring transport and care while away from the primary assigned patient care area are to be assessed to determine
the level of monitoring and care needs and the receiving service area is to be alerted if continuous monitoring and care are
needed, including isolation precautions.
2.
The receiving department or unit has the responsibility to advise the primary assigned unit if it does not possess the
professional capability to continue the level of care indicated.
3.
A department, unit or treatment area shall not release a patient to another department or person if the necessary professional
competence and equipment to continue the medically indicated level of care is not available in the new area.
4.
When the service or treatment area receiving the patient does not possess the capability to continue care at the level required
or indicated, the unit from which the patient is transported shall provide the appropriate personnel and equipment until the
patient is returned to the assigned unit.
5.
Before a unit or department accepts a patient from another area, the new unit must review all pertinent aspects of the patient’s
condition before the assigned unit personnel are allowed to be relieved of the patient.
6.
The medical record shall be delivered to the treatment area by the employee escorting the patient. The medical record should
be similarly returned to the unit when the patient returns.
7.
As appropriate, therapeutic and diagnostic services personnel are to establish the availability of Anesthesia personnel prior to
authorizing the movement of the patient to the service area.
B. Movement of PRMH Patients Between PRMH and Other Health Care Providers in Columbia for Diagnostic and Treatment Services
1.
Patients are not to be transported to non-PRMH diagnostic or therapeutic service providers or to outpatient care sites unless
the services in question cannot be provided within the hospital (ie. audiograms).
C. Transfer of PRMH Patients to Other Health Care Facilities
1.
When medically indicated, arrangements for appropriate personnel, equipment and medical records to accompany the patient
will be made by the Nursing Director or designee of the sending unit.
1.1 The requesting nursing station will generate a PRMH computer requisition to the appropriate department for the
desired service.
1.2 The appropriate department will price and code the requisition and if no specific code is available, the department’s
miscellaneous code will be used.
2.
Prior to moving the patient, the sending unit shall notify the receiving facility of any isolation precautions which may effect
patient care or placement.
3.
The Nurse Manager or designee of the sending unit shall notify the family or the person responsible for the patient’s admission
to PRMH that the patient is being transferred and the expected time of arrival at the new facility.
3.1 A purchase order number obtained from Corporate Purchasing and a copy of the computer requisition must
accompany the patient being transferred to a provider hospital.
3.2 During evenings, nights or weekends, the Nursing Director on duty or the Administrator-On-Call will issue a standby
Purchase Order number obtained from the Supply/Procurement/Distribution (SPD) Department.
4.
Upon arrival at the other hospital and upon acceptance by appropriate department personnel, PRMH personnel shall return to
PRMH, and will insure that all PRMH equipment and property is returned to PRMH.
D. Handling of Non-PRMH Patients for Diagnostic or Treatment Purposes
1.
Other hospitals are expected to develop comparable rules and procedures for providing the appropriate level of care while
moving their inpatients to PRMH for diagnostic or treatment purposes including providing appropriately qualified personnel to
accompany patients being moved by ambulance to PRMH.
2.
Inmates of the South Carolina Department of Mental Health who are transferred to PRMH for medical or surgical treatment or
procedures shall continue to be attended by a psychiatrist and appropriate nursing personnel provided by the South Carolina
Department of Mental Health throughout their stay at PRMH. Such psychiatrist must be a member of the PRMH MedicalDental Staff and meet the qualifications for and requirements of staff membership.
187
3.
In cases in which the appropriate level of care is not provided by the ambulance service or the other hospital, PRMH will
provide the care required and bill the institution in which the patient is an inpatient if that institution is the final discharging
provider.
E. General
1.
Safeguarding patient valuables will be accomplished in accordance with PRMH Policy 8145-5.
2.
Patient transfers within PRMH will be accomplished in accordance with PRMH Policy 8145-4.
3.
Appropriate consent shall be obtained. In cases in which a PRMH patient is being temporarily moved to another institution, the
record of the consent should include full understanding of the move. In cases in which a non-PRMH patient is being cared for,
appropriate consent shall be obtained.
4.
Appropriate PRMH requisitions for services by other institutions and PRMH charges for services provided to patients from
other institutions shall be accomplished in accordance with this policy.
PROCEDURE:
Movement within PRMH
Nurse
1. Assess patient to determine level of monitoring and care needed
while in diagnostic or therapeutic service area.
2. Alert service area to care and monitoring needs.
Nursing Director/Designee
3. Provide the necessary qualified personnel as appropriate to continue
the level of care indicate
Diagnostic/Therapeutic Service
4. Ensure that all unit personnel understand the Supervisor risks
involved in accepting patients where conditions are beyond the
capability of the department staff on duty and the need to advise the
department sending the patient.
Diagnostic/Therapeutic Service
5. If a patient may require anesthesia ascertain the Personnel availability
of the anesthesia personnel prior to having patient moved.
Anesthesia Personnel
6. Provide requested service.
Director of Respiratory Care or Designee
7. When requested by Nurse Manager or designee, provide therapist
to accompany and remain with patient requiring respiratory therapy
services.
Transfer of PRMH Patients
Department Director/Designee
1. Arrange for the necessary medical records, qualified personnel and
equipment as indicated to accompany patients being relocated.
2. Generate computer requisition for desired service/supplies and
complete remarks section indicating provider hospital name.
3. Obtain purchase order number from Corporate Purchasing or from
SPD after regular business hours.
4. Arrange for transportation as appropriate and send purchase order
number and one copy of computer requisition along with patient to
provider hospital.
5. Advise patient’s family of transfer from PRMH.
6. Approve all personnel accompaniment outside Columbia.
7. Approve personnel accompaniment outside South Carolina.
Corporate Procurement/SPD
8. Price and enter patient charge for service/supplies.
9. Issue Purchase Order number.
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Handling of Non-PRMH Patients in PRMH for Diagnostic and Treatment Purposes
Department Directors/Chief
1. Insure that all unit personnel understand the risks involved in
Technologists/Supervisors
accepting patients where condition are beyond the capability of the
department staff on duty.
2. If ambulance service abandons patients, coordinate Emergency
Medical Center personnel to register and place in observation.
3. When required, provide appropriate observation of patients awaiting
ambulance service to other institutions for inpatients who received
unscheduled services in PRMH.
4. Prepare and forward appropriate data to Director of Ambulatory
Financial Services for billing to other institutions.
5. Forward appropriate billing to other institutions for inpatients who
received unscheduled services in PRMH.
Handling of South Carolina Department of Mental Health Patients
Director of Nursing
1. Insure that South Carolina Department of Mental Health is notified of
need for continued psychiatric and nursing services.
Signature on File
Signature On File
Carolyn Swinton
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Coroners’ and Medical Examiners’ Cases
Administration & Compliance
Revised: September 30, 2004
Revised: August 10, 2004
Revised: July 16, 2007
October 1, 2001
Policy No. B.06
Section IV, Policy I
Palmetto Health will adhere to all pertinent state laws regarding deaths requiring investigation by the respective
county Coroners.
GUIDANCE:
1. The County Coroner will be notified of deaths when any of the following apply:
1.1 Death when the body is unidentified or unclaimed.
1.2 Sudden death not caused by readily recognized disease or when the cause of death cannot be properly certified by a
physician on the basis of prior, recent medical attention.
1.3 All deaths occurring under suspicious circumstances, including those where alcohol, drugs, or other toxic substances may
have a direct bearing on the outcome.
1.4 All deaths occurring as a result of violence or trauma, whether apparently homicidal, suicidal, or accidental (including those
due to mechanical, thermal, chemical, electrical, or radiational injury, drownings, cave-ins) and regardless of the time elapsing
between the time of injury and the time of death.
1.5 All deaths of patients 18 years and younger.
1.6 Fetal deaths of 20 weeks gestation or greater, weight of 350 grams or greater, stillbirths, or death of any baby within twentyfour hours of birth including criminal abortions, self-induced or otherwise.
1.7 Deaths occurring within a 24 hour period after admission to an institution.
1.8 All deaths, except when the patient has been admitted for over twenty-four hours, are under the care of a physician, and dies
of a natural death.
1.9 If the body of a fetus is transported with the mother to the Emergency Department, the Coroners of both Richland County and
the county of origin will be notified.
2. The County Coroner shall be called to certify the cause of death if the treating physician is deceased, incapacitated, or cannot be
found and has no associate.
3. In the case of death following injury or accident, the coroner of the county in which the injury or death occurred shall be notified.
3.1 On the Easley campus, the Coroner is a member of the Medical Staff. Therefore, any death of a patient under his care who
meets the criteria for Coroner notification will be referred to the Coroner in Greenville County.
4. The name and telephone number of the County Coroner may be obtained by contacting the Sheriff’s Department of that County.
5. For Richland County Coroner’s cases in which death occurred outside of Palmetto Health Richland, under the terms of a contractual
agreement, the body may be brought to Palmetto Health Richland.
5.1 The Coroner shall notify the Security Department that the body is being brought to the Hospital.
5.2 The body shall be received through the Loading Dock.
5.3 A Security employee shall meet the funeral home attendant or ambulance attendant at the morgue door.
5.4 The Security Department shall notify Emergency Room Registration Clerks and Admitting Control of the name of the body in
the morgue for identification by family members, if necessary.
5.5 If the family requests to see the deceased, the Coroner shall be promptly contacted by a Security employee and requested to
be in attendance with the family.
6. Palmetto Health may disclose protected health information about a deceased person, without individual authorization, to coroners,
medical examiners or funeral directors (in accordance with 45 C.F.R. 164.512(g)) for the following purposes:
6.1 identifying a deceased person, determining a cause of death or other duties as authorized by law; and
6.2 to assist funeral directors in carrying out their duties with respect to the decedent including, if necessary, disclosing protected
health information prior to, and in reasonable anticipation of, the individual’s death.
7. The County Coroner will need the following information:
7.1 Name of institution where death occurred.
7.2 Name of person making report and telephone number.
7.3 Name of deceased, including age, race, sex, social security number and home address.
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7.4
7.5
7.6
7.7
7.8
7.9
7.10
7.11
7.12
Time and date deceased admitted to institution.
Time pronounced dead and name of person pronouncing death.
Name of doctor that will be signing death certificate.
Mechanism of injury.
Diagnosed cause of death, if available.
Name of law enforcement agency involved.
Whether next-of-kin has been notified.
Name of funeral home requested by next of kin.
Any additional information required may be obtained by a subpoena.
8. In case of death from violent or accidental means, caller gives only their name and telephone number to the answering service and
asks that they notify the County Coroner immediately. The body cannot be released without the Coroner’s permission.
9. The Richland County Coroner shall be called to certify the cause of death if the treating physician is deceased, incapacitated, or
cannot be found and has no associate.
Signature on File
President and Chief Executive Officer, Palmetto Health
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Critical Test Results, Communication of
Patient Care
June 2006
Critical test results are values that warrant immediate attention due to potential life threatening consequences to
the patient. Communication of critical results occurs promptly via verbal communication to the ordering physician
or designee.
GUIDANCE:
1. Critical test results are defined by the performing department with input and approval from the medical staff. See specific department
manuals.
2. Critical test results are communicated to a licensed healthcare provider.
3. The person receiving the result will verify the result by read-back. The staff member reporting the result will document read-back and
verification.
4. Notification of the result must be documented in the medical record. Those areas that have electronic medical record capabilities will
document in the electronic medical record.
5. Notification of the responsible physician must occur within one hour of the time the result is available. Exception: If the physician has
previously provided orders delineating actions to take in response to a critical test result, or if care is being provided according to
protocol or standing orders, the nurse does not need to notify the physician of the critical test result within one hour.
Signature on File
Effective June 2006
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Signature On File
Carolyn Swinton
Discharge or Transfer of Patient in Bed Tracking
June 2004
Policy No. D-5
Initial Policy January 19, 2004
Utilization of the bed tracking system throughout the facility is the first step to ensure timely and seamless turn
around time for bed usage.
EXPECTATION:
All patient discharges and/or transfers will be entered into the bed tracking system in a timely manner.
GUIDANCE:
1. Once an order is written for the patient to be discharged and/or transfer, it is placed into the phone bed tracking system. This will be
completed as soon as possible by the first person who reviews the discharge order, such as the unit secretary and/or Nurse. The
order for discharge and/or transfer will be noted on the order sheet with the date, time, and initials of the person who places the
discharge order notification in the phone bed tracking system. Information may be entered utilizing the following instructions:
»» Dial:Ext. 7002
»» Enter:
Employee ID #
»» Enter:
Room # (six digits)
»» Enter:
Status # 9
»» Press Zero to Confirm Entries
2. Prepare the patient and room for discharge. Refer to Nursing Manual policy D.3.
3. When personnel enter the room to discharge and/or transfer the patient, the bed is entered into the phone bed tracking system prior
to the patient or body leaving the room. Information may be entered utilizing the following instructions:
»» Dial:Ext. 7002
»» Enter:
Employee ID #
»» Enter:
Room # (six digits)
»» Enter:
Status # 3
»» Press Zero to Confirm Entries
4. Environmental services (EVS) will automatically be notified by the bed tracking system. 45 minutes is allotted for EVS personal to
respond to a routine clean room and 15 minutes to a stat clean room. If there is no response, the bed tracking system will page the
environmental service supervisor who will intervene to ensure the room is cleaned.
5. When EVS personnel enter the room to clean, s/he will enter into the phone bed tracking system that cleaning the room is in process.
6. Upon completion of cleaning, the EVS personnel will again enter into the phone bed tracking system that the room is clean and ready.
7. Once the room is cleaned and ready, the bed tracking system will automatically notify patient placement of the room availability.
Signature on File
Carolyn Swinton
Chief Nursing Officer and Vice President, Patient Care Administration
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Discharge Planning
Policy No. 2
June 1, 1999
Palmetto Richland Memorial Hospital discharge planning involves a coordinated, interdisciplinary effort that relates
the individual needs of patients to the resources of the family, community health and human services programs and
policies of the hospital. The program is coordinated by the manager(s) of the Department of Case Management
who are designated as the Palmetto Richland Memorial Hospital Discharge Coordinators.
RULES:
1. During hospitalization the health care team assumes responsibility for identifying the patient’s health care problems and needs. The
team may include the physician, case manager, nurse, home health coordinator, ancillary service personnel, and financial counselors
as appropriate. Appropriate discharge plans are instituted according to the specific needs of each patient. The patient and family will
be included in the discharge planning process. Any person on the health care team who identifies a high-risk patient is responsible for
referring the patient to the Department of Case Management or appropriate ancillary service for discharge planning.
2. Patients who are likely to need discharge planning that involves other community resources and/or institutionalization are identified
through early screening for high-risk indicators. The following screening criteria apply generically to all services:
2.1 Patient’s age as it relates to functional ability, chronic disease, or disability.
2.2 Patient living alone and/or with no immediate support system as it relates to functional ability and/or disability.
2.3 Patient is admitted from another institution (i.e., nursing home, state hospital, community care home, etc.).
2.4 Patient admitted with the diagnosis of abuse/neglect, failure to thrive, malnutrition, or assault.
2.5 Patient diagnosed as having catastrophic or life threatening illness or accident requiring placement or alternative aftercare
arrangements and/or major changes in lifestyle or living arrangements (i.e., cancer CVA, multitrauma, neurological disease).
2.6 Patient diagnosed as having a disease or condition requiring supervision or instruction of skills, inherent adjustment problems,
or difficulty coping that will affect discharge plans or require placement in other facilities or home health.
2.7 Patient plans to surrender a newborn for adoption.
2.8 Patient with multiple readmissions, repeated injuries and/or questionable environment necessitating follow-up.
2.9 Patient with insufficient financial resources or having been hospitalized beyond institutional guidelines.
2.10 Infants with complex home care needs who may require assistance with the securing of Medicaid and other forms of payment;
assessment of the adequacy of the home environment for the safe care of the baby, assistance to parents in learning home
care techniques and in securing needed infant care equipment.
2.11 Infants whose parents report history of substance abuse (including EOH) and/or positive testing for drugs.
2.12 Knowledge deficits regarding self-care, disease process or treatments.
3. The Case Manager will evaluate high-risk discharge situations within two days of identification. Documentation in the medical record
will include:
3.1. Assessment of the patient’s needs.
3.2. Assessment of patient and family resources.
3.3. Preliminary determination of required community resources.
3.4. Preliminary plan.
4. The final discharge plans for a specific patient are cleared with the responsible physician. The physician should include a discharge
note in the medical record in support of the discharge plan. For patients being transferred to a long term care facility; the physician
must complete a discharge summary and transfer form including the anticipated level of care needed.
5. Education prior to discharge will be conducted according to the multi-disciplinary patient/family education policy.
PROCEDURE:
Manager(s), Department of Case Management
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1. Coordinates discharge planning program for Palmetto Richland
Memorial Hospital.
2. Identifies patients requiring referral to the Department of Case
Management.
3. Documents support of the discharge plan in medical chart.
4. Completes necessary forms and discharge summary prior to
discharge.
Nursing
Management.
6. Records identified problems in the medical record.
7. Works in conjunction with other disciplines in developing a teaching
plan.
8. Documents educational instruction and any needs for follow-up.
9. Prepares the appropriate documents to accompany patient transfer.
Ancillary Departments
Case Management Staff
Home Care Coordinators
Signature on File
James E. Lathren, III
Management.
11. Works in conjunction with others in developing a teaching plan.
12. Documents educational instruction and any need for follow-up.
13. Screens admissions daily for potential discharge problems.
14. Document assessment and plan in the medical record
15. Coordinates discharge planning conferences on assigned units.
16. Assists family in making arrangements from hospital to home or
aftercare facilities.
17. Assess high-risk discharge situations.
18. Coordinates with physician, patient, family, and extended care facility
a plan for post-hospital placement.
19. Provides emotional support and direction to patient and family.
20. Referral and coordination of equipment needs.
21. Assures that the proper documents are completed and that all
papers accompany thepatient upon transfer.
22. Referral and coordination of home respiratory needs.
23. Assures that the proper documents are completed and that all
papers accompany the patients upon transfer.
24. In conjunction with Case Management Services, assists those
patients who will be returning home and need Home Health
Services.
25. Arranges for necessary follow-up by a home health nurse.
26. Referral and coordination of infusion therapy needs.
27. Documentation of Home Care Coordinator.
Signature On File
Faye Bible
Vice President,Patient Care
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HIPAA Privacy Policy
Department: Corporate Compliance Effective: December 1, 2011
Palmetto Health in its roles as a health care provider and as a self-funded employee health plan may use and
disclose protected health information (PHI) for treatment, payment and health care operations (TPO) in accordance
with applicable state and federal law. This policy provides a general overview of related PHI terminology as it
pertains to Palmetto Health and HIPAA. It is the founding Palmetto Health HIPAA Privacy policy and should be
utilized in conjunction with applicable Palmetto Health privacy procedures and guidelines.
DEFINITIONS:
1. Breach: the unauthorized acquisition, access, use, or disclosure of PHI that compromises the security or privacy of such information.
Exceptions to this definition include:
1.1. disclosures where the recipient of the PHI would not reasonably have been able to retain the information;
1.2. certain unintentional acquisition, access, or use of PHI by employees or persons acting under the authority of a covered entity
or business associate;
1.3. as well as certain inadvertent disclosures among persons similarly authorized to access PHI at a business associate or
covered entity. (refer to Corporate Compliance’s Privacy/Security Breach Notification PGR)
2. Business Associate: a person or entity that provides certain functions, activities, or services for, on behalf of, or to Palmetto
Health involving the use and/or disclosure of PHI. Examples of business associate functions include: collections, claims processing
or administration, data analysis, processing or administration, utilization review, quality assurance, billing, benefit management,
practice management, and repricing. A covered entity may be a business associate of another covered entity. (refer to Corporate
Compliance’s Business Associates PGR)
3. Covered Entity: A health plan, health care clearinghouse or health care provider who transmits any health information in electronic
form in connection with a transaction covered by the HIPAA Administrative Simplification rules.
4. De-identified Information: information that does not identify an individual and with respect to which there is no reasonable basis to
believe that the information can be used to identify an individual. (refer to Corporate Compliance’s Creating De-Identified Information
PGR)
5. Designated Record Set: a group of records maintained by or for a covered entity that is
5.1. the medical records and billing records about individuals maintained by or for a covered health care provider;
5.2. the enrollment, payment, claims adjudication, and case or medical management record systems maintained by or for a health
plan;
5.3. or used, in whole or in part, by or for the covered entity to make decisions about individuals.
5.4. For purposes of this paragraph, the term record means any item, collection, or grouping of information that includes PHI and
is maintained, collected, used, or disseminated by or for a covered entity. (refer to Corporate Compliance’s Designated Record
Set PGR)
6. Disclosure: The release, transfer, provision of access to or divulging in any other manner of information outside Palmetto Health.
7. Directory: A tool used to maintain limited information regarding current Palmetto Health patients and to make appropriate
disclosures of this information. (refer to Corporate Compliance’s Directory PGR)
8. Electronic Health Record: an electronic record of health-related information on an individual that is created, gathered, managed and
consulted by authorized health care clinicians and staff.
9. Fundraising: Activities conducted for the purpose of raising funds to benefit Palmetto Health.
10. Health Care Operations: Any one of the following activities of the covered entity to the extent the activities are related to providing
health care:
10.1. Conducting quality assessment and improvement activities, population-based activities relating to improving health or reducing
health care costs, protocol development, case management and care coordination, contacting of health care providers and
patients with information about treatment alternatives and related functions that do not include treatment;
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10.2. Reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance,
health plan performance, conducting training programs in which students, trainees, or practitioners in areas of health care
learn under supervision to practice or improve their skills as health care providers, training of non-health care professionals,
accreditation, certification, licensing or credentialing activities;
10.3. Underwriting, premium rating, and other activities relating to the creation, renewal or replacement of a contract of health
insurance or health benefits, and ceding, securing, or placing a contract for reinsurance of risk relating to claims for health
care;
10.4. Conducting or arranging for medical review, legal services, and auditing functions, including fraud and abuse detection and
compliance programs;
10.5. Business planning and development, such as conducting cost-management and planning-related analyses related to
managing and operating the entity, including formulary development and administration, development or improvement of
methods of payment or coverage policies; and Business management and general administrative activities, including, but not
limited to:
10.5.1.management activities relating to HIPAA Compliance;
10.5.2.customer service;
10.5.3.resolution of internal grievances;
10.5.4.the sale, transfer, merger, or consolidation of covered entities; and
10.5.5.creating de-identified health information or a limited data set and fundraising for the benefit of
Palmetto Health.
11. Limited Data Set: PHI from which all direct identifiers, such as name, have been removed but may contain some indirect identifiers.
(refer to Corporate Compliance’s Creating and Using a Limited Data Set PGR)
12. Marketing:
12.1. To make a communication about a product or service encouraging recipients to purchase or use the product or service,
unless the communication is made:
12.1.1.to describe a health-related product or service (or payment for such product or service) that is provided by, or included
in a plan of benefits maintained by Palmetto Health, including communications about;
12.1.1.1.the entities participating in a health care provider network or health plan network;
12.1.1.2.replacement of, or enhancements to, a health plan; and
12.1.1.3.health-related products or services available only to a health plan enrollee that add value to, but are not part
of, a plan of benefits;
or
12.1.2.for treatment of the individual;
or
12.1.3.for case management or care coordination for the individual or to direct or recommend alternative treatments,
therapies, health care providers, or settings of care to the individual.
13. An arrangement between Palmetto Health and any other entity whereby Palmetto Health discloses PHI to the other entity, in
exchange for direct or indirect remuneration, for the other entity or its affiliate to make a communication about its own product or
service that encourages recipients of the communication to purchase or use that product or service.
14. Minimum Necessary: Uses and disclosures of PHI must be limited to the minimum amount of information necessary to satisfy
the request or to complete the task; however, minimum necessary does not apply in certain circumstances (refer to Corporate
Compliance’s Minimum Necessary PGR).
15. Patient Representative: someone identified through professional judgment to be qualified to comment on or receive information about
a patient because of his/her relationship to the patient and/or his/her inclusion in the patient’s care. (refer to Corporate Compliance’s
Patient and Personal Representatives PGR)
15.1. The patient representative has limited authority on a case by case basis to provide information to and receive appropriate
information from Palmetto Health as it relates to the patient. However, the patient representative relationship only applies in
certain circumstances such as filing patient complaints and payment-related discussions.
16. Payment: The activities undertaken by a health plan or by a health care provider to obtain premiums determine or fulfill it’s
responsibility for coverage and provision of benefits or to obtain or provide reimbursement for the provision of health care, including
but not limited to:
16.1. determining eligibility or coverage and adjudication or subrogation of health benefit claims;
16.2. risk adjusting amounts due based on enrollee health status and demographic characteristics;
16.3. billing, claims management, collection activities, obtaining payment under a contract for reinsurance, and related health care
data processing;
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16.4. review of health care services with respect to medical necessity, coverage under a health plan, appropriateness of care or
justification of charges;
16.5. utilization review activities, including pre-certification and pre-authorization of services, concurrent and retrospective review of
services; and
16.6. disclosure to consumer reporting agencies of any of certain PHI relating to collection of premiums or reimbursement.
17. Personal Representative: any adult having decision-making capacity on behalf of a patient, including any individual who has authority,
by law or by agreement from the individual receiving treatment, to act in the place of the individual. This includes parents of a minor,
legal guardians or properly appointed agents, like those designated in a Durable Power of Attorney for Healthcare, or individuals
designated by state law. (refer to Corporate Compliance’s Patient and Personal Representatives PGR)
18. Protected Health Information: Encompasses all individually identifiable health information created, received, transmitted or maintained
in any form or medium. It is information relating to the past, present or future physical health, mental health or condition of an
individual. PHI either identifies or could be used to identify the individual.
19. Psychotherapy Note: Notes recorded (in any medium) by a health care provider who is a mental health professional documenting or
analyzing the contents of conversation during a counseling session. Psychotherapy notes do not include medication prescription and
monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests,
and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.
(refer to the Corporate Compliance Psychotherapy Notes: Using and Disclosing PGR)
20. Request: When any person affiliated with Palmetto Health asks for health information from a person or entity outside of the
organization, or when Palmetto Health is asked for health information by a person not affiliated with the organization.
21. Sanction: the detriment, loss of reward, or coercive intervention attached to a violation of a law or policy as a means of enforcing the
law or policy. (refer to Corporate Compliance’s HIPAA Sanctions PGR)
22. Treatment: The provision, coordination or management of health care related services by one or more health care providers, including
the coordination or management of health care by a health care provider with a third party, consultation between health care providers
relating to a patient or for the referral of a patient for health care from one health care provider to another.
23. Unsecured PHI: PHI that is not secured through the use of a technology or methodology, specified by the Secretary of the
Department of Health and Human Services.
24. Use: The sharing, employing, applying, utilizing, examining or analyzing individually identifiable health information within Palmetto
Health.
25. Workforce Members: refers to employees, independent contractor, volunteers, students, trainees, medical residents, fellows and
other persons whose conduct in the performance of work for Palmetto Health is under the control of the organization.
1. Palmetto Health will inform patients and employee health plan beneficiaries of their rights through the provision of a Notice of Privacy
Practices. Individuals may exercise these rights through the processes outlined in the specific Palmetto Health policies or procedures
addressing each of these rights.
2. Palmetto Health will disclose PHI to the Secretary of the Department of Health and Human Services (HHS) as necessary to determine
whether Palmetto Health is in compliance with HIPAA Federal Regulations.
3. In order to manage the facilitation and implementation of activities related to the privacy of PHI, Palmetto Health will appoint and
maintain an internal Privacy Officer position. In general, the Privacy Officer is responsible for coordination and oversight of the policies
regarding the privacy of health information, conducting educational programs, and administering reviews relating to the company’s
privacy program.
4. Palmetto Health shall identify categories of records maintained, collected, used or disseminated that contain individually identifiable
health and/or financial information that is used to make decisions about individuals. Such records shall be termed Designated Record
Sets and shall be considered the personal health information records to which individuals and/or personal/legal representatives have
a right to request access, amendment, and copies. Personal health information will be located in the Health Information Management
department or the specific department maintaining the health information.
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5. Palmetto Health will ensure that the appropriate steps are taken to use, disclose or request only the minimum amount of protected
health information (PHI) necessary to accomplish the intended purpose, as required under 45 C.F.R. §164.502(b), and other
applicable federal, state, and/or local laws and regulations.
6. A valid authorization signed by the patient or employee health plan beneficiary must be obtained for all uses and disclosures of an
individual’s PHI, other than those required by law or for treatment, payment and health care operations.
6.1. Palmetto Health may use or disclose PHI without individual authorization for health oversight activities pursuant to 45 C.F.R.
§164.512.
6.2. Palmetto Health may disclose PHI to public health authorities for a full range of public health activities carried out by federal,
state, and local public health authorities.
6.3. Palmetto Health may not release psychotherapy notes, except in specific situations. (refer to the Corporate Compliance
Psychotherapy Notes: Using and Disclosing PGR) When it is appropriate to release psychotherapy notes, a valid authorization
must be obtained.
7. Palmetto Health will provide reasonable safeguards for PHI in an effort to prevent any intentional or unintentional use or disclosure.
8. Palmetto Health will provide individuals with access to their PHI. However, situations may arise when Palmetto Health personnel must
make a determination to deny an individual access to their PHI, in accordance with applicable laws and regulations.
9. A patient is automatically included in the Directory upon admission. The Directory will be utilized to release specific PHI for patients
who are included. Patients will be offered the opportunity to remain included in or be excluded from Palmetto Health’s Directory.
Palmetto Health will make every effort to obtain the patient’s signed acknowledgement for Directory purposes. The patient may
choose to have their information listed in or removed from the Directory at any time.
10. Palmetto Health will use professional judgment and its experience with common practice to use or disclose PHI in the event of
disaster recovery purposes.
11. Under certain circumstances, and if certain requirements are met, Palmetto Health may use and disclose protected health information (PHI)
for specialized government functions such as military and veterans activities; national security and intelligence activities; protective services
for the President and others; medical suitability determinations; correctional institutions and other law enforcement custodial situations.
12. Palmetto Health engages in fund-raising activities to support healthcare programs, research, patient care and family care needs.
While exercising appropriate safeguards, Palmetto Health may use or disclose limited PHI for fund-raising activities.
13. Palmetto Health will engage in limited marketing activities, which may provide information relative to patient care and services.
Palmetto Health will ensure any PHI used or disclosed for marketing purposes will fully comply with federal, state and/or local laws
and regulations.
14. Palmetto Health may release PHI to certain law enforcement authorities, in response to judicial and administrative orders and/or to
avert serious threat to health and safety as long as other state and federal laws do not prohibit the disclosure.
15. HIPAA requires that covered entities have and apply appropriate sanctions against members of their workforce who fail to comply
with privacy and security policies or the requirements of the Privacy and Security Rules. Palmetto Health will apply sanctions in
accordance with the HIPAA Sanctions PGR as well as the Human Resources Disciplinary Action policy.
16. Federal law allows health care organizations to create and use a limited data set under certain conditions. Palmetto Health may use or
disclose limited data sets for the purposes of research, public health and health care operations. In doing so, Palmetto Health ensures
that the appropriate administrative and technical processes are in place to properly remove direct identifiers from PHI as required
under 45 C.F.R. §164.514(e) and other applicable federal, state, and/or local laws and regulations.
17. Federal law allows certain health care organizations to use or disclose PHI for the purpose of creating de-identified information.
Palmetto Health may use de-identified PHI for various purposes such as utilization research. In doing so, Palmetto Health ensures
that the appropriate administrative and technical processes are in place to properly de-identity PHI, as well as to secure reidentification, as required under 45 C.F.R. §164.514 and other applicable federal, state, and/or local laws and regulations.
18. It is sometimes necessary to allow medical equipment vendors to be in patient care areas, such as the surgical suite, in order to
provide the highest quality patient care. In order to inform patients of the possibility of this occurrence, Palmetto Health has included
information to this effect in its Surgery Consent form. Additionally, the patient’s physician should specifically inform the patient when it
is apparent a vendor will be present during a procedure.
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19. Palmetto Health shall not directly or indirectly receive remuneration in exchange for any PHI of an individual unless a valid authorization
has been obtained. The authorization must also specifically state whether the PHI can be further exchanged for remuneration by the
entity receiving PHI of that individual. However, this statement does not apply if the PHI is exchanged for the following purposes:
19.1. public health activities;
19.2. research;
19.3. treatment of the individual;
19.4. healthcare operations;
19.5. exchanges with a business associate; or
19.6. exchanges with the individual who is the subject of the PHI, or as otherwise specified by the Secretary of the Department of
Health and Human Services.
20. Palmetto Health will maintain administrative documentation, in written or electronic form, of policies, procedures, communications and
other administrative activities as required by HIPAA. Palmetto Health must retain all administrative documentation for at least six years
from the date of its creation or the date when it last was in effect, whichever is later.
21. The following Palmetto Health corporate policies should be consulted in addition to HIPAA policies and procedures when handling
PHI related to these areas:
21.1. Abuse and Neglect
21.2. Confidentiality
21.3. Coroner’s and Medical Examiner’s Cases
21.4. Human Remains
21.5. Involving Other’s in a Patient’s Care/Notifying Next of Kin
21.6. Media/Public Request for Patient Information
21.7. Medical Record Information Release
21.8. Organ and Tissue Donation
21.9. Reporting of Illegal Drug Use During Pregnancy
21.10.Research Uses and Disclosures of Protected Health Information
REFERENCES:
HIPAA Federal Regulations 45 C.F.R. 164.500-164.530
Signature on File
Effective December 1, 2011
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Informed Consent
Administration
October 1, 2001
Revised: November 11 ,2006
Revised: February 27, 2007
Policy No. B.09
It is the policy of Palmetto Health (PH) to respect the right of each patient to voluntarily make their own decisions
with regard to matters that affect their medical treatment, and requires the provision of information to allow the
individual to make an informed decision. The patient (or legal representative) has the right to assert informed
consent or informed refusal of any treatment or procedure. Informed consent issues will be handled in a manner
consistent with the South Carolina (S.C.) Adult Health Care Consent Act, the S.C. Death with Dignity Act, and other
legal/ethical considerations which relate to patient choice.
DEFINITION:
Informed Consent: A process whereby the patient is given an explanation of the proposed treatment or procedure (hereinafter treatment)
which provides the patient with information to make his/her decision to undergo or forego the treatment. The explanation should include:
1. the patient’s diagnosis
2. the general nature and purpose of the contemplated treatment in non-technical terms where practical
3. the potential benefits of the treatment
4. the material risks involved and potential problems related to recuperation
5. the likelihood of success associated with the treatment
6. the prognosis if treatment is not carried out
7. the existence of any feasible alternative methods of treatment
Patient consent must be voluntary. It is the responsibility of the physician or dentist (hereinafter physician) to disclose that which a
reasonable medical practitioner of like training would disclose under the same or similar circumstances.
GUIDANCE:
1. When Informed Consent is Required
Informed consent of the patient (or legal representative) is required when the patient will undergo a procedure, treatment or surgery that is
not considered part of routine hospital care, nursing care, or routine diagnostic procedures. Therefore, an informed consent must be
obtained for any non-routine treatment, procedure, or surgery prior to the start of the treatment, procedure, or surgery.
2. Other Situations Requiring Informed Consent
2.1 Prior to the administration of blood and/or blood products, anesthetic, preoperative or other sedation agents.
2.2 Prior to the initiation of any surgical intervention or special diagnostic or therapeutic treatment considered to be experimental
or research, (subject to Institutional Review Board approval) OR is irreversible, or carries significant medical risks as determined
by the physician.
2.3 Prior to photographing a patient in those instances in which the photograph can identify the patient.
3. Who Must Consent:
3.1 Competent Adults: are those eighteen (18) years old or older
3.2 An adult is competent to make health care decisions if he/she has the ability to:
3.2.1 appreciate the nature and implications of his/her condition and the proposed health care;
3.2.2 make a reasoned decision concerning the proposed health care; and
3.2.3 communicate that decision in an unambiguous manner
3.3 If a competent adult patient cannot sign his/her own name, PH will accept an “X” made by the patient. If the competent
patient is unable to physically sign the consent form, the patient’s legal representative may sign at the patient’s request. In this
situation, the patient’s verbal consent is also appropriate (Ex: “Verbal consent by John Doe”). In the event of a verbal consent,
two (2) employees should witness and sign the consent form.
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4. Incompetent Adult Patients:
4.1 A patient is unable to consent if not competent as described in 3.2 above.
4.2 Certification of “inability to consent” to health care: A patient’s inability to consent must be certified by two (2) licensed
physicians, each of whom has examined the patient. However, in an emergency, the patient’s inability to consent may be
certified by a health care professional responsible for the care of the patient if the health care professional states in writing in
the patient’s record that the delay occasioned by obtaining certification from two (2) licensed physicians would be detrimental
to the patient’s health. A certifying physician or other health care professional shall give an opinion regarding the cause and
nature of the inability to consent, its extent, and its probable duration. (See S.C. Code Ann., Section 44-66-20(6))
4.3 Another person must consent for the incompetent adult patient if the attending physician determines the patient’s inability to
consent is not temporary and that the delay occasioned by postponing treatment until the patient regains the ability to consent
will result in significant detriment to the patient’s health.
4.4 “Order of Priority” for Consent: Where a patient has been determined to be “unable to consent”, decisions concerning his/her
health care may be made by the following persons in the following “Order of Priority”
4.4.1 a court-appointed guardian (if health care decisions are within the scope of the guardianship);
4.4.2 an attorney-in-fact appointed by the patient in a durable power of attorney (if health care decisions are within the scope
of his/her authority);
4.4.3 a person given priority to make health care decisions for the patient by another statutory provision;
4.4.4 a spouse of the patient (including common-law), unless the spouse and the patient are separated pursuant to one of
the following:
4.4.4.1.1entry of a pendente lite order in a (i.e. temporary order) divorce or separate maintenance action
4.4.4.1.2formal signing of a written property or marital settlement agreement; or
4.4.4.1.3entry of a permanent order of separate maintenance and support or of a permanent order approving a
property or marital settlement agreement between the parties
4.4.5 a parent or adult son or daughter of the patient;
4.4.6 an adult brother, sister, grandparent, or adult grandchild of the patient;
4.4.7 any other relative by blood or marriage who reasonably is believed by the health care professional to have a close
personal relationship with the patient;
4.4.8 a person given authority to make health care decisions for the patient by another statutory provision. (See S.C. Code
Ann., Section 44-66-30)
4.4.9 Consent may be given by a person listed in the order of priority above if no person having higher priority is available
immediately and if the physician determines that the delay occasioned by attempting to locate a person having higher
priority presents substantial risk of death, serious permanent disfigurement, loss or impairment of the functioning of a
bodily member or organ, or other serious threat to the health of the patient.
4.5 Exceptions to “Order of Priority”: Priority for consent must not be given to a person if the health care provider determines that
the person is:
4.5.1 Not reasonably available;
4.5.2 Not willing to make health care decisions for the patient; or
4.5.3 “Unable to consent” as defined in Section 4.0
4.5.4 Someone whom the attending physician or health care professional has actual knowledge that, before becoming
unable to consent, the patient did not want that person involved in decisions concerning his/her care.
4.6 A person authorized to make health care decisions under Section 4.4 of this policy must base those decisions on the patient’s
wishes to the extent that the patient’s wishes can be determined. Where the patient’s wishes cannot be determined, the
person must base the decision on the patient’s best interest. A person authorized to make health care decisions either may
consent or withhold consent to health care on behalf of the patient.
4.7 Disagreements: If persons of equal priority disagree on whether certain health care should be provided to a patient who
is unable to consent, an authorized person, a health care provider involved in the care of the patient, or any other person
interested in the welfare of the patient may petition the probate court for an order determining what care is to be provided, or
for the appointment of a temporary or permanent guardian.
4.8 Health care should not be provided to a patient who is unable to consent if the attending physician or other health care
professional responsible for the care of the patient has actual knowledge that the health care is contrary to the patient’s
“unambiguous and uncontradicted instructions” expressed at a time when the patient was able to consent. (See S.C. Code
Ann., Section 44-66-60 (B))
4.9 Unless the patient, while able to consent, has stated a contrary intent to the attending physician or other health care
professional responsible for the care of the patient, health care should not be provided to a patient who is unable to consent if
the attending physician or other health care professional has “actual knowledge” that the health care is contrary to the religious
beliefs of the patient. (See S.C. Code Ann., Section 44-66-60(A))
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5. Emergency Exception Where Health Care May be Given Without Consent:
5.1 Health care may be provided without consent to a patient who is unable to consent, if no person authorized to make health
care decisions for the patient is immediately available, and if in the reasonable medical judgment of the attending physician or
other health care professional responsible for the care of the patient, the delay that would occur by attempting to locate an
authorized person to give consent presents a:
5.1.1 substantial risk of death
5.1.2 serious permanent disfigurement
5.1.3 loss or impairment of the functioning of a bodily member or organ; or
5.1.4 other serious threat to the health of the patient
Health care for the relief of suffering may be provided without consent at any time that an authorized person is unavailable.
(See S.C. Code Ann., Section 44-66-50)
5.2 Emergency Situations:
No consent is required under certain situations that are defined by the patient’s condition. Under such circumstances,
the treatment may be performed without the patient’s expressed consent if all of the following criteria are met and fully
documented by the attending physician in the patient’s medical record.
5.2.1 A reasonable effort has been made to locate someone with authority to consent for the patient or insufficient time to
locate such person exists
5.2.2 The health care is necessary for the relief of suffering or restoration of bodily function or to preserve the life, health, or
bodily integrity of the patient. Prior to the emergency treatment, the attending physician has consulted with one other
physician, if one is available and time permits, and this is documented in the patient’s medical record.
5.3 Emergency Research Involving Waiver of Informed Consent
The Institutional Review Board (IRB) may approve a research protocol in which informed consent of all research subjects not
be obtained in rare emergent circumstances (DHHS FDA 21CFR50; 45CFR46).
6. Minor Patient: Any person under 18 years of age, who is not married nor has been married, and has not been emancipated by court
order.
6.1 A minor 16 years old or older may consent to health services other than operations for himself/herself and the consent of no other
person shall be necessary if the services will be performed by a person authorized by law to render the particular health service.
6.2 A parent, legal guardian, or person given authority to make health care decisions for the patient by another statutory provision
can consent for treatment of a minor with the following exceptions:
6.2.1 A married minor or emancipated minor may consent to any lawful diagnostic, therapeutic, surgical, or postmortem
treatment on behalf of himself/herself, his/her spouse (if spouse unable to consent for self), and his/her minor children.
(If married minor is unable to consent, see Section 4 to determine appropriate party to consent).
6.2.2 A minor who has been married or borne a child may consent to any health services for the child to include disposal of a
still-born fetus and abortive contents.
6.2.3 Health services of any kind may be given to minors of any age without the consent of a parent or legal guardian when,
in the judgement of the authorized health care provider, such services are deemed necessary OR, if such involves an
operation which shall be performed that is essential to the health or life of the child, in the opinion of the performing
physician and a consultant physician if one is available. (See S.C. Code Ann., Section 20-7-290)
7. Responsibility for Obtaining Informed Consent:
7.1 Physician
7.1.1 The patient’s physician, not the hospital or its employees, is responsible for providing the patient with the information
necessary for the patient to make an informed consent. The physician should document what was explained to the
patient; however, the patient’s signature in the consent form indicates that he/she has been fully informed and he/she
understood the proposed treatment. The physician must sign the consent for operation. Diagnostic and/or treatment
procedure form. If a different physician than the one listed on the form is to do the surgery or procedure than, the
patient must be informed and the patient’s consent must be documented on the surgical or medical record.
7.1.2 The physician explaining the procedure is encouraged to complete the consent form and have the patient sign the
form. Should the physician desire nursing personnel to complete the Consent Form, he/she shall write an order which
specifies, without the use of abbreviations, the information necessary to accurately complete the consent form. In these
cases, the nurse’s duty is limited to making certain that an explanation by the physician has taken place and that the
patient is satisfied with the explanation. The treating physician is responsible for verifying the accuracy of the completed
consent form prior to performing the treatment.
7.1.3 If a physician is informed that a patient does not fully understand the treatment, he/she should discuss the treatment
further with the patient, and the patient’s record should reflect this additional explanation and the patient’s consent.
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7.2
7.3
Nursing Personnel
Upon proper order, nursing personnel may complete the consent form, without the use of abbreviations, and have the
patient sign the form. In these cases, the nurse should ascertain that an explanation of the proposed treatment has occurred,
in accordance with 7.1.1, prior to requesting that the patient or other appropriate individual sign the consent form. If the
individual indicates he/she does not fully understand the treatment, the treating physician should be consulted prior to
obtaining the individual’s signature on the consent form, and this should be documented in the patient’s record.
Hospital Personnel (Non-Nursing):
If the individual who consented for treatment should indicate he/she does not fully understand the treatment, hospital
personnel should inform the treating physician, and this should be documented in the patient’s medical record.
8. Witness of Consent Signature: The patient’s signature on an informed consent form must be witnessed by an individual 18 years of
age or older. The witness must be physically present at the time the document is signed by the patient, unless consent via telephone
is obtained (refer to Section 13 below). The informed consent may be faxed from a physician’s office to the hospital.
9. Telephone Consent: Permitted if a consent signature is not available for an urgent need. An acknowledgement of the consent should
be signed at the earliest time possible by the person giving the telephone consent.
9.1 All telephone consents must be witnessed by two (2) individuals other than the physician; the witnesses must listen to the
telephone conversation.
9.2 The physician must document the following in the patient’s medical record:
9.2.1 Name of the individual from whom consent was obtained
9.2.2 His/her relationship to the patient
9.2.3 Any instructions he/she was given regarding signing a consent form
9.2.4 The names of the two (2) individuals who witnessed the telephone consent.
10. Completion of Informed Consent Form:
10.1 All consent forms shall be completed in ink and without the use of abbreviations. The patient’s signature on the Informed
Consent Form must be witnessed by an individual 18 years of age or older; a Health care employee may witness the
signature. The witness must be physically present at the time the document is signed by the patient. The informed consent
may be faxed from a physician’s office to the hospital. The physician must sign the consent for operation, Diagnostic and/
or treatment procedure form. Other practitioners who may be involved in assisting the physician should be listed by position
on the consent for operation, diagnostic and/or treatment procedure form. Any modifications to the information listed on the
consent form should be documented in the surgical or medical record.
10.2 The diagnostic or treatment procedure(s) listed on the consent form should be specific (Ex: amputation of left great toe).
Multiple procedures to be done at one time must be listed (Ex: (1) vaginal hysterectomy with anterior and posterior repair; and
(2) removal of mole on left shoulder).
10.3 If other practitioners may be assisting with this procedure please list them. If none are known you may put “none known” or
leave this line blank. The blank line will represent that none were known at the time of form completion.
10.4 If additions or deletions to the form are made after the signature is obtained, the patient/legally-qualified representative must
initial/date/time the changes.
10.5 If the consent form is more than one page, the patient and/or legally qualified representative must initial, date, and indicate the
page number of each page. (Ex: TMS, 5/20/99, page 2 of 3). The last page should have the patient’s signature and date.
10.6 The completed consent form is placed in the patient record.
10.7 Research consent forms are specific for each study and must have the IRB approval date stamped on the first page. All
elements in the consent form must follow Federal regulations for research studies; therefore, standard hospital forms cannot
be substituted for any reason. The patient must be given a copy of the signed research consent form.
11. Time Frame for Obtaining Signed Informed Consent Form
The consent form should be completed as close to performance of the treatment as practical. A patient who has received
preoperative sedation is not able to give informed consent.
12. Expiration/Retraction of Informed Consent
12.1 The consent form expires sixty (60) days after it is signed.
12.2 Consent is subject to revocation at any time prior to the treatment being performed.
12.3 Research Informed Consent is valid for the length of time that the patient is on the study. The research patient has the option
to retract Informed Consent for the study at any time.
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13. Refusal of Consent:
Palmetto Health Alliance acknowledges the rights of patients to refuse treatment in accordance with the South Carolina Death with
Dignity Act and as set forth in a patient’s Advance Directive or other documented statement of the patient’s desire to refuse certain
medical treatment.
Mentally competent adults have the right to refuse any medical or surgical treatment. In such cases, the physician is encouraged to:
13.1 Advise the patient of the medical consequences of the refusal.
13.2 Document the patient’s refusal of treatment in the progress notes.
14. Implied Consent:
14.1 Emergency Situations – See Rule #5
14.2 When a patient’s consent is for treatment to remedy a condition, rather than for a particular procedure and additional
procedures necessary to remedy this condition might be discovered during the performance of the initial procedure, it is
desirable to obtain a consent form executed by the patient which, by its terms, authorizes the physician a degree of latitude.
14.3 Implied consent exists when the patient has consented to a particular surgical procedure and, while the patient is under
anesthesia, the surgeon(s) finds an unrelated condition which can be cured or remedied by surgery and it is not feasible to
consult the patient or someone who can give consent on the patient’s behalf at the time the treatment decision must be
made.
Signature on File
205
Infusion Management Safety Precautions
October 2005
To ensure patient safety while administering therapies listed in the rules sections of this policy as part of the patient’s
plan of care.
RULES:
Patients on Infusion Management including: intravenous fluids, total parenteral nutrition, tube feedings, chemotherapy, blood transfusions,
patient controlled analgesia, epidural infusions, or intravenous push/drip narcotic therapy are not allowed to leave the floor unless
medically indicated. Physicians are discouraged from writing orders that allow patients to leave the unit. This policy is for Adults at
Palmetto Health Richland Hospital, excluding children 16 years old and under, who would be accompanied by an adult.
PROCEDURE:
1. Patients are informed of this unit policy:
1.1. Upon admission to nursing units, if therapy was initiated prior to their arrival on the floor.
1.2. Prior to initiation of therapy as part of their care on the units.
2. Alternative therapy for smoking may be offered by the physician at the time of initiating this policy. This may include: nicotine gum and
nicotine patch.
3. The psychiatric liaison nurse will offer supportive behavioral therapy if so desired by the patient and/or family.
4. Protocol for patients requesting to leave the unit with a physician’s order.
4.1. Patients must notify nursing staff prior to leaving the unit and request a pass.
4.2. Nursing will review the procedure with the patient and administer a pass to the patient. The pass must be attached to the
patient and visible at all times. Nursing staff will document patient’s departure from the unit.
4.3. The patient is to notify the nursing staff upon returning to the unit. Nursing staff will retrieve the pass and document the
patient’s return to the unit.
5. Nursing/Security Protocol if patient leaves unit without permission.
5.1. Nursing Staff will notify security that patient has left the unit without permission and provide name, room number, and
description of patient. If the patient returns to the unit prior to being located by security, nursing will notify security of the
patient’s return.
5.2. Nursing Staff will attempt to locate the patient and request that patient return to the unit. Attending physician will be notified in
clinical notes, on rounds, or by phone as situation warrants.
5.3. If Nursing Staff meets resistance from the patient, security will be notified. Security will attempt to accompany patient back to
the unit. If the patient refuses to return to the unit, the Attending Physician will be notified. Continued noncompliance will result
in a meeting with the attending physician, other staff members, and the patient and his/her family to reevaluate the plan of
care.
Signature on File
James E. Lathren, III
Executive Vice President and Chief Operating Officer,
Effective November 2005
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Signature On File
Carolyn Swinton
Hospice, Inpatient Transfer
Patient Care
May 2006
To insure physician ordered level of care change from inpatient acute care to inpatient Hospice care, the nursing
staff will initiate Intra-Hospital Transfer to Hospice Admission Orders as prescribed by the physician or his/her
designee. Patient Registration will be notified in order to make appropriate billing and account changes. This
process will provide continuity of care for patients converting from inpatient acute care, to inpatient Hospice care.
RULES:
The Hospice Coordinator communicates with the nursing unit RN/LPN and Unit Secretary to insure proper initiation of the Intra-Hospital
Transfer to Hospice Admission Order Set and insures Health Information and Registration Departments are properly notified for account
and billing changes and updates.
PROCEDURE:
1. Physician orders discharge of patient from inpatient acute care or transfer to inpatient Hospice Care. A Discharge Summary is
dictated by the discharging physician and Intra-Hospital Transfer to Hospice Admission Order set is initiated.
2. The Unit Secretary/Nurse will contact Hospice Coordinator for assistance with the process of discharge and readmission.
3. The Hospice Coordinator will contact Patient Placement to have the patient discharged, using Code 51 after consulting Hospice
Coordinator.
4. The Hospice Coordinator communicates the readmission, room number, admitting diagnosis, and physician to Patient Placement to
complete the new encounter.
5. Patient Placement generates a new, separate account for the patient’s Hospice care visit.
6. The Admissions Department obtains a new Consent for Treatment for the new Hospice care visit.
7. The receiving unit or unit where patient resides obtains new orders from the physician.
8. The Unit Secretary and nurse complete and close the original chart as with a routine discharge. That closed medical record is sent
to Health Information Management by the discharging nurse. No further documentation is done on this record. Copy of Transfer
summary, current day’s MAR, and Progress notes from the previous chart are copied for the new Hospice admission record, as
described in the Intra-Hospital Transfer to Hospice Admission Order set.
9. The nurse replaces the previous armband with the new armband (reflecting the new patient account) for the Hospice admission.
10. When the patient is being discharged from the Hospice visit, the nurse or unit secretary notifies Patient Placement of the discharge
status.
11. Patient Placement insures that an inpatient Hospice patient is discharged home under Hospice Code 50 or under Code 41 if the
patient expires in hospital while under Hospice care.
Signature on File
Signature On File
Carolyn Swinton
Effective June 2006
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Isolation Procedures/Guidelines/Rules
Facility: Palmetto Health
Effective: March 2011
Department: Infection Control
Name of Associated Policy: Isolation Policy
RESPONSIBLE POSITIONS (TITLE):
All Palmetto Health Employees
EQUIPMENT NEE DED:
Personal protective equipment is provided in the isolation box/caddy.
TABLE OF CONTENTS
Rapid Reference – Isolation Precautions Standard
Airborne
Droplet
Contact
Procedure
3.0 Standard Precautions
3.1 Hand Hygiene
3.2 Personal Protective Equipment
4.0 Transmission-Based Precautions
4.2 Dishes
4.3 Education
4.4 Visitors
4.5 Medical Waste
4.6 Routine and Terminal Cleaning
4.7 Postmortem Handling of Bodies
4.8 Employee Exposures
5.0 Airborne Precaution
5.0 Infections/Diseases Needing Airborne Precautions
5.1 Patient Placement
5.2 Healthcare Worker Respiratory Protection
5.3 Visitors Respiratory Protection
5.4 Scheduling/Transport
5.5 Employee Work Restrictions
6.0 Droplet Precautions
6.0 Infections/Diseases Needing Droplet Precautions
6.2 HealthCare Worker Protection
6.3 Visitors
6.4 Infectious Waste/Laundry
Page
3
4-5
6
7-9
10
10
10
12
12
12
13
13
13
13
13
13
13
14
14
14
14
14
15
15
15
15
15
15
15
Precautions
Page
7.0 Contact Precautions
15
7.0 Infections/Diseases Needing Contact Precautions
15
16
7.2 Healthcare Worker Protection
16
7.3 Visitors
16
7.4 Dedicated Equipment
16
7.5 Other Equipment
16
16
7.7 Medical Waste/Laundry
17
7.8 Multidrug Resistant Organisms
17
7.8.1 MRSA
17
7.8.1.1History of MRSA
17
7.8.1.2 Active or Suspected MRSA
17
7.8.2 VRE
17
7.8.3 Multidrug Resistant Gram Negative Organisms
18
7.9 Special Situations
18
7.9.1 Psychiatry
18
7.9.2 Rehabilitation Unit
18
7.9.3 NICU
18
7.9.4 Immunocompromised Patients
18
7.9.6 Dialysis Patients
19
7.9.7 Physicial/Occupational Therapy
19
7.9.8 Outpatient Clinics and Physicians’ Office
19
7.9.9 Home Health
19
8.0 Active Surveillance
19
9.0 Employees Communicable Disease Exposure
19
10.0 CDC Infection Type by Infection/Disease, Duration, and
Comment Table
1-20
Standard Precautions
1. Indications
Standard Precautions are to be used ALL the time with ALL patients’ body fluids and blood. ALL blood and body fluids will be treated
as if infectious.
2. PPE (Personal Protective Equipment)
Gloves, gowns, isolation masks and eye protection will be worn when there is the potential for splashing, splattering or spraying of
body fluids or blood. They will be removed upon completion of the task before leaving the area of use.
3. Interdepartmental Communication/Pt. Placement
No special signs are needed. No additional orders. Use any available room.
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4. Medical Waste
PPE that is not supersaturated is to be placed in the regular trash receptacle. Properly closed sharps containers and materials that
are supersaturated (drips freely or with a minimal amount of pressure or if caked with dried blood) with body fluids or blood are to be
taken to the infectious waste container in the soiled utility room.
5. Hand Hygiene
Hand hygiene must be performed upon entering room, before exiting room, and before and after each patient encounter. Use soap
and water (if visibly soiled or with C. difficile or Norovirus pts) or alcohol hand sanitizers. This is the MOST important way to STOP the
spread of infection.
6. Transport
•
Ensure wounds are covered and drainage contained.
•
Use a clean transportation vehicle, i.e., stretcher, wheel chair, etc.
•
A clean linen is placed over the patient.
•
Remove PPE (gloves, gown, mask, and eye protection) and perform hand hygiene prior to leaving the room.
•
When the patient needs care during transport, one staff member wears appropriate PPE and the other transports, pushes
elevator buttons, touches surfaces
•
Upon arrival to the transport destination, apply clean PPE necessary to care for the patient.
Airborne Precautions
1. Indications
Diseases (examples, not limited to these) spread by the Airborne route: Pulmonary/Laryngeal TB, Varicella (Chickenpox), Measles,
Smallpox, and SARS
2. Presentation with Respiratory Symptoms
If a patient presents to the hospital, i.e., ED with respiratory symptoms, the patient is given a mask and asked to wear it to protect
others from a potentially communicable disease.
Standard Precautions PLUS N-95 Respirator at (Employees must be fit tested prior to use) or Powered Air Purifying Respirator (PAPR).
•
Pink Airborne isolation sign on door with room entry requirements, purple armband on patient and pink sticker on chart (PHR).
•
Computer entry of Airborne precautions communication order.
•
Negative pressure room required. Notify Engineering.
•
Door is to be kept closed.
5. Medical Waste
Gowns and gloves are to be placed in regular trash. Reuse N-95 respirators unless compromised (i.e. torn, wet, elastic broken).
6. Visitors
Limit visitors when possible. Visitors of TB patients are to wear a regular isolation mask, NEVER an N-95 respirator. Masks are not to
be worn (or left dangling around neck) outside of the room. Measles/Varicella: If visitors are immune, they may visit. If visitors are nonimmune or pregnant, visiting is discouraged. If SARS or Smallpox is suspected or known, call Infection Control staff for instructions.
7. Hand Hygiene
Hand hygiene must be performed upon entering, before exiting room and before and after each patient encounter. Use soap and
water (if visibly soiled or with C. difficile or Norovirus pts) or alcohol hand sanitizers. This is the MOST important way to STOP the
8.
•
•
•
•
•
•
Transport
Transport patients for necessary treatments/tests only.
Staff who is scheduling the procedure, notifies the department of precautions.
Ensure wounds are covered and drainage contained
Ensure the purple arm band is on the patient
Prior to transport, the nurse assigned to patient/resident care notifies the “receiving” department of the precautions. The OR is
responsible for notifying the PACU.
Place a regular mask on patient by tucking the bottom of mask under chin, molding the top metal wire to nose and securing
ties in back. Nurse ensures appropriate barriers are used during transfer and transport.
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•
•
•
Place a clean linen over the patient.
Remove PPE and perform hand hygiene prior to leaving the room
Droplet Precautions
1. Indications
Diseases (examples, not limited to these) spread by the Droplet route: Influenza, Meningococcal meningitis, Mumps and Pertussis.
2. Presentation with Respiratory Symptoms
If a patient presents to the hospital, i.e., ED with respiratory symptoms, the patient is given a mask and asked to wear it to protect
others from a potentially communicable disease.
Standard Precautions PLUS regular mask AND eye protection upon room entry.
•
ORANGE, Droplet isolation sign on door with room entry requirements, orange sticker on chart (PHR) and purple armband on
the patient.
•
Computer entry of Droplet precautions communication order.
•
Private room is desirable, otherwise 3-5 feet of space around bed required.
•
Room door may remain open.
5. Medical Waste
Masks and used tissues to be thrown in the regular trash.
6. Hand Hygiene
7. Transport
•
•
Staff who is scheduling the procedure, notifies the department of precautions.
•
Ensure wounds are covered and drainage contained.
•
•
•
Place a regular mask on patient by tucking the bottom of mask under chin, molding the top metal wire to nose and securing
ties in back. Nurse ensures appropriate barriers are used during transfer and transport.
•
•
Place a clean linen over the patient
•
Remove PPE and perform hand hygiene prior to leaving the room
Contact Precautions
1. Indications
Diseases (examples, not limited to these) spread by the contact route: MRSA; VRE; Lice (Pediculosis); RSV; C. difficile; Norovirus;
Multidrug resistant gram negative organisms (MDR-GNO)
Standard Precautions PLUS gloves and gowns are to be worn upon entry into the patient’s room or cubicle. Masks and eyewear
will be worn as needed. PPE will be removed upon completion of the task before leaving the area of use. Hands must be washed or
alcohol hand sanitizers used before leaving room.
•
Green Contact isolation sign on door with room entry requirements, green sticker on chart (PHR) and purple armband on
patient.
•
Computer entry of Contact precautions communication order.
•
Private room desirable, otherwise 3-5 feet of space around bed required or cohorting patients (see main policy for details).
Door may remain open.
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4. Medical Waste
Gowns and Gloves are to be thrown in regular trash.
5. Dedicated Equipment
Use disposable equipment and/or individual patient items (stethoscope, B/P cuff, and thermometer, etc.) and leave in the room until
isolation is discontinued. When this is not possible, disinfect the equipment before taking it out of the patient’s room. Upon discharge,
disposable equipment is to be discarded.
6. Hand Hygiene
7. Transport
•
•
Staff scheduling the procedure, notifies the department of precautions.
•
Ensure wounds are covered and drainage contained
•
•
•
Nurse ensures appropriate barriers are used during transfer and transport. Discard any PPE (gloves, gown mask and eye
protection.) Perform hand hygiene prior to leaving room.
•
One person transport: Place the patient in a clean transportation vehicle (bed, stretcher, wheel chair). If patient must go in their
bed, clean it with hospital approved disinfectant prior to leaving the room. Remove and discard any PPE (gloves, gown mask
and eye protection). Perform hand hygiene prior to leaving room. Place clean linen over patient.
•
Two person transport: One staff member completes the one person transport procedures above so they may touch surfaces,
push buttons, etc. to prevent surface contamination as they transport the patient. Place clean linen over patient. The other
staff member remains gowned and gloved so they may care for the patient. In the case staff will not be providing hands on
care i.e., surgery, then both staff may remove and discard PPE and perform hand hygiene.
8. Ambulation in Hallways
Prior to ambulating in the hallway the patient performs hand hygiene and wears a clean hospital gown. If the patient is a level II fall
risk, then staff dons a clean isolation gown and clean gloves to ambulate patient. The nurse ensures wounds are covered so no
drainage may escape. The transfer belt should be dedicated to the isolation patient and disinfected between patients.
9. Curtains
PH’s goal is to have privacy curtains being cleaned or changed as part of the terminal cleaning process. Each campus is at different
places with working towards goal achievement. Please direct questions concerning curtains to infection control at respective campus.
10. Contact Isolation Placement/Discontinuation
History of MRSA - On admission, place the patient in contact isolation and perform a PCR Rapid MRSA test: using 1 cotton-tip swab for
the anterior nares and a 2nd swab for the throat. If the test result is negative the patient may be taken off contact isolation.
Active or Suspected MRSA infected site – Place the patient in contact isolation. If the patient has clinically improved, does not have
an open draining wound, diarrhea or uncontrolled secretions, you may discontinue contact isolation when the following cultures are
negative.
•
1st Culture = original site
•
2nd MRSA Culture = 1 swab for nares and 1 swab for throat
OR if original site not possible
•
1 MRSA Culture = 1 swab for nares and 1 swab for throat
Rapid MRSA PCR testing may not be used to determine whether a patient may be removed from isolation after treatment for an
active MRSA infection.
DO NOT remove the “history of MRSA” from the face sheet.
History of VRE – Place the patient in contact isolation. A culture may be done for a patient with a history of VRE to determine if the
patient is currently colonized. The patient may be removed from isolation if they have 1 negative stool, rectal or peri-rectal culture.
Active Treatment for VRE infection - Place the patient in contact isolation. If the patient has clinically improved, does not have an open
draining wound, diarrhea or uncontrolled secretions, you may discontinue contact isolation with 1 negative stool, rectal, or peri-rectal
culture.
DO NOT remove the “history of VRE” from the face sheet (PHB & PHR).
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Active Treatment for Multidrug Resistant Gram Negative Organism (MDR-GNO)
PHR For discontinuation of precautions, call Infection Control
PHB One culture may be done for a patient with MDR-GNO to determine if contact isolation may be discontinued. The culture is
taken from the peri-rectal or rectal area alone or in combination with urine, oropharyngeal, endotracheal sputum or ET aspirates,
inguinal or wound and the patient has clinically improved, does not have an open wound, diarrhea or uncontrolled secretions.
Procedure Steps, Guidelines, Rules, Or Reference:
PROCEDURE:
1. Notification to Staff about Multidrug Resistant Organisms (MDRO) Infection Control staff enters MRSA or VRE in STAR which
populates the Antibiotic resistant Organism (ARO) field on the face sheet. Nursing/infection control staff enters MRSA or VRE in the
Cerner nursing history and/or under Ad Hoc charting. This places MRSA or VRE under the chronic conditions field.
2. Isolation Precautions System
PH isolation system is a three-tier system or three levels of precautions based on CDC evidence based recommendations and
information.
3. Standard Precautions – First Tier
It involves work practices and engineering controls that will protect healthcare workers. All healthcare employees are to assume
that all body fluids from ALL patients/residents are infectious regardless of known or unknown history, diagnosis, age or social
background. EVERYONE’S BLOOD AND BODY FLUIDS ARE TREATED AS IF THEY ARE INFECTIOUS. Body fluids include blood,
secretions (to include tears and saliva), excretions, non-intact skin and mucous membranes of all patients whether or not blood
is visible. No signs or special rooms are required for Standard Precautions. Precautions also involve work practices such as hand
hygiene, appropriate usage of barrier devices, removal and disposal of barrier devices, appropriate handling and disposal of sharps
and other infectious waste and being up to date with immunizations.
3.1. Hand hygiene is the single most important way to prevent the spread of infection. Staff must clean their hands upon entry and
before exiting the patient’s room, before and after each patient encounter, after gloves are removed, after using the restroom
and before eating, to list a few situations. Hospital approved alcohol hand sanitizers may be used except when hands are
visibly soiled; patient has C. difficile or Norovirus. Alcohol hand sanitizers do not remove the C. difficile spores or Norovirus.
In these instances and anytime the staff member chooses, they may clean their hands by washing for 15 seconds with soap
and water. If using alcohol hand sanitizers, place foam on hand and rub hands together until hands are dry. Then proceed with
care. For more specific hand hygiene information refer to the Hand Hygiene PGR.
3.2. Personal Protective Equipment (PPE) includes items that place a barrier between the healthcare worker (HCW) and potential
exposure to body fluids. PPE consists of gloves, gowns, masks, and eyewear. Details about each barrier are listed below.
3.2.1. GLOVES are to be available in all sizes that are needed by the staff in a given area. Non-sterile gloves are to be worn
when there is possible or anticipated contact with blood, body fluids, mucous membranes, excretions or secretions.
Change gloves when moving from a dirty to a clean area or task. Remove promptly after completion of task and
clean hands. Gloves are not to be worn outside of the room, procedural area, cubicle, etc. due to potential for cross
contamination.
3.2.2. GOWNS for isolation are to be fluid resistant in order to be compliant with the Occupational Safety and Health
Administration (OSHA) Blood Borne Pathogen (BBP) regulations.
3.2.3. MASKS are worn to prevent blood/body fluid exposures to the health care worker’s mucous membranes in the event
of a splash or splattering. Masks are to be used only one time then discarded and never to be worn around neck or
carried in a pocket. Masks are to be placed on patients who have suspected or confirmed airborne or droplet diseases
and need to be transported to another department. Masks are also to be worn by employees in patient rooms where
droplet precautions are being observed. This is to prevent contact with droplets that are projected into the air (within
3-5 feet) following a cough or sneeze. To protect eyes, EYE protection is ALWAYS TO BE WORN WHEN A MASK IS
WORN.
3.2.4. EYEWEAR is worn to protect eyes from splashing or splattering of blood or body fluids. A MASK IS ALWAYS TO BE
WORN WITH EYE PROTECTION TO PROTECT MUCOUS MEMBRANES. Eyewear may be defined as goggles, rigid
safety glasses with shields, and/or face shields. Regular eyeglasses without side and top shields are not considered to
be adequate PPE.
3.2.4.1. Cleaning of eyewear – If reusable rigid eyewear is used and becomes contaminated, wash with soap and
water, then dry thoroughly. Disinfection may follow by using an alcohol prep pad and allowing to air dry. If the
eye shields are disposable, throw them away in the regular trash as needed.
3.2.5. MICROSHIELDS are disposable, single use Cardio Pulmonary Resuscitative (CPR) devices for administering mouth-tomouth resuscitation until an ambu-bag is available. They are to be kept in their manufacturer provided case until use.
They are to be discarded in the regular trash after use. A replacement device is to be ordered and put in the location
from which the original one was taken.
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3.3.
3.4.
3.5.
3.6.
3.2.6. DONNING PPE – PPE is to be put on in this order, whether wearing all or only a couple items. Perform hand hygiene.
Put the gown on first remembering to tie at neck and waist. A mask follows, tying it high on the head and being sure to
mold the metal band over the bridge of the nose. Eyewear is next. This is followed by gloves that are to be last. Extend
gloves to cover the wrist of the isolation gown.
3.2.7. REMOVAL OF PPE – Remove gloves without contaminating hands and discard. Remove goggles or face shield by
holding the head band or ear pieces to prevent hand contamination. Discard. Unfasten ties on gown. Remove the
gown by touching the inside only. Turn gown inside out while removing and roll into a bundle and discard. Remove
mask or respirator using ties or elastic to prevent hand contamination and discard. Perform hand hygiene in the room
immediately after removal of all PPE.
Transport – Ensure wounds are covered and drainage contained. Use a clean transportation vehicle, i.e., stretcher, wheel
chair, etc. A clean linen is placed over the patient. Remove PPE (gloves, gown, mask, and eye protection) and perform hand
hygiene prior to leaving the room. When the patient needs care during transport, one staff member wears appropriate PPE
and the other transports, pushes elevator buttons, and touches surfaces, so they do not get contaminated. Upon arrival to the
transport destination, apply clean PPE necessary to care for the patient.
Laundry - All laundry is treated the same whether it is wet or dry. It is to be placed in a plastic bag that is specifically
designated for “SOILED LINEN”. Double bagging is not necessary unless the outside bag is soiled with blood or body fluids.
Gloves are not necessary to carry linen bags since the outside of the bags are clean.
Medical Waste – PPE that is not supersaturated is to be placed in the regular trash receptacle. Properly closed sharps
containers and materials that are supersaturated (drips freely or with a minimal amount of pressure or if caked with dried
blood) with body fluids or blood are to be taken to the infectious waste container in the soiled utility room. Also see Infectious
Waste PGR.
Dirty Equipment – Equipment may be disinfected on site or staff may wear gloves to handle and transport the equipment to
Supply and Distribution.
4. Transmission-Based Precautions – Second Tier
4.1. There are three different types of Transmission-based precautions. Standard Precautions are practiced PLUS one or more of
the Transmission-based precautions listed below. A purple armband is placed on the patient to indicate Transmission-Based
Precautions.
Each type of isolation has an assigned sign color and the appropriate sign is placed on the door.
4.1.1. Airborne Precautions = Pink Isolation Sign
4.1.2. Droplet Precautions = Orange Isolation Sign
4.1.3. Contact Precautions = Green Isolation Sign
4.2. Dishes – No special dishes are required for any of type isolation precautions. Either paper or regular dishes are acceptable.
4.2.1. Paper dishes/trays are taken into the room following the appropriate type isolation precautions. The paper trays/dishes
are disposed of in the patient’s room.
4.2.2. Regular dishes/trays are taken into the room following the appropriate type isolation precautions. Nurses or dietary
hostesses may deliver trays with the following exception. Dietary hostesses may not deliver trays for isolation patients
on Airborne or Droplet precautions.
4.2.2.1. Delivery – Move the food cart to just outside the patient’s door and open the food cart door. Perform hand
hygiene. Don PPE, remove food tray from food cart and deliver. Remove gown and gloves, discard in the
room, and perform hand hygiene. Ice pitchers will remain in the patient’s room. Ziploc bags found in the
supply pyxis will be filled with ice and emptied into the patient’s pitcher.
4.2.2.2. Removal – Move the food cart to just outside the patient’s door and open the food cart door. Perform hand
hygiene. Don PPE. Take tray to food cart outside room and slide into cart. Remove PPE. Perform hand
hygiene.
4.2.2.3. Tray Decontamination - If the dishes/tray are contaminated with body fluids (i.e., vomit or blood), the tray
must be cleaned before returning it to the Food Services Department. Blood/Body fluids must be removed by
rinsing into a commode or hopper trying to avoid contaminating the environment. Dishes are to be thoroughly
sprayed with disinfectant and allowed to completely air dry. The nurse will perform the decontamination when
notified by the dietary hostess or when (s)he becomes aware the tray is contaminated. Hospital approved
disinfectant is taken into the room to clean tray.
4.3. Education - Patients and patient approved family members are to be taught about the patient’s communicable disease, how it
is spread and how to prevent transmission. Educational pamphlets about isolation precautions, MRSA and VRE are available
in Xerox Digipath and in the Infection Control Manual. Teaching material or information outside of these conditions may be
requested of Infection Control.
4.4. Visitors – receive education about contact isolation from the nursing/staff prior to entering a room. Visitors make the decision
whether they gown and glove, it is not required. Visitors are instructed to perform hand hygiene upon entrance and exit of the
room. Educate the visitors that do not gown and glove that it is important for them not to visit other patients and to leave the
hospital following the visit. Help them understand this is to decrease the spread of infection.
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4.5.
4.6.
4.7.
4.8.
Medical Waste – PPE that is not supersaturated is to be placed in the regular trash receptacle. Properly closed sharps
containers and materials that are supersaturated (drips freely or with a minimal amount of pressure or if caked with dried
blood) with body fluids or blood are to be taken to the infectious waste container in the soiled utility room. Also see Infectious
Waste PGR.
Routine and Terminal Cleaning – Cleaning procedures for the room, cubicle, and bedside equipment of a patient on
Transmission Based Precautions are the same cleaning procedures used for other patients. Thorough cleaning and
disinfection of bedside equipment and the environment (bed rails, bedside tables, carts, commodes, doorknobs, faucet
handles, telephones, etc.) with emphasis on high-touch areas is needed due to the survival time of some organisms on
inanimate surfaces for prolonged periods. Successful control of MDROs is achieved using a variety of combined interventions.
PH campuses would like to add cleaning or taking down privacy curtains as an intervention. Each campus is in different
stages of working toward privacy curtains being cleaned with a hospital approved disinfectant or changed as part of the
terminal cleaning process.
Postmortem Handling of Bodies – Healthcare workers will use the same precautions to protect themselves during postmortem
care that they would use if the patient were still alive. If the patient was suspected to have or was diagnosed with Anthrax,
Hepatitis, HIV/AIDS, Leprosy, Plague, Rabies, and or Syphilis then notify the in-house administrator (i.e., nursing supervisor)
and request a DHEC toe tag (yellow rectangular card). This card is to accompany the body to the funeral home. Staff is NOT
to identify the disease(s) on the toe tag.
Employee Exposures – Employees who have been in contact with a patient prior to knowing about the patient’s
communicable disease and have not been adequately protected by PPE are to report this to their manager or appropriate in
house administrator (i.e., nursing supervisor, etc.). Management will notify the Infection Control (IC) staff. IC will establish a time
frame of the alleged exposure and confirm it (refer to Healthworks PGR “Infectious Exposure Follow Up).
5. Airborne Precautions
General Information- Airborne precautions are to be implemented for patients/residents who are suspected or confirmed to be
infected with diseases that are transmitted via the airborne route. These disease organisms remain suspended on the air currents
in a room after being dispersed via a cough, laugh or sneeze from the infected person. Examples of these diseases are: Varicella
(Chickenpox), Measles (Rubeola), Smallpox, Severe Acute Respiratory Syndrome (SARS), Disseminated Herpes Zoster (Shingles),
Pulmonary or Laryngeal Tuberculosis (TB). Patients with sputum positive for AFB (Acid-Fast Bacillus) are placed on Airborne
Precautions until TB is ruled out. (Refer to the TB Control PGR.
5.1. Patient Placement – An Airborne Infection isolation Room (AIIR) is required for the room assignment. Arrangements must
be made through the admitting office or the Nursing Supervisor (PHB), Administrative Officer on Duty (PHR) if a room is not
available. If a room is not available, notify Engineering (PHB) to set up a portable negative pressure unit (see Portable Negative
Pressure Unit PGR). Also, notify the Engineering Department when an AIIR is in use so monitoring will take place. The door
must be kept closed, except when entering or exiting in order to maintain the negative pressure airflow. The patient should be
instructed to cough or sneeze into tissues. The tissues should be discarded into their regular room trash.
5.2. Healthcare Worker (HCW) Respiratory Protection – If the patient/resident has a confirmed infection or is suspected to be
infected with an airborne transmitted disease, the HCW must wear one of the following when entering the room:
5.2.1. NIOSH-approved N-95 or higher respirator. Prior to the time of use, employees are to be fitted for N-95 particulate
respirators by Healthworks. N-95 respirators may be reused during a shift. If it becomes compromised (wet, torn,
elastic broken, etc.) discard in the patient’s regular trash. Replacements are available in the pixis, the room isolation
supplies, or in Supply and Distribution (S & D).
OR
5.2.2. Powered Air Purifying Respirator (PAPR) is available from S & D. The hoods are disposable however may be reused by
same staff member if contained as described below, When the PAPR is no longer needed it needs to be returned to S
& D (without the disposable hood).
5.2.2.1. Care of the PAPR – PAPR consists of a disposable hood and a “back pack. Each PAPR is on a cart and
should be plugged into the outlet nearest the patient’s room. This may require the patient to be assigned to
another room. When not in use, each hood should be kept on the cart in a bag marked with the individual
staff member’s name. Hoods are NOT to be shared between employees. Hoods may be disposed of in the
regular trash.
5.3. Visitor Respiratory Protection – Limit visitors when possible. Visitors are to wear a regular mask, NEVER an N-95 respirator.
Masks are not to be worn or left dangling around neck outside of the room. Only those who live in the same house on a day
to day basis with the patient are not required to wear respiratory protection. Measles/Varicella: If visitors are immune, they may
visit. If visitors are non-immune or pregnant, visiting is discouraged. If SARS or Smallpox is suspected or known, call Infection
Control staff for instructions.
5.4. Patient Scheduling/Transport – Transport patients for necessary tests/treatments only. Staff who is scheduling the procedure
notifies the department of precautions. Ensure wounds are covered, drainage contained and a purple armband is on the
patient. Prior to transport, the nurse assigned to patient/resident care notifies the “receiving” department of the precautions.
The OR is responsible for notifying the PACU. Place a regular mask on patient by tucking the bottom of mask under chin,
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5.5.
molding the top metal wire to nose and securing ties in back. Use a clean transportation vehicle, i.e., stretcher, wheel chair,
etc. Place a clean linen over the patient. Remove PPE and perform hand hygiene prior to leaving the room.
Employee Work Restrictions – HCWs who are not immune to Varicella and/or Measles should not be assigned to the patient
with these illnesses. If they must enter the room, a particulate respirator (N-95) is to be worn. PH strongly encourages
employees who are not immune to take the vaccines for these diseases. The vaccinations are available through Healthworks.
Employees who are immune to Varicella and/or Measles do not have to wear respiratory protection.
6. Droplet Precautions
General Information – Droplet Precautions are implemented when a disease that is transmitted by the droplet route is suspected or
confirmed. These diseases are transmitted via large droplets that are propelled into the air when an infected person coughs, sneezes,
talks or during procedures such as a bronchoscopy or intubation. Disease transmission occurs when the droplets contact mucous
surfaces or object to mucous membranes (i.e., rubbing eyes with unwashed hands). Examples of Droplet diseases: Influenza,
Mumps, Mycoplasma Pneumonia, Neisseria meningitis disease (meningitis, pneumonia, and sepsis).
6.1. Patient Placement – Private room is desirable, otherwise 3-5 feet of space around bed required. Door may remain open.
6.2. HCW Protection – Regular masks and eye protection are worn to protect mucous membranes.
6.3. Visitor Protection – Limit visitors when possible. Visitors are to wear a regular mask, NEVER an N-95 respirator. Masks are not
to be worn (or left dangling around neck) outside of the room.
6.4. Infectious Waste and Laundry – All masks not supersaturated are discarded into the regular trash receptacles. Any trash that
is supersaturated with blood or body fluids is placed in a biohazard bag and taken to the soiled utility room. All linen is placed
in a soiled linen bag and placed in the soiled utility room.
6.5. Patient Scheduling/Transport – The transporting of isolation patients will be done for necessary treatments or testing only. The
staff member scheduling the procedure is responsible for notifying the department of patient precautions. Prior to transfer, the
nurse assigned to patient/resident care is responsible for notifying the “receiving” department of the precautions. The OR is
responsible for notifying the Post Anesthesia Care Unit (PACU) about precautions. Prior to transport, ensure that any wounds
are covered and drainage is contained. Check that the purple armband is on the patient. During transport, in order to minimize
dispersal of microorganisms spread by the droplet route, place a regular mask on the patient by tucking the bottom of mask
under chin, molding the top metal wire to nose and securing ties in the back.
It is important that the patient be encouraged to cough or sneeze into tissues. Have patient discard tissues into trash receptacle.
Transporter is not to wear a mask outside of room. The nurse is the resource person to ensure that appropriate barriers
are used during transfer/transport. Place the patient in a clean transportation vehicle. If patient must go in their bed, clean
it with hospital approved disinfectant prior to leaving room. Remove and discard any PPE (gloves, gown, mask, and/or eye
protection, etc). Perform hand hygiene prior to leaving room. Upon arrival to the transport destination, apply clean PPE
necessary to care for the patient.
7. Contact Precautions
General Information – Contact Precautions are implemented when a patient is suspected or confirmed to have a disease or infection
spread by direct contact (skin-to-skin) or indirect contact (touching contaminated surfaces or items in the patient’s environment).
Patients may be infected, colonized, have a history of the condition, and/or have a multidrug resistant organism (MDRO). Examples
of these conditions are as follows: MRSA, VRE, Pediculosis (lice), Scabies, RSV and/or Impetigo, C. difficile, Norovirus or Multi-drug
resistant gram negative organisms.
7.1. Patient Placement- Private room is desirable. Room door may remain open. Cohorting of patients with the same disease is
permitted during high census or if patients are siblings. Call Infection Control for guidance.
7.2. HCW Protection
7.2.1. Hand Hygiene is the single most important action taken to prevent cross-transmission while caring for patients on
Contact Precautions. Washing with soap and water is necessary for C. difficile and Norovirus patients, as an alcohol
hand sanitizer is less effective. Patients and visitors must be taught the importance of hand hygiene.
7.2.2. PPE – Gown and gloves are to be worn upon entry into the patient’s room or cubicle. Masks and eye protection
are worn when splashing or spraying of blood or body fluids can reasonably be anticipated, i.e., when suctioning or
irrigating a wound. All PPE must be removed and hand hygiene performed before leaving the room.
7.3. Visitors – Visitors receive education about contact isolation from nursing/staff prior to entering the room. Visitors make the
decision whether they gown or glove, it is not required. Visitors are instructed to perform hand hygiene upon entry and exit
from the room. They also are instructed to directly leave the hospital when finished visiting that patient, if they elected not to
gown and glove.
7.4. Dedicated Equipment – The use of disposable equipment is encouraged so it may be left in the room. These items may
include, but are not limited to, disposable stethoscopes, thermometers, BP cuff, etc. When equipment cannot be dedicated, it
must be disinfected between patients. To disinfect, use a hospital approved disinfectant. Allow this to dry. After this process, it
may be removed from the room.
7.5. Other Equipment – To prevent cross-contamination items that can be wiped clean with disinfectant, i.e. CaviCide wipes may
be taken in the room. Examples of equipment are as follows: IV team carts, workstations on wheels, phlebotomy baskets,
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7.6.
7.7.
7.8.
C-5s They are to be thoroughly cleaned with disinfectant prior to leaving the room.
Patient Scheduling/Transport – The transporting of isolation patients to other departments will be done for necessary
treatments or testing only. The staff member scheduling the procedure is responsible for notifying the department of patient
precautions. Prior to transfer, the nurse assigned to the patient/resident care is responsible for notifying the “receiving”
department of the precautions. The OR is responsible for notifying PACU about precautions. Prior to transport ensure that
wounds are covered and drainage is contained. Check to see that the purple armband is on the patient. The nurse is the
resource person to ensure that appropriate barriers are used during transfer/transport.
7.6.1. One person transport – Use for patients who will not need assistance or patient care during transport. Place the patient
in a clean transportation vehicle (bed, stretcher, wheel chair). If the patient must go in their bed, clean it with a hospital
approved disinfectant prior to leaving room. Place a clean linen over the patient. Remove and discard any PPE (gloves
and gown plus mask and eye protection if wearing). Perform hand hygiene prior to leaving the room. The staff member
does not need to gown and glove for transport, as they will only touch the clean transportation vehicle. Upon arrival to
the transport destination, apply clean PPE necessary to care for the patient.
7.6.2. Two person transport – Use when patient will need care en route. Prior to transport apply a clean linen over the patient.
One staff member completes the one person transport procedures (above) so they may touch surfaces, push buttons,
etc. to prevent surface contamination as (s)he transports the patient. The other staff member remains gowned and
gloved so they may care for the patient en route.
Medical Waste and Laundry – All gowns, gloves, and masks not supersaturated are to be placed in the regular trash
receptacle. Any trash that is supersaturated with blood or body fluids is placed in a biohazard bag and taken to the soiled
utility room. All linen is placed in a soiled linen bag and placed in the soiled utility room.
Multidrug Resistant Organisms
7.8.1. MRSA
7.8.1.1. History of MRSA – On admission, place the patient in contact isolation and perform a PCR Rapid MRSA test:
use 1 cotton-tip swab for the anterior nares and a 2nd swab for the throat. If the test result is negative the
patient may be taken off contact isolation.
7.8.1.2. Active or Suspected MRSA infected site - Place the patient in contact isolation. If the patient has clinically
improved, does not have an open draining wound, diarrhea or uncontrolled secretions, you may discontinue
contact isolation when the following cultures are negative.
o
o
1st Culture = original site
2nd MRSA Culture = 1 swab for nares and 1 swab for throat
OR if original site not possible
o
1 MRSA Culture = 1 swab for nares and 1 swab for throat
7.8.1.3. Rapid MRSA PCR testing may not be used to determine whether a patient may be removed from isolation
after treatment for an active MRSA infection.
7.8.1.4. DO NOT remove the “history of MRSA” from the face sheet (PHB and PHR).
7.8.1.5. Decolonization regimens are not sufficiently effective to warrant routine use. Plus recolonization with the same
strain, initial colonization with a mupirocin-resistant strain and emergence of resistance to mupirocin treatment
can occur.
7.8.2. VRE
7.8.2.1. History of VRE – Place the patient in contact isolation. A culture may be done for a patient with a history of
VRE to determine if the patient is currently colonized. The patient may be removed from isolation if they have
1 negative stool, rectal or peri-rectal culture.
7.8.2.2. Active Treatment for VRE infection:
Place the patient in contact isolation. If the patient has clinically improved, does not have an open draining wound,
diarrhea or uncontrolled secretions, you may discontinue contact isolation with 1 negative stool, rectal, or
peri-rectal culture.
7.8.2.3. DO NOT remove the “history of VRE” from the face sheet.
7.8.3. Multidrug Resistant Gram Negative Organism (MDR-GNO)
7.8.3.1. Active Treatment for MDR-GNO
PHR For discontinuation of precautions, call Infection Control
PHB One culture may be done for a patient with MDR-GNO to determine if contact isolation may be discontinued.
The culture is taken from the peri-rectal or rectal area alone or in combination with urine, oropharyngeal,
endotracheal sputum or ET aspirates, inguinal or wound and the patient has clinically improved, does not
have an open wound, diarrhea or uncontrolled secretions.
216
7.9.
Special Situations
7.9.1. Psychiatry Units – An integral and very important part of patients’ treatment plans is group activities and socializing in
common areas and dining rooms.
The Psychiatry population does not use contact isolation unless blood and body fluids cannot be contained because it
prohibits them from taking part in the activities that are very important to the patients’ recovery.
Hand hygiene and use of barrier techniques should be included in patients’ education. In general, residents colonized or
infected with an MDRO are allowed to use common living areas, recreational areas and dining facilities. The staff must
ensure the following to prevent disease transmission:
7.9.1.1. Dressings – Prior to leaving their rooms for activities patients/residents are to have clean, dry dressings.
Dressings must be occlusive if wound is draining. Residents/Patients are to wear clean clothes or gowns.
7.9.1.2. Hand Hygiene – Patients/Residents are to wash their hands before they leave their rooms for the common
areas or therapy.
7.9.1.3. Continence – if alert, oriented, ambulatory and aware of their incontinence and able to respond appropriately
patients may participate in activities. If the patient is disoriented, not ambulatory and unaware of bladder and
bowel incontinence they may not engage in group activities.
7.9.1.4. Reasons to Restrict Participation in Group/Common Area Activities - Those who may contaminate the
environment with uncontainable: drainage, incontinence, diarrhea, ileostomy or colostomy cannot participate
in common area or group activities until controlled.
7.9.2. Rehabilitation Unit – This resident/patient population usually is not immunocompromised so there is less risk of
progression from colonization to infection than for patients in acute care. The purpose of the rehabilitation unit is to
assist the resident in maximizing abilities to perform activities of daily living. The rehabilitation unit uses contact isolation.
7.9.3. NICU – PHR: When isolates are separated by curtains only, then purple tape is to be used as a visual indicator that
transmission based and standard precautions (airborne, droplet or contact) are to be used. PHB: Patients in a private
room will have the isolation box placed on the door.
7.9.4. Immunocompromised Patients – Immunocompromised patients vary in their susceptibility to nosocomial infections
depending on the severity and duration of immunosuppresion. They are generally at increased risk for bacterial,
fungal, parasitic, and viral infections from both endogenous (within the patient) and exogenous sources. The use of
Standard Precautions for all patients and Transmission-Based Precautions for specified patients as recommended by
CDC/PH should reduce the acquisition by these patients of institutionally acquired bacteria from other patients and
environments.
7.9.5. The term “reverse” isolation that was the type of isolation used for immunocompromised patients is no longer
recognized by the CDC as a type of isolation.
7.9.6. Dialysis Patients – Hospital patients on contact or droplet isolation requiring dialysis, may be transported to the dialysis
area for treatment. At PHR, patients on Airborne Isolation will be dialyzed in a negative pressure room on the dialysis
unit. At PHB and PHR, patients on Airborne Isolation will receive dialysis in accordance to this policy, including posting
signage on the dialysis room door and wearing appropriate PPE. Dialysis staff will notify Environmental Services to
clean the room prior to the next patient. Dialysis staff will wear N-95 or portable respirators when in this room. Disinfect
all equipment prior to removal from the room.
7.9.7. Physical/Occupational Therapy – When physical or occupational therapy is performed in the isolation room, staff is
required to wear protective barriers. If the patient will be ambulated in the hall and is a level II fall risk, the staff member
wears a clean gown and gloves. The patient is to perform hand hygiene and then wear a clean hospital gown for
hallway ambulation. A transfer belt may be dedicated to the isolation patient and disinfected following discontinuation
of contact isolation or the plastic material transfer belts may be used and cleaned with hospital approved disinfectant
between patients.
7.9.8. Outpatient Clinics and Physicians’ Offices – Standard precautions are used for all patients.
7.9.9. Home Healthcare and Hospice – In addition to Standard Precautions and Contact Precautions, home healthcare
providers are to focus on preventing cross-transmission via the clinical bag, clothing and equipment. It is recommended
that the clinical bag be left in the vehicle and only disposable items needed for the patient be carried into the home.
Reusable equipment must be cleaned either in the patients home or bagged prior to returning to the clinician’s vehicle
or facility for disinfection. Hands are to be cleaned with soap and water or alcohol hand sanitizer before leaving the
home.
8. Active Surveillance – Third Tier
Active Surveillance cultures may be obtained in certain high risk areas or populations for identifying patients who are colonized or
infected with an MDRO on admission.
9. Employees Communicable Disease Exposure
Disease Exposure – Employees who have been in contact with a patient, prior to knowing about the diagnosis of a communicable
disease and have not been adequately protected by PPE, are to report this event to their manager or the in-house administrator (i.e.,
217
nursing supervisor, etc.) The HCW/In-house administrator will notify the Infection Control (IC) staff. IC will establish a time frame of
alleged exposure and establish confirmation. If confirmed, the manager or In House Administrator (i.e., nursing supervisor) will notify
Employee Health of the situation and work with staff to identify other exposed employees. Employee Health will provide care and
treatment as appropriate to the employees.
APPENDIX A 1
TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS
Infection/Condition
Precautions
Type
*
Duration †
Abscess
Draining, major
C
Draining, minor or limited
Acquired human immunodeficiency syndrome (HIV)
Actinomycosis
Adenovirus infection ( see agent-specific guidance under
gastroenteritis, conjuctivitis, pneumonia)
S
S
S
Amebiasis
S
Anthrax
S
Cutaneous
1
S
DI
Comments
No dressing or containment of drainage; until drainage stops or can be
contained by dressing
Dressing covers and contains drainage
Post-exposure chemoprophylaxis for some blood exposures 866.
Not transmitted from person to person
Person to person transmission is rare. Transmission in settings for the
mentally challenged and in a family group has been reported 1045. Use
care when handling diapered infants and mentally challenged persons
1046
.
Infected patients do not generally pose a transmission risk.
Transmission through non-intact skin contact with draining lesions
possible, therefore use Contact Precautions if large amount of
uncontained drainage. Handwashing with soap and water preferable
to use of waterless alcohol based antiseptics since alcohol does not
Type of Precautions: A, Airborne Precautions; C, Contact; D, Droplet; S, Standard; when A, C, and D are specified, also use S.
† Duration of precautions: CN, until off antimicrobial treatment and culture-negative; DI, duration of illness (with wound lesions, DI means until wounds stop
draining); DE, until environment completely decontaminated; U, until time specified in hours (hrs) after initiation of effective therapy; Unknown: criteria for
establishing eradication of pathogen has not been determined
218
APPENDIX A 1
Infection/Condition
Precautions
Type
Pulmonary
*
Duration †
S
Environmental: aerosolizable spore-containing powder or other
substance
DE
Antibiotic-associated colitis (see Clostridium difficile)
Arthropod-borne viral encephalitides (eastern, western, Venezuelan
equine encephalomyelitis; St Louis, California encephalitis; West Nile
Virus) and viral fevers (dengue, yellow fever, Colorado tick fever)
S
Aspergillosis
S
Avian influenza (see influenza, avian below)
Babesiosis
Blastomycosis, North American, cutaneous or pulmonary
Botulism
Bronchiolitis (see respiratory infections in infants and young children)
S
S
S
C
have sporicidal activity 983.
Until decontamination of environment complete 203 . Wear respirator
(N95 mask or PAPRs), protective clothing; decontaminate persons
with powder on them
(http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5135a3.htm)
Hand hygiene: Handwashing for 30-60 seconds with soap and water
or 2% chlorhexidene gluconate after spore contact (alcohol handrubs
inactive against spores 983.
Post-exposure prophylaxis following environmental exposure: 60
days of antimicrobials (either doxycycline, ciprofloxacin, or
levofloxacin) and post-exposure vaccine under IND
Not transmitted from person to person except rarely by transfusion,
and for West Nile virus by organ transplant, breastmilk or
transplacentally 530, 1047. Install screens in windows and doors in
endemic areas
Use DEET-containing mosquito repellants and clothing to cover
extremities
Contact Precautions and Airborne Precautions if massive soft tissue
infection with copious drainage and repeated irrigations required 154.
S
Ascariasis
Comments
DI
Not transmitted from person to person except rarely by transfusion,
Use mask according to Standard Precautions.
95
APPENDIX A 1
Infection/Condition
Precautions
Type
*
Duration †
Comments
Not transmitted from person to person except rarely via banked
spermatozoa and sexual contact 1048, 1049. Provid antimicrobial
prophylaxis following laboratory exposure 1050.
Brucellosis (undulant, Malta, Mediterranean fever)
S
Campylobacter gastroenteritis (see gastroenteritis)
Candidiasis, all forms including mucocutaneous
Cat-scratch fever (benign inoculation lymphoreticulosis)
S
S
Cellulitis
S
Chancroid (soft chancre) (H. ducreyi)
Chickenpox (see varicella)
Chlamydia trachomatis
Conjunctivitis
Genital (lymphogranuloma venereum)
Pneumonia (infants < 3 mos. of age))
Chlamydia pneumoniae
Cholera (see gastroenteritis)
Closed-cavity infection
Open drain in place; limited or minor drainage
No drain or closed drainage system in place
Clostridium
C. botulinum
C. difficile (see Gastroenteritis, C. difficile)
C. perfringens
Food poisoning
S
Transmitted sexually from person to person
S
S
S
S
Outbreaks in institutionalized populations reported, rarely 1051, 1052
Gas gangrene
S
S
S
C
S
S
Contact Precautions if there is copious uncontained drainage
DI
Transmission from person to person rare; one outbreak in a surgical
setting reported 1053. Use Contact Precautions if wound drainage is
219
APPENDIX A 1
Infection/Condition
Precautions
Type
*
Duration †
Comments
extensive.
Coccidioidomycosis (valley fever)
Draining lesions
S
Pneumonia
S
Colorado tick fever
S
Congenital rubella
C
Conjunctivitis
Acute bacterial
Chlamydia
Gonococcal
S
S
S
Not transmitted from person to person except under extraordinary
circumstances because the infectious arthroconidial form of
Coccidioides immitis is not produced in humans 1054 .
Not transmitted from person to person except under extraordinary
circumstances, (e.g., inhalation of aerosolized tissue phase
endospores during necropsy, transplantation of infected lung) because
the infectious arthroconidial form of Coccidioides immitis is not
produced in humans 1054, 1055.
Standard Precautions if nasopharyngeal and urine cultures repeatedly
Until 1 yr of age
neg. after 3 mos. of age
Adenovirus most common; enterovirus 70 1056, Coxsackie virus A24
) also associated with community outbreaks. Highly contagious;
outbreaks in eye clinics, pediatric and neonatal settings, institutional
settings reported. Eye clinics should follow Standard Precautions
when handling patients with conjunctivitis. Routine use of infection
control measures in the handling of instruments and equipment will
prevent the occurrence of outbreaks in this and other settings. 460, 814,
1058, 1059 461, 1060
.
1057
Acute viral (acute hemorrhagic)
C
DI
Corona virus associated with SARS (SARS-CoV) (see severe acute
respiratory syndrome)
97
APPENDIX A 1
Infection/Condition
Precautions
Type
*
Duration
Coxsackie virus disease (see enteroviral infection)
Creutzfeldt-Jakob disease
CJD, vCJD
220
Comments
Use disposable instruments or special sterilization/disinfection for
surfaces, objects contaminated with neural tissue if CJD or vCJD
suspected and has not been R/O; No special burial procedures
S
1061
Croup (see respiratory infections in infants and young children)
Crimean-Congo Fever (see Viral Hemorrhagic Fever)
S
Cryptococcosis
S
Cryptosporidiosis (see gastroenteritis)
Cysticercosis
Cytomegalovirus infection, including in neonates and
immunosuppressed patients
Decubitus ulcer (see Pressure ulcer)
Dengue fever
Diarrhea, acute-infective etiology suspected (see gastroenteritis)
Diphtheria
Cutaneous
Pharyngeal
Ebola virus (see viral hemorrhagic fevers)
Echinococcosis (hydatidosis)
Echovirus (see enteroviral infection)
Encephalitis or encephalomyelitis (see specific etiologic agents)
Endometritis (endomyometritis)
Enterobiasis (pinworm disease, oxyuriasis)
Enterococcus species (see multidrug-resistant organisms if
†
Not transmitted from person to person, except rarely via tissue and
corneal transplant 1062, 1063
S
No additional precautions for pregnant HCWs
S
S
C
D
S
S
S
CN
CN
Until 2 cultures taken 24 hrs. apart negative
Until 2 cultures taken 24 hrs. apart negative
APPENDIX A 1
Infection/Condition
Precautions
Type
epidemiologically significant or vancomycin resistant)
Enterocolitis, C. difficile (see C. difficile, gastroenteritis)
Enteroviral infections (i.e., Group A and B Coxsackie viruses and
Echo viruses) (excludes polio virus)
Epiglottitis, due to Haemophilus influenzae type b
Epstein-Barr virus infection, including infectious mononucleosis
Erythema infectiosum (also see Parvovirus B19)
Escherichia coli gastroenteritis (see gastroenteritis)
Food poisoning
Botulism
C. perfringens or welchii
Staphylococcal
Furunculosis, staphylococcal
Infants and young children
Gangrene (gas gangrene)
S
S
S
S
C
S
Gastroenteritis
S
Adenovirus
S
Campylobacter species
S
Cholera (Vibrio cholerae)
S
C. difficile
C
*
Duration †
Comments
Use Contact Precautions for diapered or incontinent children for
duration of illness and to control institutional outbreaks
S
D
S
U 24 hrs
See specific disease agents for epiglottitis due to other etiologies)
Contact if drainage not controlled. Follow institutional policies if MRSA
DI
Use Contact Precautions for diapered or incontinent persons for the
duration of illness or to control institutional outbreaks for
gastroenteritis caused by all of the agents below
duration of illness or to control institutional outbreaks
Discontinue antibiotics if appropriate. Do not share electronic
thermometers 853, 854; ensure consistent environmental cleaning and
DI
99
APPENDIX A 1
Infection/Condition
Precautions
Type
Cryptosporidium species
E. coli
Enteropathogenic O157:H7 and other shiga toxin-producing
Strains
Other species
*
Duration
S
S
S
Noroviruses
S
Rotavirus
C
Comments
disinfection. Hypochlorite solutions may be required for cleaning if
transmission continues 847. Handwashing with soap and water
preferred because of the absence of sporicidal activity of alcohol in
waterless antiseptic handrubs 983.
S
Giardia lamblia
†
DI
duration of illness or to control institutional outbreaks. Persons who
clean areas heavily contaminated with feces or vomitus may benefit
from wearing masks since virus can be aerosolized from these body
substances 142, 147 148; ensure consistent environmental cleaning and
disinfection with focus on restrooms even when apparently unsoiled
273, 1064
). Hypochlorite solutions may be required when there is
continued transmission 290-292. Alcohol is less active, but there is no
evidence that alcohol antiseptic handrubs are not effective for hand
decontamination 294. Cohorting of affected patients to separate
airspaces and toilet facilities may help interrupt transmission during
outbreaks.
Ensure consistent environmental cleaning and disinfection and
frequent removal of soiled diapers. Prolonged shedding may occur in
221
APPENDIX A 1
Infection/Condition
Precautions
Type
Salmonella species (including S. typhi)
S
Shigella species (Bacillary dysentery)
S
Vibrio parahaemolyticus
S
Viral (if not covered elsewhere)
S
Yersinia enterocolitica
S
German measles (see rubella; see congenital rubella)
Giardiasis (see gastroenteritis)
Gonococcal ophthalmia neonatorum (gonorrheal ophthalmia,
acute conjunctivitis of newborn)
Gonorrhea
Granuloma inguinale (Donovanosis, granuloma venereum)
Guillain-Barré’ syndrome
Haemophilus influenzae (see disease-specific recommendations)
Hand, foot, and mouth disease (see enteroviral infection)
Hansen’s Disease (see Leprosy)
Hantavirus pulmonary syndrome
Helicobacter pylori
Hepatitis, viral
Type A
Diapered or incontinent patients
*
Duration †
Comments
both immunocompetent and immunocompromised children and the
elderly 932, 933.
S
S
S
S
Not an infectious condition
S
S
S
C
Provide hepatitis A vaccine post-exposure as recommended 1065
Maintain Contact Precautions in infants and children <3 years of age
101
APPENDIX A 1
Infection/Condition
Precautions
Type
Type B-HBsAg positive; acute or chronic
S
Type D (seen only with hepatitis B)
S
Type E
S
Use Contact Precautions for diapered or incontinent individuals for the
duration of illness 1068
S
S
C
Mucocutaneous, recurrent (skin, oral, genital)
S
Neonatal
C
Herpes zoster (varicella-zoster) (shingles)
222
Comments
for duration of hospitalization; for children 3-14 yrs. of age for 2 weeks
after onset of symptoms; >14 yrs. of age for 1 week after onset of
symptoms 833, 1066, 1067.
See specific recommendations for care of patients in hemodialysis
centers 778
See specific recommendations for care of patients in hemodialysis
centers 778
S
Mucocutaneous, disseminated or primary, severe
Disseminated disease in any patient
Localized disease in immunocompromised patient until disseminated
infection ruled out
Duration †
S
Type C and other unspecified non-A, non-B
Type G
Herpangina (see enteroviral infection)
Hookworm
Herpes simplex (Herpesvirus hominis)
Encephalitis
*
A,C
Until lesions dry
and crusted
Also, for asymptomatic, exposed infants delivered vaginally or by CUntil lesions dry section and if mother has active infection and membranes have been
and crusted ruptured for more than 4 to 6 hrs until infant surface cultures obtained
at 24-36 hrs. of age negative after 48 hrs incubation 1069, 1070
DI
Susceptible HCWs should not enter room if immune caregivers are
available; no recommendation for protection of immune HCWs; no
recommendation for type of protection, i.e. surgical mask or respirator;
for susceptible HCWs.
APPENDIX A 1
Infection/Condition
Precautions
Type
*
Duration †
Localized in patient with intact immune system with lesions that can
be contained/covered
Histoplasmosis
Human immunodeficiency virus (HIV)
S
S
Human metapneumovirus
C
DI
Impetigo
Infectious mononucleosis
C
U 24 hrs
S
DI
Single patient room when available or cohort; avoid placement with
high-risk patients; mask patient when transported out of room;
5 days except DI chemoprophylaxis/vaccine to control/prevent outbreaks 611. Use gown
in immuno
and gloves according to Standard Precautions may be especially
compromised
important in pediatric settings. Duration of precautions for
persons
immunocompromised patients cannot be defined; prolonged duration
of viral shedding (i.e. for several weeks) has been observed;
implications for transmission are unknown 930.
See www.cdc.gov/flu/avian/professional/infect-control.htm for current
avian influenza guidance.
5 days from
See http://www.pandemicflu.gov for current pandemic influenza
onset of
guidance.
symptoms
D
Avian (e.g., H5N1, H7, H9 strains))
Pandemic influenza (also a human influenza virus)
Kawasaki syndrome
Lassa fever (see viral hemorrhagic fevers)
Post-exposure chemoprophylaxis for some blood exposures 866.
HAI reported 1071, but route of transmission not established 823.
Assumed to be Contact transmission as for RSV since the viruses are
closely related and have similar clinical manifestations and
epidemiology. Wear masks according to Standard Precautions..
S
Influenza
Human (seasonal influenza)
Comments
Susceptible HCWs should not provide direct patient care when other
immune caregivers are available.
D
S
103
APPENDIX A 1
Infection/Condition
Precautions
Type
Legionnaires’ disease
Leprosy
Leptospirosis
Lice
Head (pediculosis)
Body
Pubic
*
Duration †
S
S
S
C
S
S
Comments
U 24 hrs
http://www.cdc.gov/ncidod/dpd/parasites/lice/default.htm
Transmitted person to person through infested clothing. Wear gown
and gloves when removing clothing; bag and wash clothes according
to CDC guidance above
Transmitted person to person through sexual contact
Person-to-person transmission rare; cross-transmission in neonatal
settings reported 1072, 1073 1074, 1075
Listeriosis (listeria monocytogenes)
S
Lyme disease
Lymphocytic choriomeningitis
Lymphogranuloma venereum
S
S
S
Malaria
S
Not transmitted from person to person except through transfusion
rarely and through a failure to follow Standard Precautions during
patient care 1076-1079. Install screens in windows and doors in endemic
areas. Use DEET-containing mosquito repellants and clothing to cover
extremities
A
Susceptible HCWs should not enter room if immune care providers
are available; no recommendation for face protection for immune
4 days after
HCW; no recommendation for type of face protection for susceptible
onset of rash; DI
HCWs, i.e., mask or respirator 1027, 1028. For exposed susceptibles,
in immune
post-exposure vaccine within 72 hrs. or immune globulin within 6 days
compromised
when available 17, 1032, 1034. Place exposed susceptible patients on
Airborne Precautions and exclude susceptible healthcare personnel
Marburg virus disease (see viral hemorrhagic fevers)
Measles (rubeola)
223
APPENDIX A 1
Infection/Condition
Precautions
Type
Melioidosis, all forms
Meningitis
Aseptic (nonbacterial or viral; also see enteroviral infections)
Bacterial, gram-negative enteric, in neonates
Fungal
Haemophilus influenzae, type b known or suspected
Listeria monocytogenes (See Listeriosis)
Neisseria meningitidis (meningococcal) known or suspected
Streptococcus pneumoniae
Duration †
S
S
S
D
S
D
S
S
Other diagnosed bacterial
S
Meningococcal disease: sepsis, pneumonia, meningitis
D
Molluscum contagiosum
S
Comments
from duty from day 5 after first exposure to day 21 after last exposure,
regardless of post-exposure vaccine 17.
S
M. tuberculosis
Monkeypox
*
Contact for infants and young children
U 24 hrs
U 24 hrs
See meningococcal disease below
Concurrent, active pulmonary disease or draining cutaneous lesions
may necessitate addition of Contact and/or Airborne Precautions;
For children, airborne precautions until active tuberculosis ruled out in
visiting family members (see tuberculosis below) 42
U 24 hrs
A-Until
monkeypox
confirmed and
smallpox
excluded
C-Until lesions
crusted
A,C
Postexposure chemoprophylaxis for household contacts, HCWs
exposed to respiratory secretions; postexposure vaccine only to
control outbreaks 15, 17.
Use See www.cdc.gov/ncidod/monkeypox for most current
recommendations. Transmission in hospital settings unlikely 269. Preand post-exposure smallpox vaccine recommended for exposed
HCWs
105
APPENDIX A 1
Infection/Condition
Precautions
Type
Mucormycosis
Multidrug-resistant organisms (MDROs), infection or colonization
(e.g., MRSA, VRE, VISA/VRSA, ESBLs, resistant S. pneumoniae)
Mumps (infectious parotitis)
Mycobacteria, nontuberculosis (atypical)
Pulmonary
Wound
Mycoplasma pneumonia
Necrotizing enterocolitis
Nocardiosis, draining lesions, or other presentations
Norovirus (see gastroenteritis)
Norwalk agent gastroenteritis (see gastroenteritis)
Orf
224
*
Duration †
S
S/C
D
S
S
D
S
S
S
U 9 days
DI
Comments
MDROs judged by the infection control program, based on local, state,
regional, or national recommendations, to be of clinical and
epidemiologic significance. Contact Precautions recommended in
settings with evidence of ongoing transmission, acute care settings
with increased risk for transmission or wounds that cannot be
contained by dressings. See recommendations for management
options in Management of Multidrug-Resistant Organisms In
Healthcare Settings, 2006 870. Contact state health department for
guidance regarding new or emerging MDRO.
After onset of swelling; susceptible HCWs should not provide care if
immune caregivers are available.
Note: (Recent assessment of outbreaks in healthy 18-24 year olds has
indicated that salivary viral shedding occurred early in the course of
illness and that 5 days of isolation after onset of parotitis may be
appropriate in community settings; however the implications for
healthcare personnel and high-risk patient populations remain to be
clarified.)
Not transmitted person-to-person
Contact Precautions when cases clustered temporally 1080-1083 .
APPENDIX A 1
Infection/Condition
Precautions
Type
*
Duration †
Comments
Viral shedding may be prolonged in immunosuppressed patients 1009,
. Reliability of antigen testing to determine when to remove patients
with prolonged hospitalizations from Contact Precautions uncertain.
Maintain precautions for duration of hospitalization when chronic
disease occurs in an immunocompromised patient. For patients with
transient aplastic crisis or red-cell crisis, maintain precautions for 7
days. Duration of precautions for immunosuppressed patients with
persistently positive PCR not defined, but transmission has occurred
929
.
1010
Parainfluenza virus infection, respiratory in infants and young children
C
Parvovirus B19 (Erythema infectiosum)
D
Pediculosis (lice)
C
U 24 hrs after
treatment
Pertussis (whooping cough)
D
U 5 days
Pinworm infection (Enterobiasis)
Plague (Yersinia pestis)
Bubonic
Pneumonic
Pneumonia
S
Single patient room preferred. Cohorting an option. Post-exposure
chemoprophylaxis for household contacts and HCWs with prolonged
exposure to respiratory secretions 863. Recommendations for Tdap
vaccine in adults under development.
S
D
U 48 hrs
Antimicrobial prophylaxis for exposed HCW 207.
D, C
DI
Adenovirus
Bacterial not listed elsewhere (including gram-negative bacterial)
S
B. cepacia in patients with CF, including
respiratory tract colonization
C
DI
Outbreaks in pediatric and institutional settings reported 376, 1084-1086. In
immunocompromised hosts, extend duration of Droplet and Contact
Precautions due to prolonged shedding of virus 931
Avoid exposure to other persons with CF; private room preferred.
Criteria for D/C precautions not established. See CF Foundation
guideline 20
Unknown
107
APPENDIX A 1
Infection/Condition
Precautions
Type
*
Duration
B. cepacia in patients without CF(see
Multidrug-resistant organisms)
Chlamydia
Fungal
Haemophilus influenzae, type b
Adults
Infants and children
Legionella spp.
Meningococcal
Multidrug-resistant bacterial (see multidrug-resistant organisms)
Mycoplasma (primary atypical pneumonia)
S
D
S
D
U 24 hrs
D
DI
Pneumococcal pneumonia
S
Pneumocystis jiroveci (Pneumocystis carinii )
S
Staphylococcus aureus
Streptococcus, group A
S
Adults
Varicella-zoster (See Varicella-Zoster)
Viral
Adults
Infants and young children (see respiratory infectious disease,
acute, or specific viral agent)
Poliomyelitis
Pressure ulcer (decubitus ulcer, pressure sore) infected
†
Comments
S
S
U 24 hrs
D
U 24 hrs
D
U 24 hrs
See meningococcal disease above
Use Droplet Precautions if evidence of transmission within a patient
care unit or facility 196-198, 1087
Avoid placement in the same room with an immunocompromised
patient.
For MRSA, see MDROs
See streptococcal disease (group A streptococcus) below
Contact precautions if skin lesions present
Contact Precautions if skin lesions present
S
C
DI
225
108
APPENDIX A 1
Infection/Condition
Precautions
Type
Major
*
Duration †
C
Minor or limited
Prion disease (See Creutzfeld-Jacob Disease)
Psittacosis (ornithosis) (Chlamydia psittaci)
Q fever
S
Rabies
S
Rat-bite fever (Streptobacillus moniliformis disease, Spirillum minus
disease)
Relapsing fever
Resistant bacterial infection or colonization (see multidrug-resistant
organisms)
Respiratory infectious disease, acute (if not covered elsewhere)
Adults
DI
S
S
Comments
If no dressing or containment of drainage; until drainage stops or can
be contained by dressing
If dressing covers and contains drainage
Person to person transmission rare; transmission via corneal, tissue
and organ transplants has been reported 539, 1088. If patient has bitten
another individual or saliva has contaminated an open wound or
mucous membrane, wash exposed area thoroughly and administer
postexposure prophylaxis. 1089
S
S
S
C
DI
Respiratory syncytial virus infection, in infants,
young children and immunocompromised adults
C
DI
Reye's syndrome
Rheumatic fever
Rhinovirus
S
S
D
DI
Also see syndromes or conditions listed in Table 2
Wear mask according to Standard Precautions 24 CB 116, 117. In
immunocompromised patients, extend the duration of Contact
Precautions due to prolonged shedding 928). Reliability of antigen
testing to determine when to remove patients with prolonged
hospitalizations from Contact Precautions uncertain.
Droplet most important route of transmission 104 1090. Outbreaks have
109
APPENDIX A 1
Infection/Condition
Precautions
Type
Rickettsial fevers, tickborne (Rocky Mountain spotted fever, tickborne
typhus fever)
Rickettsialpox (vesicular rickettsiosis)
226
*
Duration †
S
S
Ringworm (dermatophytosis, dermatomycosis, tinea)
S
Ritter's disease (staphylococcal scalded skin syndrome)
C
Rocky Mountain spotted fever
S
Roseola infantum (exanthem subitum; caused by HHV-6)
Rotavirus infection (see gastroenteritis)
S
Rubella (German measles) ( also see congenital rubella)
D
Rubeola (see measles)
Salmonellosis (see gastroenteritis)
Scabies
Scalded skin syndrome, staphylococcal
Schistosomiasis (bilharziasis)
C
C
S
DI
U 7 days after
onset of rash
U 24
DI
Comments
occurred in NICUs and LTCFs 413, 1091, 1092. Add Contact Precautions if
copious moist secretions and close contact likely to occur (e.g., young
infants) 111, 833.
Not transmitted from person to person except through transfusion,
rarely
Rarely, outbreaks have occurred in healthcare settings, (e.g., NICU
1093
, rehabilitation hospital 1094. Use Contact Precautions for outbreak.
See staphylococcal disease, scalded skin syndrome below
Not transmitted from person to person except through transfusion,
rarely
available. No recommendation for wearing face protection (e.g., a
surgical mask) if immune. Pregnant women who are not immune
should not care for these patients 17, 33. Administer vaccine within
three days of exposure to non-pregnant susceptible individuals. Place
exposed susceptible patients on Droplet Precautions; exclude
susceptible healthcare personnel from duty from day 5 after first
exposure to day 21 after last exposure, regardless of post-exposure
vaccine.
See staphylococcal disease, scalded skin syndrome below)
APPENDIX A 1
Infection/Condition
Precautions
Type
Severe acute respiratory syndrome (SARS)
*
A, D,C
Shigellosis (see gastroenteritis)
Smallpox (variola; see vaccinia for management of vaccinated
persons)
Sporotrichosis
Spirillum minor disease (rat-bite fever)
Staphylococcal disease (S aureus)
Skin, wound, or burn
Major
Minor or limited
Enterocolitis
Duration †
A,C
Until all scabs have crusted and separated (3-4 weeks). Nonvaccinated HCWs should not provide care when immune HCWs are
available; N95 or higher respiratory protection for susceptible and
successfully vaccinated individuals; postexposure vaccine within 4
days of exposure protective 108, 129, 1038-1040.
DI
S
S
C
S
DI
No dressing or dressing does not contain drainage adequately
Dressing covers and contains drainage adequately
Use Contact Precautions for diapered or incontinent children for
duration of illness
S
Multidrug-resistant (see multidrug-resistant organisms)
Pneumonia
S
Scalded skin syndrome
C
Toxic shock syndrome
Streptobacillus moniliformis disease (rat-bite fever)
Comments
DI plus 10 days Airborne Precautions preferred; D if AIIR unavailable. N95 or higher
after resolution of respiratory protection; surgical mask if N95 unavailable; eye protection
fever, provided (goggles, face shield); aerosol-generating procedures and
respiratory
“supershedders” highest risk for transmission via small droplet nuclei
93, 94, 96
.Vigilant environmental disinfection (see
symptoms are
and large droplets
www.cdc.gov/ncidod/sars)
absent or
improving
Consider healthcare personnel as potential source of nursery, NICU
outbreak 1095.
DI
S
S
111
APPENDIX A 1
Infection/Condition
Precautions
Type
Streptococcal disease (group A streptococcus)
Skin, wound, or burn
Major
Minor or limited
Endometritis (puerperal sepsis)
Pharyngitis in infants and young children
Pneumonia
Scarlet fever in infants and young children
Serious invasive disease
Streptococcal disease (group B streptococcus), neonatal
Streptococcal disease (not group A or B) unless covered elsewhere
Multidrug-resistant (see multidrug-resistant organisms)
Strongyloidiasis
Syphilis
Latent (tertiary) and seropositivity without lesions
Skin and mucous membrane, including congenital, primary,
Secondary
Tapeworm disease
Hymenolepis nana
Taenia solium (pork)
Other
Tetanus
Tinea (e.g., dermatophytosis, dermatomycosis, ringworm)
*
Duration
C,D
S
S
D
D
D
U 24 hrs
U 24 hrs
U 24 hrs
D
U24 hrs
S
S
U 24 hrs
†
Comments
Outbreaks of serious invasive disease have occurred secondary to
transmission among patients and healthcare personnel 162, 972, 1096-1098
Contact Precautions for draining wound as above; follow rec. for
antimicrobial prophylaxis in selected conditions 160.
S
S
S
S
S
S
S
S
Rare episodes of person-to-person transmission
227
APPENDIX A 1
Infection/Condition
Precautions
Type
Toxoplasmosis
*
Duration †
S
Toxic shock syndrome (staphylococcal disease, streptococcal
disease)
Trachoma, acute
Transmissible spongiform encephalopathy (see Creutzfeld-Jacob
disease, CJD, vCJD)
Trench mouth (Vincent's angina)
Trichinosis
Trichomoniasis
Trichuriasis (whipworm disease)
Tuberculosis (M. tuberculosis)
Extrapulmonary, draining lesion)
Comments
Transmission from person to person is rare; vertical transmission from
mother to child, transmission through organs and blood transfusion
rare
Droplet Precautions for the first 24 hours after implementation of
antibiotic therapy if Group A streptococcus is a likely etiology
S
S
S
S
S
S
Discontinue precautions only when patient is improving clinically, and
drainage has ceased or there are three consecutive negative cultures
of continued drainage 1025, 1026. Examine for evidence of active
pulmonary tuberculosis.
Examine for evidence of pulmonary tuberculosis. For infants and
children, use Airborne Precautions until active pulmonary tuberculosis
in visiting family members ruled out 42
Discontinue precautions only when patient on effective therapy is
improving clinically and has three consecutive sputum smears
negative for acid-fast bacilli collected on separate days(MMWR 2005;
54: RR-17
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm?s_cid=rr5
417a1_e ) 12.
Discontinue precautions only when the likelihood of infectious TB
A,C
Extrapulmonary, no draining lesion, meningitis
S
Pulmonary or laryngeal disease, confirmed
A
Pulmonary or laryngeal disease, suspected
A
113
APPENDIX A 1
Infection/Condition
Precautions
Type
Skin-test positive with no evidence of current active disease
Tularemia
Draining lesion
Pulmonary
Typhoid (Salmonella typhi) fever (see gastroenteritis)
Typhus
Rickettsia prowazekii (Epidemic or Louse-borne typhus)
Rickettsia typhi
Urinary tract infection (including pyelonephritis), with or without
urinary catheter
S
S
S
S
S
Duration †
Comments
disease is deemed negligible, and either 1) there is another diagnosis
that explains the clinical syndrome or 2) the results of three sputum
smears for AFB are negative. Each of the three sputum specimens
should be collected 8-24 hours apart, and at least one should be an
early morning specimen
Transmitted from person to person through close personal or clothing
contact
S
Vaccinia (vaccination site, adverse events following vaccination) *
228
*
Vaccination site care (including autoinoculated areas)
S
Eczema vaccinatum
Fetal vaccinia
Generalized vaccinia
C
C
C
Only vaccinated HCWs have contact with active vaccination sites and
care for persons with adverse vaccinia events; if unvaccinated, only
HCWs without contraindications to vaccine may provide care.
Vaccination recommended for vaccinators; for newly vaccinated
HCWs: semi-permeable dressing over gauze until scab separates,
with dressing change as fluid accumulates, ~3-5 days; gloves, hand
hygiene for dressing change; vaccinated HCW or HCW without
contraindication to vaccine for dressing changes 205, 221, 225.
Until lesions dry For contact with virus-containing lesions and exudative material
and crusted,
scabs separated
APPENDIX A 1
Infection/Condition
Precautions
Type
Progressive vaccinia
Postvaccinia encephalitis
Blepharitis or conjunctivitis
Iritis or keratitis
Vaccinia-associated erythema multiforme (Stevens Johnson
Syndrome)
Secondary bacterial infection (e.g., S. aureus, group A beta
hemolytic streptococcus
Varicella Zoster
*
C
S
S/C
S
Comments
Use Contact Precautions if there is copious drainage
S
Follow organism-specific (strep, staph most frequent)
recommendations and consider magnitude of drainage
available; no recommendation for face protection of immune HCWs;
no recommendation for type of protection, i.e. surgical mask or
respirator for susceptible HCWs. In immunocompromised host with
varicella pneumonia, prolong duration of precautions for duration of
illness. Post-exposure prophylaxis: provide post-exposure vaccine
Until lesions dry
ASAP but within 120 hours; for susceptible exposed persons for whom
and crusted
vaccine is contraindicated (immunocompromised persons, pregnant
women, newborns whose mother’s varicella onset is <5days before
delivery or within 48 hrs after delivery) provide VZIG, when available,
within 96 hours; if unavailable, use IVIG, Use Airborne Precautions for
exposed susceptible persons and exclude exposed susceptible
healthcare workers beginning 8 days after first exposure until 21 days
after last exposure or 28 if received VZIG, regardless of postexposure
vaccination. 1036.
S/C
A,C
Variola (see smallpox)
Vibrio parahaemolyticus (see gastroenteritis)
Vincent's angina (trench mouth)
Viral hemorrhagic fevers
Duration †
S
S, D, C
DI
Single-patient room preferred. Emphasize: 1) use of sharps safety
115
APPENDIX A 1
Infection/Condition
Precautions
Type
*
Duration †
due to Lassa, Ebola, Marburg, Crimean-Congo fever viruses
Viral respiratory diseases (not covered elsewhere)
Adults
Infants and young children (see respiratory infectious disease,
acute)
Whooping cough (see pertussis)
Wound infections
Major
Minor or limited
Yersinia enterocolitica gastroenteritis (see gastroenteritis)
Zoster (varicella-zoster) (see herpes zoster)
Zygomycosis (phycomycosis, mucormycosis)
Comments
devices and safe work practices, 2) hand hygiene; 3) barrier protection
against blood and body fluids upon entry into room (single gloves and
fluid-resistant or impermeable gown, face/eye protection with masks,
goggles or face shields); and 4) appropriate waste handling. Use N95
or higher respirators when performing aerosol-generating procedures.
Largest viral load in final stages of illness when hemorrhage may
occur; additional PPE, including double gloves, leg and shoe
coverings may be used, especially in resource-limited settings where
options for cleaning and laundry are limited. Notify public health
officials immediately if Ebola is suspected 212, 314, 740, 772 Also see Table
3 for Ebola as a bioterrorism agent
S
C
S
S
DI
229
Latex Allergy/Sensitivity
Policy No. # 5
Initial Policy: November 1, 1999
Revised Date:
February 23, 2010
It is the policy of Palmetto Health Richland Hospital to screen for and minimize the risk of hypersensitivity/allergic
reactions to latex by patients.
GUIDANCE:
Patients may be exposed to latex through 1) direct contact with latex products, 2) indirect contact, i.e.: a healthcare provider touching a
latex product and then touching a patient 3) inhalation of latex proteins, particularly, glove powder, and 4) through injection of latex proteins
via IV ports. Types of latex responses are defined as follows:
Type I or Latex allergy (immediate sensitivity) is defined as an immediate allergic reaction or IgE mediated hypersensitivity reaction caused
by latex proteins which directly sensitize the patient and subsequently cause allergic symptoms including rhinitis, conjunctivitis, urticaria,
angioedema, asthma, anaphylaxis and death. Direct contact with the medical product is not needed for sensitization to latex. Allergic latex
proteins are also absorbed on the glove powder, which, when latex gloves are removed, become airborne and can be directly inhaled.
Direct latex exposure at mucosal or aerosol surfaces also occurs.
Type IV or Allergic contact dermatitis (delayed hypersensitivity) is defined as a specific immune response of sensitized lymphocytes to
chemical additives contained in latex products. This response is known as delayed hypersensitivity. Clinically, at the outset, there may be
an acute eczematous dermatitis often with vesicle formation. The lesions typically appear 48-96 hours after exposure. Subsequently, the
skin may become dry, crusted, and thickened. Etiologic agents involve chemical additives, such as accelerators or antioxidants. Thiurams
and carbamates are commonly implicated agents. Contact dermatitis may be involved in latex sensitization. Allergic contact reactions
reduce the barrier properties of the skin and allow absorption of larger amounts of chemicals or proteins.
Irritant contact dermatitis is defined as a reaction to natural rubber latex that is characterized by dry, itchy, irritated areas on the skin,
usually hands. It is not a true allergy.
1. Efforts to provide a latex safe environment will be made by all hospital personnel to eliminate or reduce patient’s exposure to direct
and indirect contact with natural rubber latex when indicated
2. Patients will be categorized as to their risk for latex allergy using the Point of Entry Questionnaire. Patients will be categorized as
High Risk- Type I (Latex Allergy), Medium risk- Type (IV) (Delayed hypersensitivity, allergic dermatitis) or Low risk (contact dermatitis or
irritant dermatitis). (see attached point of entry questionnaire)
3. Appropriate precautions and measures to provide for a Latex safe environment will be implemented based upon the patient’s latex
risk category. See attached latex risk category and level of latex precaution chart. Levels of precautions include High Risk-Type I,
Medium Risk Type IV and Low Risk- Irritant contact dermatitis.
4. Patients will be identified as at risk for latex exposure using:
•
Orange Latex Alert/Allergy bracelet
•
Latex Allergy/Latex Risk signs and labels
•
Assigned data fields for allergies/precautions on forms or automated clinical information system
5. Patients will be observed for possible reactions to latex and treated as appropriate.
5.1 Severe allergic reactions consists of symptoms including urticaria (hives), angioedema (swelling), closing of throat or
difficulty breathing, lightheadedness and the appearance of flushing of the patient. Reactions can quickly proceed to severe
anaphylactic shock; this includes hypotension and cardiovascular collapse
5.2 Guidelines for medication dosing of treatment of severe allergic reactions and Anaphylaxis are found in Drug code cart
notebook.
6. For patient and employee safety, the use of latex balloons is prohibited.
230
LEVEL OF RISK
LEVEL OF LATEX PRECAUTION
HIGH RISK-TYPE I (LATEX ALLERGY)
Known or suspected latex allergy patients.
Definitive history of allergy to latex products (IgE mediated
symptoms)
1.
Sneezing
2.
Runny nose
3.
Urticaria
4.
Angioedema
5.
Bronchospasm upon exposure to latex products
Diagnostic testing positive
5. Blood test detecting anti-latex IgE
6. Skin Prick test to latex or glove extract (may be
symptomatic when exposed to latex)
History of anaphylaxis:
• Anaphylactic reaction to latex products during a medical
procedure or surgery.
• Anaphylactic reaction to unknown etiology during a medical
procedure or surgery.
History of spina bifida (myelomeningiocele)
HIGH RISK –TYPE I (LATEX ALLERGY)
Latex safe environment (Requires latex free products and special
attention to decrease patient exposure to latex-and latex proteins
in the environment)
• All latex products removed from patient’s room
• Use of latex free products only
• Special cleaning or room to decrease latex proteins in
environment
• Latex safe pharmacy protocol for medications
• Latex safe surgical protocol
• Latex safe procedure protocol
• Consider pre-treatment for procedures/surgery
• Use latex Allergy Labels/Signs
MEDIUM RISK- TYPE IV (ALLERGIC DERMATITIS,
DELAYED HYPERSENSITIVITY)( At risk to becoming
sensitized, but no history of latex allergy)
Congenital urogenital defects
History of indwelling urinary catheters or repeated
catheterizations
High latex exposure( health care worker, housekeepers, food
handlers, tire manufacturers, beauticians, workers using gloves
regularly who have history of allergic contact dermatitis)
History of multiple childhood surgeries
History of food allergy (banana*, avocado*, chestnuts*, kiwi*,
papaya, passion fruit, raw potato*, celery, pineapple, peach*,
nectarine, plum cherry, melon, fig, grape tomato*) * indicates
highest rate of cross sensitivity.
MEDIUM RISK- TYPE IV ( ALLERGIC DERMATITIS,
DELAYED SENSITIVITY)
Medium risk latex environment ( Use latex free products to
reduce patient becoming sensitized but does not require other
environmental controls)
1.
All latex products removed from patient’s care area
5. Latex free gloves
• Avoid any latex product that involves direct skin or mucous
membrane contact( catheters, gloves, Band-Aid, stethoscopes,
EKG pads, etc)
• No special procedures for IV medications, IV tubing, or IV
pharmaceuticals
• No special protocols for surgical procedures except for use of
latex free equipment/products
• No special procedural protocol except for use of latex free
equipment/products
• Use Latex Risk labels/Signs
LOW RISK: Avoidance of exposure to chemicals in Natural
rubber latex
Use protective liners under latex products or use latex free
alternative product
LOW RISK
History of contact dermatitis or irritant contact
231
MANAGING THE LATEX SENSITIVE OR ALLERGIC PATIENT
ASSESSMENT:
Performed by assigned care giver
PLAN:
All latex-free items are available in Supply Pyxis
Latex Drug Box – Available from pharmacy
IMPLEMENTATION:
1. All patients will be queried for latex allergy during the initial
patient interview using the Point of Entry Questionnaire
RATIONALE AND KEY POINTS:
Latex allergy and sensitivity is an increasing health care issue.
2. Document identified level of risk and level of precautions
in assigned data fields “allergies/precautions” on form or
automated clinical information system.
3. Communicate patient’s identified level of risk and level of
precautions to ancillary services/departments through use of
clinical information systems and/or chart labels.
3.1. Inform patient’s physician if not already cognizant of
the latex allergy or sensitivity
3.2. Notify pharmacy by order sheet if patient is at high risk
(Type I-latex allergy)
3.3. Notify dietary of if pt has any specific food allergies
3.4. Notify respiratory care of level of risk and category of
precaution.
4. Provide for latex safe environment in patient care area,
including patient room, hallways, and common area.
Measures to be taken are based on patient’s risk and
category of protection needed.
4.1. Obtain Latex-free supplies and place inside patient
care area
4.2. Remove all latex gloves from patient care area
4.3. Place Latex alert/allergy bracelet on patient
4.4. High Risk- Type I-(Latex Allergic)
4.4.1 Place latex Allergy sign on patient’s chart, door
to patient care area and over bed
4.4.2 Obtain Latex free Emergency Drug Box and
place inside patient care area (For High Risk
Patients only)
4.4.3 Remove latex containing objects from patient
care area
4.4.4 Cover black tubing on all wall mounted BP
manometers with Kling
4.4.5 Confirm all equipment to be used on patient
is latex free: ECG electrodes, BP cuffs, foley
catheters, Pulse oximeter, oxygen mask (cover
elastic band with Kling or use alternative
method of securing such as trach ties,) etc.
4.4.6 Notify Pharmacy of High Risk Category and High
Risk level of precaution.
4.4.6.1 Place latex allergy sticker on each
written order
4.4.6.2 Utilize special IV procedures to reduce
risk of latex exposure
4.4.7 Keep door to patient care area closed.
232
To alert health care workers that the patient is latex allergic or
sensitive
Nutrition consults and note specific food allergies in clinical
information system in the Allergies Tab. Also indicate food allergies
in the special instructions of the diet order.
Protection of patients, visitors and employees. Latex balloons are
prohibited in the hospital due to high latex content.
Contact SPD, available in supply pyxis
To alert pharmacy to the necessary precautions while preparing
medications. Significant latex exposure occurs during some
medication preparation.
4.5.
Medium Risk (Type IV or Allergic dermatitis)
4.5.1 Place latex risk sign on patient’s chart, on door
to patient care area and over bed.
4.5.2 Remove latex containing objects from patient
care area.
4.5.3 Use only latex free products/supplies if mucous
membrane contact or direct skin contact is
likely( catheters, Band-Aids, stethoscope, EKG
pads, etc)
4.5.4 No special medication preparation is required.
4.5.5 No special cleaning of patient care area
required.
5. Verbally notify the receiving patient care area or hospital
department of the patient’s level of risk and level of latex
precautions.
5.1. Confirm orange allergy bracelet is on patient’s arm
whenever the patient leaves the floor or unit
Allows receiving patient care area to maintain latex safe
environment.
6. Read product labels to determine latex content. If unsure of
latex content refer to latex free reference manual.
7. Refer to the latex free reference manual for additional
methods to protect patients from inadvertent latex exposure.
8. Provide education to the patient and family regarding
latex allergy and latex sensitivity using the supplied patient
literature.
9. Management of Allergic Reactions and Anaphylaxis:
Severe allergic reactions consist of Symptoms including
urticaria (hives), Angioedema (swelling), closing of throat or
Difficulty breathing, lightheadedness and the appearance
of flushing of the patient. Reactions can quickly proceed to
severe Anaphylactic shock. This includes Hypotension and
cardiovascular collapse.
9.1 Do not leave patient
9.2 Maintain patent airway
9.3 Monitor vital signs
9.4 Initiate cardiopulmonary resuscitation if required.
9.5 Notify attending physician immediately of symptoms/
emergency
9.6 Medication dosing guidelines for Treating Allergic
Reactions and Anaphylaxis are found in code drug
note book. See attached guidelines.
Signature on File
The FDA has mandated that by September 1998 product
packaging must provide latex content. Compliance may vary
product to product. Note: labeling may not be on individual
package but on larger package container.
Guidelines for medication dosing of treatment of severe allergic
reactions and Anaphylaxis are found in code drug note book.
Signature On File
Carolyn Swinton
Effective November 1, 1999
233
Lewis Blackman Hospital Safety Act
Administration
Revised:
June 8, 2005
November 1, 2006; July 16, 2007
Policy Number A.09
Palmetto Health will meet the requirements of the Lewis Blackman Hospital Patient Safety Act, which requires
the hospital to identify for patients the role of the attending physician and to provide a mechanism for patients to
access the attending physician. The Act also requires hospitals to have their clinical employees wear name badges
with their names, using at a minimum either first or last names with appropriate initials, department, job or trainee
title. Palmetto Health will meet the South Carolina law as interpreted and enforced by DHEC.
GUIDANCE:
In compliance with the Lewis Blackman Hospital Patient Safety Act, Palmetto Health has adopted the following policies.
1. Name Badges. All clinical staff, clinical trainees, medical students, interns, and resident physicians will wear badges clearly stating
their names, using at a minimum either first or last names with appropriate initials, their departments, and their job or trainee titles.
Clinical trainees, medical students, interns, and resident physicians will be clearly identified as such in terms or abbreviations
reasonably understandable to the average person.
2. Written Information Provided to Inpatients and Outpatient Surgery Patients. Prior to or upon admission, the hospital admission staff
will provide each patient with written information identifying the role of the attending physician and explaining that clinical trainees
may participate in their care. The written information will be provided to all persons admitted to the hospital, registered in outpatient
surgery and the emergency department. In all cases, the information will be provided in a document that is separate from the general
consent for treatment. The acknowledgement of the receipt of the Lewis Blackman Hospital Patient Safety Act Letter will be included
as part of the General Consent for Treatment form. The patient or their designee (Power of Attorney or Representative) will be asked
to initial the Lewis Blackman Hospital Patient Safety Act portion of the General Consent form. During admission assessment, nursing
will include the written information regarding the Lewis Blackman Hospital Patient Safety Act as part of orientation.
2.1. The written information must:
2.1.1. Explain that the patient’s attending physician is the person primarily responsible for the patient’s care;
2.1.2. Explain that the patient’s attending physician may change during hospitalization as their condition changes;
2.1.3. Explain that the patient’s nurse will help the patient contact the attending physician if the patient requests assistance;
2.1.4. Explain that the hospital has established a patient assistance system to help resolve any concerns that may not require
the attention of the attending physician; and
2.1.5. Instruct the patient how to access the patient assistance system.
2.2 When the hospital employs clinical trainees, the language below will apply. The written information will also include:
2.2.1 An explanation of the roles of clinical trainees, medical students, interns, and resident physicians in patient care;
2.2.2 Notification that medical students, interns, or resident physicians may be participating in the patient’s care (by making
treatment decisions or by assisting or performing surgery on the patient).
3. Contacting the Patient’s Attending Physician. If at any time a patient requests that a nurse call his or her attending physician regarding
the patient’s personal medical care, the nurse will place a call to the attending physician or his or her designee to inform him or her of
the patient’s concern. If the patient is able to communicate with and desires to call his or her attending physician or designee, upon
the patient’s request, the nurse must provide the patient with the telephone number and assist the patient in placing the call. A nurse
or other clinical staff to whom such a request is made or who receives multiple requests may notify his or her immediate supervisor
for assistance.
4. Patient Assistance System. Palmetto Health will maintain a patient assistance system designed to help patients resolve their personal
medical care concerns in a prompt manner. A mechanism (telephone number, beeper number, etc.) will be established that allows the
patient to independently access the patient assistance system, and this mechanism may not require the patient to request assistance
in order to access the system. However, a clinical staff member or clinical trainee must promptly access the system on behalf of a
patient if the patient requests assistance. A representative of the hospital’s administrative or supervisory clinical staff must be available
at all times to respond to patient concerns. Once the patient assistance system has been contacted, the administrative or supervisory
clinical staff representative shall promptly assess (or cause to be assessed) the patient’s concern and provide appropriate follow up.
5. Documentation. Palmetto Health will document when a patient receives the written information and when a patient requests to speak
to the attending physician.
234
REFERENCE:
S.C. Code of Laws, Article 27, Section 44-7-3410, Lewis Blackman Hospital Patient Safety Act.
S. C. Code of Laws, Article 27, Section 44-7-3430 of the 1976 Code, as added by Act 146 or 2005, Lewis Blackman Hospital Patient
Safety Act.
Signature on File
235
Media/Public Requests for Patient Information
(Formerly Release of Information Policy)
Administration
October 1, 2001
Revised: April 14, 2003
Policy No. D.07
Revised: September 30, 2004; July 16, 2007; June 8, 2009
Palmetto Health releases information to the news media and others that comply with HIPAA and in accordance with
state and federal laws.
GUIDANCE:
1. The Departments of Corporate Communications and Public Relations are the official liaisons with the news media.
1.1 Employees may participate in media interviews related to Palmetto Health matters when those interviews have been initiated
by or arranged through the Corporate Communications or Public Relations departments.
1.2 The Chief Operating Officer of a Palmetto Health facility must approve the installation of any news gathering equipment (lights,
cameras, recorders) that may interfere with the operation of Palmetto Health or create an inconvenience to patients located
near the area of news interest.
2. General patient condition reports will be released to the news media through the Department of Public Relations weekdays 8 a.m.–
5 p.m., and by Nursing Supervisors for Evenings and Nights on weekends, holidays and weekdays from 5p.m. – 8a.m. The Public
Relations person on-call may be asked to assist at any time.
2.1 Acknowledgement of a patient’s admission and condition may be made without the patient’s authorization if the patient is
asked for by name and has agreed to be included in the patient directory.
2.2
If additional information is requested, Palmetto Health will obtain written authorization. If authorization has not been obtained
but circumstances warrant a response, Corporate Compliance will be consulted before any information is given. No
information will be provided unless approved by Corporate Compliance.
3. The condition of a patient as determined by the Physician or the Nurse in Charge. Condition may be reported as follows:
3.1 GOOD—Indicators are excellent; vital signs are stable and within normal limits. Patient is conscious and comfortable.
3.2 FAIR—Indicators are favorable; vital signs are stable and within normal limits. Patient is conscious but may be uncomfortable.
3.3 SERIOUS—Indicators are questionable; vital signs may be stable, or unstable and not within normal limits. Patient is acutely ill
and may not be conscious.
3.4 CRITICAL—Indicators are unfavorable; vital signs are unstable and not within normal limits. Patient may not be conscious.
4. No information is released on patients with psychiatric conditions, patients whose admission is a result of an attempted suicide or
patients who are victims of rape and abuse.
5. In the event of a declared Palmetto Health facility disaster, Palmetto Health will release to the media the number of patients and the
condition of patients without identifying any patient by name. After the disaster is under control, names and condition of patients will
be released with authorization pursuant to Palmetto Health’s Directory policy.
6. For release of patient information on medical records, refer to Palmetto Health’s Medical Record Information Release policy.
7. The Department of Human Resources will verify employment for personnel matters.
8. Births announcements are released to newspapers and posted on the Palmetto Health web site only with written authorization of the
parents.
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9. Questionnaires, surveys or general requests for information will not be provided to an individual firm, agency or other organization
without appropriate approval.
9.1 Licensing or accreditation information is released through the President.
9.2 Medical Staff information is released through the President and the Chief of Staff of the facility of inquiry.
9.3 Operational status of a Palmetto Health facility is released through the President and the Chief Operating Officers.
9.4 Financial information (e.g. charges, financial statements, audits, etc.) is released through the Chief Financial Officer.
9.5 Medical Education and Research information is released through the Senior Vice President for Medical Education and
Research.
9.6 Employee information, including salary surveys, are released through the Senior Vice President for Human Resources.
Signature on File
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Medical Record Information Release
Administration
October 1, 2001
Revised: April 14, 2003
Policy No. D.05
The medical record is the property of Palmetto Health, pursuant to South Carolina law. Medical records shall be
maintained to serve the patient, the health care providers and the institution in accordance with legal, accreditation,
licensure and other appropriate regulatory requirements. The information contained in the medical record belongs
to the patient, and the patient is entitled to the protection of this information. All protected health information (PHI)
shall be regarded as confidential and available only to authorized users.
DEFINITIONS:
Authorization: A valid authorization must be written in plain language and contain the core elements described in Palmetto Health’s
Authorization for Uses and Disclosures of Protected Health Information policy.
Designee: The Health Information Management (HIM) department Director’s designated representative or any department maintaining
medical records and handling the release of that information. Departmental designees are listed in Palmetto Health’s Departments at
Palmetto Health that Maintain PHI list.
GUIDANCE:
1. All requests for information from the patient’s medical record shall be directed to the HIM department (formerly the Medical Records
department) or designee and handled in accordance with Palmetto Health’s Access and Denial of Patient Request for Protected
Health Information and Authorization for Use and Disclosure of Protected Health Information policies.
1.1 Information contained in the medical record is confidential; the release of this information will be closely controlled. The HIM
department or designee may release information from the patient’s medical record:
1.1.1 in response to a valid authorization
1.1.2 in response to proper inquiry without authorization as it relates to treatment, payment, health care operations and/or
other instances outlined in Palmetto Health’s Authorization for Uses and Disclosures of Protected Health Information
policy.
1.2 All disclosures of PHI must be limited to the minimum necessary as described in Palmetto Health’s Minimum Necessary Uses
and Disclosures policy.
2. Requests for medical information received via telephone will be referred to the Director of the HIM department or designee. In cases
of immediate need for patient care, the information will be released with proper identification and verification to assure that the
requesting party is entitled to receive such information. A written record of the request and information released will be kept.
3. Individuals may have access to his/her completed medical record, upon written request including patient’s signature, in accordance
with Palmetto Health’s Access and Denial of Patient Request for Protected Health Information policy.
4. Hospitalized patients seeking to review their medical records must request permission through their attending physician. Palmetto
Health hospitals reserve the right to refuse disclosure of medical records to hospitalized patients if the attending physician has reason
to believe such information may be harmful to the patient’s emotional or physical well-being. If the physician concurs with the patient’s
right to review the record, an order to this effect should be documented in the patient’s medical record, and the review shall occur
within a reasonable time during the inpatient stay.
5. Exceptions to the Release of Medical Information
5.1. A physician may instruct the hospital to refuse to release all or a portion of a patient’s health information to the patient if the
physician has reason to believe such release would be harmful to the patient’s emotional or physical well-being. A written
directive from the physician as to the purpose of refusal must be kept in the patient’s record.
5.2. Certain patient health information is strictly confidential and protected and cannot be released even with a subpoena. These
records will require a Court Order from the Judge requiring them to be released.
5.2.1. All information and records related to a known or suspected case of a sexually transmitted disease are strictly
confidential and must not be released or made public. S.C. Code Ann. 44-29-140
5.2.2. Federal law, 42 U.S.C. 290ee, requires that federally assisted alcohol or drug abuse program records be kept
confidential and disclosed only in accordance with federal regulation 42 CFR Part 2.
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5.2.3. Certain mental health records are confidential and must be withheld from inspection except upon a Court Order.
Information that directly or indirectly identifies a person whose commitment has been sought or obtained can only be
disclosed by following S.C. Code Ann. 44-22-100. A Court Order from the Judge may order disclosure upon finding
that it is necessary to conduct proceedings and that failure to disclose would be contrary to public interest.
5.2.4. All files and records pertaining to an adoption are confidential and must be withheld from inspection except upon a
Court Order.
5.2.5. All information and records related to therapist/patient and counselor/patient and priest/patient are confidential and
must be treated according to S.C. Code Ann. 40-75-190.
6. Refer to Palmetto Health’s Authorization for Uses and Disclosures of Protected Health Information policy for a description of a valid
authorization and its required elements. When HIM/designee receives a valid authorization:
6.1. The authorization, along with notation of specific information released, shall remain a part of the correspondence section in the
patient’s medical record folder. In case of a multimedia record, the authorization will be kept in a separate folder.
6.2. Information released from a patient’s medical record shall be strictly limited to the information required to fulfill the purpose
stated on the authorization. Authorizations specifying “any and all information” or other such broadly inclusive statements shall
not be honored. However, an effort will be made to determine the specificity of the request.
7. Medical information may be faxed to healthcare facilities and practitioners in accordance with Palmetto Health’s Fax Transmittal of
Protected Health Information policy.
8. Release of Drug and Alcohol Abuse Records: Medical records containing the identity, diagnosis, prognosis, or treatment of any
patient or client as it relates to drug and/or alcohol abuse will only be released under the following circumstances:
8.1. With written authorization from the patient, minor patient’s parent/legal guardian, or individual designated to make health care
decisions.
8.2. In cases without patient authorization, this information will only be disclosed under the following circumstances:
8.2.1. To medical personnel in the case of a medical emergency;
8.2.2. To qualified individuals conducting scientific research, management audits, financial audits, or program evaluation, as
long as the patient’s identity is not disclosed in any reports resulting from the study; and
8.2.3. To any party if authorized by court order.
9. Subpoena Duces Tecum:
9.1. When a subpoena duces tecum is received, the Office of General Counsel shall be consulted prior to responding to it.
9.2. The Director of Health Information Management shall designate the person(s) responsible for court appearance.
9.3. The designee shall request that the court accept a copy of the medical record to be admitted as evidence in lieu of the original.
10. All Quality Improvement Organization (QIO) requests for information shall be referred to the appropriate HIM Director.
11. Medical records shall be available to authorized students enrolled in the educational programs affiliated with the institution for use
within the HIM Department. Students must present a proper identification and have written permission of instructor. Data compiled in
education studies may not include patients’ names or other information which could identify them.
12. Refer to Palmetto Health’s Media/Public Requests for Patient Information policy for releases in response to media request(s).
13. It is the responsibility of the HIM department and designees to assist the Privacy Officer in monitoring adherence to this policy by all
individuals with access to patient information.
14. The original medical record shall not be removed from the jurisdiction and safekeeping of Palmetto Health except in accordance with
a court order and must be accompanied by an appropriate custodian.
15. Patient information may be used or disclosed for research purposes in accordance with Palmetto Health’s Uses and Disclosures of
PHI for Research Purposes policy.
16. All individuals engaged in the collection, handling or dissemination of patient medical information shall be specifically informed of
their responsibility to protect patient data and of the penalty for violating this trust. (Refer to Palmetto Health’s Confidentiality and
Disciplinary Action policies)
16.1. This policy shall be made known to HIM staff and designees at the time of employment.
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16.2. Direct access to patient’s medical record for routine administrative functions, including billing, shall not be permitted except
where the employees are instructed in and held accountable for policies on confidentiality and subject to penalties arising from
violation of these as specified above.
Signature on File
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Medtronic Synchro Med Infusion System/Implantable Pump
Policy No. M- 17 April 2001
Administration of Intrathecal medication (opiates, local anesthetics, steroids, alpha-agonist, or combination thereof)
for relief of uncontrollable pain in chronic pain patients via an implantable pump.
RULES:
Care Provider Requirements
1. Caring for a patient with intrathecal medication by an implantable pump requires “special education” and training. Completion of an
approved educational program and demonstration of competency by skills assessment of actual performance are the two methods
of achieving these requirements.
2. Registered nurses who have documented special education and training, may monitor, refill and program the implantable pump.
3. Reprogramming requires verification by two trained Registered Nurses or by an Registered Nurse and a physician.
Medication Management
1. Only preservative-free and sterile medications may be administered via the intrathecal implantable pump.
2. While the patient is receiving intrathecal narcotics, no additional narcotics and sedatives by other routes are to be administered unless
ordered or approved by the physician or resident.
3. Aseptic technique must be maintained throughout the refill procedure to maintain sterility of the pump reservoir, fluid pathway, and
device pocket.
4. Use only Medtronic refill kits-Model #8551 Refill Kit.
Initial fill and refill volumes must not exceed levels specified in the technical manuals.
Always use template when accessing the implanted pump’s center reservoir fill port.
Monitoring and Surveillance
1. Refer to the product technical manual, SynchroMed Infusion System Clinical Reference Guide For Pain Therapy, when monitoring a
patient with the Medtronic SynchroMed Pump.
2. All patients with the implantable pump and who are receiving additional narcotics/ sedatives should have their vital signs and oxygen
saturation checked if patient’s condition changes or there is a change in dosing, i.e. bolus or new dosing. Document interventions
and results.
3. Assess the patient’s program upon admission to the hospital/ unit.
4. A targeted assessment of the patient with an implantable pump must be done. Document (MAR, Nurses’ Notes, Flowsheet, Epidural/
Intrathecal Flowsheet, Computer, etc.) after a refill procedure and any time a change to the pump’s program is made.
Physician Notification
1. The attending physician is to contact the patient’s pain management physician for consultation regarding any questions or concerns
related to the implantable infusion pump. The attending physician or resident should be notified immediately if the patient develops
problems with pain, side effects or suspected adverse reactions.
2. The attending physician/ or a resident in consultation with the patient’s pain management physician should be notified for:
a.
Inadequate pain relief
b.
Blood pressure drop > (greater than)20%
c.
Respiratory rate < (less than) 10 per minute on adults
d.
Oxygen saturation < (less than) 93%
e.
Side effects unrelieved by prescribed medication
f.
Heart rate drop > (greater than) 25%
g.
Somnolent or difficulty to arouse
h.
Changes in sensory or motor functioning
i.
Any adverse patient outcomes
SynchroMed Infusion System Brief Summary: Product technical manual must be reviewed prior to use for full disclosure.
Indications
Chronic intrathecal or epidural infusion of preservative-free morphine sulfate for chronic, intractable pain of malignant or nonmalignant
origin. Chronic intravascular infusion of floxuridine, doxorubicin, cisplatin, or methotrexate for the treatment of primary or metastatic cancer.
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Contraindications
When infection is present, when the pump cannot be implanted less than 2.5 cm (one inch) from the surface of the skin; when body size is
not sufficient to accept pump bulk and weight; when contraindications exist related to the drug.
Warnings
Use only with approved drugs. Clinically significant or fatal drug overdose may result from improper use such as overpressurization of
the pump reservoir, improper injection of drug through the side catheter access port or into the pump pocket; or failure to account for
significant amounts of drug which may reside in the catheter, side catheter access port, pump tubing, and the reservoir. The effects of
implanting this pump in patients with other implanted programmable devices and the effects of magnetic resonance imaging (MRI) on
implanted pumps are unknown.
Precautions
Only qualified personnel should implant, program, fill and refill the SynchroMed pump or access the side catheter access port. Maintain
strict aseptic technique during all procedures. Consider use of peri- and postoperative antibiotics for pump implantation and any
subsequent surgical procedures. Care must be taken in pediatric population to select an appropriate anatomical pump site. Initial fill and
refill volumes must not exceed levels specified in the technical manuals. Always use a template when accessing the
implanted pump’s center reservoir fill port or side catheter access port. Do not expose the pump to temperatures above 43 degrees C
(110 degrees F) or below 5 degree C (40 degrees F). Do not implant a pump that has been dropped onto a hard surface or shows signs of
damage. Do not steam autoclave or flash autoclave the pump.
Adverse Events
Include but not limited to, cessation/ change in therapy due to battery depletion or component failure; pocket seroma, hematoma, erosion
or infection; complete or partial catheter occlusion, kinking, breakage, leakage or disconnection; catheter dislodgement or migration;
bleeding; arachnoiditis; meningitis; spinal headache; drug toxicity and related side effects; and procedural complications.
Caution: Federal law (U.S.A.) restricts this device to sale by or on the order of a physician.
Signature on File
Effective April 2001
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Signature On File
Carolyn Swinton
Metformin and Metformin Combination Products Policy
(Also known as: IV Iodinated Contrast Administration in
Patients Receiving Metformin)
Initial Policies: April 15, 2009
It is the policy of Palmetto Health Richland to hold metformin and metformin-containing products 48 hours after a
patient is administered intravenous, iodinated contrast.
GUIDANCE:
1. Metformin and metformin combination products should be temporarily withheld in patients undergoing radiological studies involving
intravascular administration of iodinated contrast materials (for example, intravenous pyelogram, intravenous cholangiography, cardiac
catheterization, and computed tomography scans, etc.).
2. Intravascular iodinated contrast studies in patients receiving metformin and metformin combination products can lead to dehydration,
acute alteration of renal function, and have been associated with lactic acidosis.
3. A physician order is required to prescribe or hold medications, and to order diagnostic tests. Orders and guidelines may be utilized as
approved by Palmetto Health.
PROCEDURES:
All patients receiving iodinated contrast should be questioned regarding the use of metformin or metformin combination products prior to
administration of contrast.
1. The requesting physician is responsible for ordering a recent creatinine level for all patients scheduled to receive IV iodinated contrast.
2. If the patient has a creatinine level greater than 2.0 (with the exception of patients on dialysis), the radiologist/performing physician will
be notified and will determine how the procedure is to proceed (i.e., with or without contrast, type of contrast, etc.).
3. The patient should be hydrated per requesting/ordering physician guidelines before and after the procedure if iodinated contrast is
used.
4. Patients seen in the Emergency Department or outpatient areas will have contrast administered at the discretion of the Physician/
Radiologist.
5. For outpatients, discharge instructions will be provided by the department personnel. If intra-arterial or intravenous iodinated contrast
is administered, the patient should be instructed to discontinue metformin or metformin containing medications for 48 hours post
procedure, unless otherwise directed by the physician.
6. Areas/departments administering contrast will communicate to the transferring or receiving unit the administration and type of
contrast used.
7. For inpatients, following iodinated contrast administration, a written physician’s order from Radiology (HOLD Metformin order)
will be sent with the patient to the unit following the study to hold metformin or any metformin containing products for 48 hours
post procedure (should also be communicated in the SBAR conversations from Radiology to the staff nurse on the unit to ensure
metformin is not administered and is held appropriately following these procedures.
8. Follow-up labs will be done at the requesting/ordering physician’s discretion.
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Palmetto Health Richland Medical Staff Policy on Moderate
Sedation
PURPOSE:
To provide a uniform policy which promotes patient safety in the use of sedative/analgesic drugs to facilitate the performance of diagnostic
and/or therapeutic procedures within the PRMH system.
LIMITATIONS:
This policy does not apply to the routine use of sedative/analgesic drugs for Minimal Sedation, acute or chronic pain therapy, perioperative
sedative/analgesic drug therapy, seizure control, or to the administration of sedative/analgesic agents to patients who are intubated
and ventilated mechanically. This policy does not apply to use of chloral hydrate under specific circumstances (see attached statement
regarding chloral hydrate).
DEFINITIONS:
Minimal Sedation (Anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. Although cognitive
function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.
Moderate Sedation (“Conscious Sedation”) is a drug-induced depression of consciousness during which patients respond purposefully**
to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway,
and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
Deep Sedation is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully**
following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require
assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.
General Anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The
ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and
positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular
function. Cardiovascular function may be impaired. This level of sedation should not be the goal of sedation, but undertaken only with
assistance of a qualified anesthesia provider.
**Reflex withdrawal from a painful stimulus is not considered a purposeful response.
Sedation is a continuum, and it is not always possible to predict how an individual patient will respond due to differences in patient
sensitivity to sedative/analgesic medications, concurrent medications, associated medical condition, age, and route of medication
administration. For this reason, administration of sedative/analgesic medications using small incremental doses that are titrated to
effect is preferred. This approach offers the least likelihood of producing unintended deeper levels of sedation. Even in the case of
careful administration, occasionally deeper levels of sedation will occur than that which is intended. Such deeper levels of sedation,
with their associated loss of protective airway reflexes, are virtually identical to general anesthesia for safety purposes. Because of the
safety concerns associated with sedation, all patients receiving sedation to facilitate performance of procedures must be assessed and
monitored during the period of sedation. This requirement applies when sedation is administered in any setting, with exceptions as noted
above.
AUTHORITY FOR POLICY/PROCEDURES ON SEDATION:
Authority for final adoption of this document rests with the Patient Care Committee, the Medical Executive Committee, and PRMH Board.
Credentialed physicians are responsible at all times for the administration of sedation. The Chief and Nurse Manager of each unit or
department using sedation will be responsible for implementation of the policy.
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In order to obtain or reobtain sedation privileges, the physician must:
a) document that he/she has read the PRMH Sedation policy and the paper “Practice guidelines for sedation and analgesia by nonanesthesiologists;”
b) successfully (80%) complete the sedation test. Test results for each physician will be kept in the office of Medical Staff Affairs.
When requested, the Department of Anesthesiology will provide expertise and information to other departments or individuals in the
following areas:
a) appropriate drugs, dosages, and techniques for sedation
b) patient selection criteria, including identification of “at risk” patients for whom the delivery of sedation by non-anesthesia personnel
might be inappropriate. Patients undergoing elective procedures who are classified as ASA PS IV or V are candidates for referral to
the Department of Anesthesiology for evaluation.
c) patient monitoring requirements
The Department of Outcomes shall perform a quarterly audit of each location administering sedation. The audits will be sent to the Nurse
Manager and Medical Director of each location. The results of the audits will be sent to the Chief of the Department of Anesthesiology and
the Patient Care Committee for review.
REPORTING OF ADVERSE EVENTS:
Any of the following events will be documented on an Occurrence Report and sent to the Department of Outcomes:
1. Use of reversal agents
2. Loss of airway or obstruction which requires assisted or controlled mask ventilation
3. Unanticipated hospital admission
4. Unanticipated transfer to increased level of care (ICU)
5. O2 saturation less than 92% for more than 10 minutes
6. Significant dysrhythmia
FASTING REQUIREMENTS:
The NPO status of the patient, prior to the conscious sedation being administered, must be considered in regards to the timing of the
procedure. Except in circumstances in which the procedure is urgent or is an emergency due to medical reasons, the patient must be
NPO for a period of time prior to the administration of conscious sedation. The attached Schedule A offers NPO guidelines.
PERSONNEL AND MONITORING:
In addition to the person (s) performing the procedure, there must be at least one other licensed individual (MD, DMD, PA, or RN) present
to monitor the patient. The monitor shall have no other duties which would compromise his/her ability to monitor the patient. Registered
Respiratory Therapists may also assist in monitoring patients though they may not administer medications. Before beginning sedation,
the patient’s vital signs, weight, allergies, medications, and NPO status must be documented. Before beginning sedation, the person
performing the procedure must document, in accordance with PRMH bylaws where applicable, a history and physical, physical status
assessment, and explanation of risks and benefits.
Monitoring should consist of continuous pulse oximetry, heart rate, ventilatory status (by auscultation or observation), level of
consciousness, and intermittent blood pressure measurement. Each medical department may require additional monitors as indicated for
specific procedures. Vital signs, including oxygen saturation, should be recorded before sedation begins as well a periodically thereafter, at
least as frequently as every five minutes. Oxygen, suction apparatus, ambu bag, reversal-drugs, defibrillator and resuscitation equipment
must be readily available (in the immediate area).
DISCHARGE:
Post-procedure documentation: every 15 minutes.
Inpatients may be transferred to their prior level of care a) by direct order of a physician or b) when achieving a Modified Aldrete score
greater than or equal to 8 or c) when achieving pre-procedure status
Outpatients may be discharged a) by direct order of a physician or b) when achieving an Aldrete II score of greater than or equal to 18 or
c) when achieving pre-procedure status
LOCATIONS:
These guidelines apply to all locations in the hospital where conscious sedation is administered. These areas include:
Endoscopy Suites
Emergency Department
Operating Rooms
Dental Department
Labor & Delivery
Critical Care Units
Radiology Department
Cardiac Catheterization Laboratory
Radiation Oncology
10th Floor TEE/Echo
Pediatric Procedure Room (9th floor)
REVIEW/REVISION OF POLICY:
This policy shall be reviewed and, if necessary, revised at least every three years.
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NPO GUIDELINES FOR CONSCIOUS SEDATION
Gastric emptying may be influenced by many factors, including anxiety, pain, autonomic dysfunction (e.g. diabetes), pregnancy, and
mechanical obstruction. These guidelines do not guarantee that complete gastric emptying has occurred.
Adults
Solids and
Non-Clear liquids
6-8 hours or NPO after
Midnight
Clear
Liquids
2-3 hours
Children 6 months-5 years
4-6 hours
2-3 hours
Infants up to 6 months
4 hours
2 hours
Neonates (less than 1 month)
2-3 hours
2 hours
Non-clear liquids include milk and milk products and formula; the high fat content may delay gastric emptying.
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DRUG RECOMMENDATIONS: ADULT
The most important element in providing safe and effective sedation is careful titration to an appropriate endpoint:
Narcotics
Morphine
sedatives
Initial Dosage
IV: 2-5 mg Dynamic
Onset: 5-10”
Comments
Reduce by ¼ when given with
Titrate in increments
2mg
Duration: 3-4 hours
Meperidine
sedatives
IV: 12.5-25 mg
Onset: 5-10” Reduce by ¼ when given with
Of 25mg.
IM: 50-100 mg
Duration: 1-2 hours
given with sedatives
Fentanyl
sedatives
IV: 50-100 mcg
Onset: 2-3”
Of 25-50 mcg
Duration: 30-60”
Benzodiazapines
Midazolam
Initial Dosage
IV: 1-3 mg
Of 0.5-1.0 mg
Dynamic
Onset: 1-5”
Duration: up to 2 hours
Comments
Elderly and/or debilitated:
use smaller boluses
Diazepam
IV: 2-5 mg
Of 1-2 mg
Onset: 2-5”
Duration: beyond 3 hours
Same for elderly
Reversal Agents
Naloxone
Initial Dosage
IV: 0.2-0.4 mg
Repeat every 2”
Until desired effect
Dynamic
Onset: 1-3”
Duration: 40-60”
May need repeat dose
Comments
May wear off before narcotic;
Agitation due to return of pain;
Flumazenil
IV: 0.2mg over 15s
Onset: 1-3”
Repeat at 1” intervals
Duration: 45”
To a max dose of 1mg
Use with caution in patients with
history of chronic benzodiazepine
use
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DRUG RECOMMENDATIONS: PEDIATRIC
THE MOST IMPORTANT ELEMENT IN PROVIDING SAFE AND EFFECTIVE SEDATION IS CAREFUL TITRATION TO AN APPROPRIATE
ENDPOINT:
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Narcotics
Morphine
sedatives
Initial Dosage
IV: 0.05-0.1 mg/kg
Dynamic
Onset: 3-5”
Comments
Meperidine
sedatives
IV: 1 mg/kg
Onset: 3-10”
Fentanyl
sedatives
IV: 1-2 mcg/kg
Onset: 2-3”
Benzodiazapines
Midazolam
Initial Dosage
IV: 0.05-0.1 mg/kg
Duration: 1-2 hours
PO: 0.5-0.75 mg/kg
(Max dose 20mg)
Dynamic
Onset: 1-5”
PO: erratic absorption
Onset: 20-30”
Comments
Slurred speech good endpoint;
Diazepam
IV: 0.04-0.1 mg/kg
Duration: 2-3 hours
Onset: 5-10”
Same as midazolam
Pain on injection
Duration: 1-2 hours
Duration: 30-60”
Reversal Agents
Initial Dosage
Dynamic
Naloxone
IV: 0.01 mg/kg,
Onset: 3-5”
Up to 1mg IV
Duration: 30-45”
Comments
May cause return of pain;
Need extended monitoring after
reversal
Flumazenil
May induce withdrawal seizures;
Need extended monitoring after
<20kg: 0.01 mg/kg
IV, up to total dose
Of 0.04 mg/kg
Onset: 1-3”
Duration: 45”
reversal
CHLORAL HYDRATE ADMINISTRATION: GUIDELINES
1. Prior to chloral hydrate administration, baseline pulse oximetry, heart rate, and respiratory rate must be documented. Heart
rate, respiratory rate and pulse oximetry should be documented every hour until the patient has returned to baseline level of
consciousness.
2. The chloral hydrate dose must not exceed 50 mg/kg. If the patient requires greater than 50 mg/kg, the PRMH Sedation Policy must
be implemented and followed. Chloral hydrate will not be administered to patients less than three months of age and the maximal
single dose will be one gram.
3. The following equipment is required when transporting patients receiving chloral hydrate:
a.
Size appropriate oral airway
b.
Ambu bag and mask
c.
Oxygen source
d.
Suction catheters
AMERICAN SOCIETY OF ANESTHESIOLOGISTS PHYSICAL STATUS CLASSIFICATION
Class I:
There is no organic, physiological, biochemical or psychiatric disturbance. The pathologic process for which operation is to be
performed is localized and is not a systemic disturbance.
Class II:
Mild to moderate systemic disturbance caused either by the condition to be treated surgically or by other pathophysiological
processes.
Class III:
Severe systemic disturbance or disease from whatever cause, even though it may not be possible to define the degree of
disability with finality.
Class IV:
Indicative of the patient with severe systemic disorder already life threatening, not always correctable by the operative
procedure.
Class V:
The moribund patient who has little chance of survival but is submitted to operation in desperation.
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DISCHARGE CRITERIA: MODIFIED ALDRETE SCORE FOR OUTPATIENT STREET FITNESS
PATIENT SHOULD ACHIEVE A SCORE >18 (OR RETURN TO BASELINE STATUS)
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ACTIVITY:
Able to move four extremities voluntarily on command
Able to move two extremities voluntarily on command Able to move no extremities voluntarily on command 2
1
0
RESPIRATION:
Able to breathe deeply and cough freely
Dyspnea or limited breathing
Apnea
2
1
0
CIRCULATION:
BP >20 of presedation level
BP >21-49 of presedation level
BP >50 of presedation level
2
1
0
CONSCIOUSNESS:
Fully awake
Arousable on calling
Not responding
2
1
0
O2 SATURATION:
Maintains room air saturation >92%
Needs O2 to maintain saturation >90%
Saturation <90% with O2 supplementation
2
1
0
DRESSING: Dry
Wet but stationery
Wet but growing
2
1
0
PAIN: Pain free
Mild pain handled by oral medication
Pain requiring parenteral medication
2
1
0
AMBULATION:
Able to stand and walk straight
Vertigo when erect
Dizziness when supine
2
1
0
ORAL INTAKE:
Able to drink fluids
Nauseated
Nausea and vomiting
2
1
0
URINE OUTPUT:
Has voided
Has not voided but comfortable
Has not voided and uncomfortable
2
1
0
Equipment for Sedation
Emergency resuscitation equipment:
»» Code cart
»» Defibrillator
»» Ambu and Mask
»» Oral and nasal airways
»» Laryngoscope and blades
»» Endotracheal tubes and stylet
»» Supplemental O2 with nasal cannula and/or mask
»» Suction apparatus
»» Pulse oximetry
»» Non-invasive blood pressure/heart rate monitoring
»» Reversal drugs-Narcan and Romazicon
»» Intravenous access
Pre-Procedure Assessment:
1. History, physical, and ASA physical status assessment documented on chart prior to administration of sedation.
2. In the Emergency Department the medical H&P must be performed, but may be documented retrospectively.
3. Patient weight
4. Allergies
5. NPO status. The patient must be NPO for a period of time prior to administering conscious sedation, except in circumstances in
which the procedure is urgent or deemed an emergency by the physician.
6. Documentation of informed consent for conscious sedation.
7. Additional information for outpatients includes: concurrent medications, written discharge instructions, and a hospital number to call
in case of emergency.
8. Pre-sedation vital signs, O2 saturation, blood pressure, and level of consciousness.
Intra-Procedure Monitoring and Documentation:
1. Continuous monitoring of:
»» Heart rate
»» O2 saturation
»» Respiratory rate
»» Level of Consciousness
»» Blood Pressure
2. Documentation of vital signs and level of consciousness should be recorded at least as frequently as every 5 minutes.
3. Other documentation includes:
»» Date, time, name of procedure
»» IV size, location, and amount of IV fluid
»» O2 administration (if applicable)
»» Medication dosage, time and route of administration
Procedure Monitoring: Following completion of the procedure, vital signs, O2 saturation, and level of consciousness will be assessed and
documented at least every 15 minutes.
Discharge Criteria: see Conscious Sedation Policy.
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Multi-Disciplinary Patient and Family Education
Policy No. 1, R-1
March 29, 2002
Palmetto Richland will provide education and support to enhance recovery and will enable patients to be directly
involved in their own care. Financial responsibilities for treatment will be discussed when known.
GUIDANCE:
1. Organization-wide resources will be available for education and patient specific goals will be developed as needed. If these goals are
not met, it will be documented.
2. Education will be provided in a way comprehended by patient (considering language, reading level, skills, knowledge, etc.) and
prioritized.
3. Consideration will be given to special learning needs and/or barriers and cultural and religious practices will be addressed.
4. Patients/families will be informed about all treatment, special nutritional needs, medications and their potential food interactions,
rehabilitation and healthy living strategies, and available facility/community services.
5. Discharge care will include documentation of education instruction and any need for follow-up.
6. Continuous quality improvement processes will evaluate patient outcomes.
7. Documentation of patient/family education will appear on the approved Patient/ Family Education Record and /or in an information
system (i.e. Care Manager). The form will be placed under the IDTP tab in the patient’s chart.
PROCEDURE:
Assigned Caregiver
1. Initially assesses learning needs of patient.
Department Managers
2. Assures that adequate resources are available and that training/
competency is assured for all personnel.
3. Monitors process to evaluate outcomes and make recommendations
for collaboration as necessary.
Departments Delivering Care
Signature on File
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4. Assesses learning needs and sets goals and priorities for patient
needs. Documents when goals are not met and makes necessary
recommendations for improvement.
5. Documents all education and collaboration.
6. Follows-up as necessary.
Signature On File
Carolyn Swinton
Involving Others in a Patient’s Care:
Notifying Next of Kin
October 1, 2001
Policy No. B.10
Revised: August 10, 2004 Section IV, Policy Y
Palmetto Health may use and/or disclose Protected Health Information (PHI) to make communications regarding
the patient when it is appropriate. PHI may be used and/or disclosed to notify family members or others of the
patient’s condition or location, or to notify a patient’s family member or others involved in the patient’s care in order
to ensure quality patient care is provided. Whenever possible, Palmetto Health will provide the patient with the
opportunity to agree or object to such uses/disclosures. However, professional judgment will be used when the
opportunity to agree or object can not be provided and the use or disclosure is in the best interest of the patient.
GUIDANCE:
Disclosures to family member(s), other relative(s), close personal friend(s) and/or others identified by the patient:
1. Palmetto Health may disclose PHI to person(s) identified by the patient when the PHI disclosed is directly relevant to an individual’s
involvement with the patient’s care or payment related to the patient’s care
2. Palmetto Health may use or disclose a patient’s PHI to notify or assist in the notification of persons responsible for the care of the
patient, including identifying or locating such person(s); the purpose of the use/disclosure must be to inform them of the patient’s
location, general condition, or death.
2.1 When the patient is present, Palmetto Health must do one of the following prior to using or disclosing PHI as described above:
2.1.1 Obtain the patient’s agreement to the use or disclosure;
2.1.2 Provide the patient with the opportunity to object to the disclosure, and ascertain there is no objection;
2.1.3 Reasonably infer from the circumstances , based upon professional judgment, the patient does not object to the
disclosure.
2.2 In the event the patient is not present, Palmetto Health may use professional judgment to determine whether the disclosure
is in the patient’s best interest and, if so, disclose only the PHI directly relevant to the person’s involvement with the patient’s
health care.
2.3 If necessary, given the condition of the patient or critical circumstances involved, Palmetto Health may reasonably infer from
the circumstances, based on the exercise of professional judgment, that:
2.3.1 The patient does not object to the disclosure of PHI relevant to the patient’s care to the patient’s family member, friend,
or any other person identified by the patient.
2.3.2 PHI relevant to the patient’s care may be disclosed to notify, or assist in the notification of a family member, a personal
representative of the individual, or another person responsible for the care of the individual, of the individual’s location,
condition or death.
2.4 Whenever possible, the attending physician or designated associate shall notify the individual identified for contact by the
patient.
2.4.1 If the attending physician or designated associate is unable to notify the identified individual, he/she may authorize the
nurse in charge to do so.
2.4.2 If identified individual cannot be contacted within a reasonable length of time, the nurse in charge will notify the
appropriate Director of Nursing or designee who will continue to attempt notification. All efforts to notify shall be
documented in the patient’s Medical Record.
3. Palmetto Health may seek information from patients upon admission regarding the identity of those family member(s), friend(s) or any
other person(s) to be notified with information pertaining to the patient’s care.
4. Palmetto Health may use professional judgment and their experience with common practice to make reasonable inferences of a
patient’s best interest in allowing a person to act on behalf of the patient to pick up filled prescriptions, medical supplies, X-rays, or
other similar forms of protected health information.
5. Palmetto Health will exercise professional judgment in determining whether disclosing PHI, even if the patient is present, will interfere
with the ability to respond to the emergency circumstances.
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REFERENCE:
HIPAA Federal Regulations 45 C.F.R. §164.510(b)
Signature on File
Effective September 30, 2004
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Occurrence Reporting and Follow-Up
Administration
Revised:
Revised: October 1, 2001
September 30, 2004
July 16, 2007
Policy No. B.11
Palmetto Health (PH) requires the prompt reporting and investigation of occurrences and the remedy of actual
and potential risks and liabilities. The information accumulated from occurrence reports shall be incorporated into
the hospital performance improvement program, as appropriate. The Occurrence Report is the property of the
Hospital Attorney. The information contained in the report and the circumstances surrounding the occurrence are
confidential and shall be treated as privileged communications to the Hospital Attorney. The Occurrence Report
shall not be filed in the patient’s medical record. The Occurrence Report shall not be copied or duplicated.
DEFINITIONS:
1. Occurrence: Any incident, accident, event or omission which results in either actual or potential injury or harm to the patient, visitor or
member of the public (including students, volunteers, private duty nurses and attending physicians).
1.1 Medical/Healthcare Error: failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim.
1.2 Near Miss: Any process variation which did not affect the outcome, but for which a recurrence carries a significant chance of a
serious adverse outcome.
GUIDANCE:
1. Completion of the Occurrence Report Form
1.1 The individual first made aware of the occurrence or near miss event shall take responsibility for completing the Occurrence
Report Form in conjunction with the Department Director or his/her Designee.
1.2 The form must be completed to include a brief description of the event, and notification of the physician, as appropriate.
1.3 All follow-up activities performed by the department involved must be noted on the form before the form is sent to Risk
Management and Safety.
2. Notification of Physician
2.1 The Attending or Resident Physician should be contacted immediately when an incident occurs which results or may result in
patient injury or change in condition.
3. Review and Investigation of Occurrence
3.1 The Department Director or his/her Designee reviews and signs the Occurrence Report and forwards the completed form to
Risk Management or Safety Department in a timely manner.
3.2 If the occurrence is deemed to be of a serious nature, the Department Director notifies appropriate Vice President, Risk
Manager as soon as possible. The Vice President notifies the Chief Operating Officer as soon as appropriate. The Risk
Manager notifies the Hospital Attorney. On weekends and after normal business hours, the Nursing Supervisor-on-Duty and
Director-on-Call or Director-on-Duty and Administrator-on-Call are notified as soon as possible. All items and/or equipment
involved in the occurrence are secured and the involved department starts investigation of the event as soon as possible.
The findings of the investigation are reviewed in peer review committees, as appropriate, for purposes of performance
improvement. Correction of any identified systems problems will be performed at the earliest possible time.
3.3 The Risk Manager reviews the occurrence reports and informs the Hospital Attorney and the hospital liability insurer if
indicated.
4. Data Management
4.1 Occurrence reports are trended for purposes of integration into performance improvement programs, as appropriate.
5. Report to Hospital Committees
5.1 A summary of occurrences is reported to appropriate hospital committees and additional performance improvement actions
may be recommended.
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6. Treatment in the Emergency Department
6.1 A completed Occurrence Report form should accompany all non-employees and patients presenting to the Emergency
Department for examination and treatment of an injury allegedly sustained on hospital premises.
6.2 If a non-employee refuses to be examined and/or treated by the Emergency Department personnel, this should be
documented on the Occurrence Report form.
6.3 A copy of the Emergency Department record will be attached to the completed Occurrence Report form and sent to the Risk
Manager or Safety Director.
6.4 After review of the report, the Risk Manager may make an adjustment of the Emergency Department fees if indicated.
Signature on File
256
Organ and Tissue Donation
October 1, 2001
Policy No. B.12
Revised: August 10, 2004 Section IV, Policy GG
Revised: January 27, 2005
Palmetto Health (PH) hospitals believe families or guardians of patients meeting acceptable medical criteria should
be presented with the option of organ/tissue/eye donation in a manner which best promotes informed consent,
while facilitating the procurement of organs/tissues/eyes for transplantation and/or research. Discretion and
sensitivity to the circumstances, beliefs and desires of the family will be used in all contacts with family members or
guardians.
GUIDANCE:
1. Patients at the time of cardio-pulmonary death (potential donor) or for whom brain death is imminent (potential donor) will be
assessed for acceptability of organ/tissue/eye donation in accordance with Federal Law 42 CFR part 482 and South Carolina state
law, Title 44, Chapter 43, Article 11. See also PH Pronunciation and Certification of Death Policy.
1.1 Imminent brain death is generally defined as Glasgow Coma Score of 4.
1.2 The attending physician shall determine that the criteria for brain death (defined in Palmetto Health Pronunciation and
Certification of Death Policy) have been met and shall note this in the patient’s medical record.
1.3 The time of death is the time at which the diagnosis of brain death is made (having fulfilled the criteria), not the time at which
artificial respiration and blood pressure maintenance are discontinued.
1.4 The physician determining brain death shall not participate in removing or transplanting organs or tissues.
2. Once a potential donor is identified, a referral shall be made immediately by telephone to the Lifepoint. Members of Lifepoint will
perform an assessment for acceptability of organ/tissue/eye donation.
2.1 Lifepoint is a collaborative effort of the three procurement agencies in South Carolina: the S.C. Organ Procurement Agency,
Inc. (SCOPA); the American Red Cross Southeastern Tissue Services (ARCSTS); and the S.C. Lions Eye Bank, Inc. (SCLEB).
2.2 If Lifepoint determines that donation is not appropriate based on established medical criteria, this determination will be noted
by hospital personnel in the patient’s medical record. Within 2 hours of this determination or within two hours of a patient’s
death and the deceased patient’s next of kin designating a funeral director, the hospital shall notify the funeral director of this
designation and when the body of the deceased will be made available to the funeral director. (Article 11, Chapter 43, Title 44
of the 1976 Code, Section 44-43-945(A))
3. If Lifepoint determines the patient is a suitable candidate for organ/tissue/eye donation, a representative of Lifepoint will contact the
appropriate person authorized to consent to the donation. Consent is still required in the event the patient has a Uniform Donor Card.
The order of precedence for next of kin (SC 44-43-330) is:
3.1 a court-appointed guardian, if health care decisions are within the scope of the guardianship;
3.2 An attorney-in-fact appointed by the patient in a Durable Power of Attorney, if health care decisions are within the scope of his/
her authority;
3.3 A person given priority to make health care decisions for the patient by another statutory provision;
3.4 A spouse* of the patient, unless the spouse and the patient are separated pursuant to one of the following:
3.4.1 Entry of a pendente lite (temporary) order in a divorce or separate maintenance action
3.4.2 Formal signing of a written property or marital settlement agreement; or
3.4.3 Entry of a permanent order of separate maintenance and support or of a permanent order approving a property or
marital settlement agreement between the parties;
3.5 A parent or adult son or daughter of the patient;
3.6 An adult brother, sister, grandparent, or adult grandchild of the patient;
3.7 Any other relative by blood or marriage who reasonably is believed by the health care professional to have a close personal
relationship with the patient;
3.8 A person given authority to make health care decisions for the patient by another statutory provision. (See S.C. Code Ann.,
Section 44-66-30)
3.9 Consent may be given by a person listed in the order of priority above if no person having higher priority is available
immediately and if the physician determines that the delay occasioned by attempting to locate a person having higher priority
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presents substantial risk of death, serious permanent disfigurement, loss or impairment of the functioning of a bodily member
or organ, or other serious threat to the health of the patient.
*Common law spouse will be considered on a case by case basis by Lifepoint.
4. Once permission is obtained for the organ/tissue/eye donation, Lifepoint personnel will coordinate all activities concerning the
donation.
5. The following will be documented in the patient’s medical record: (SC 44-43-1000)
5.1 Why a family is not contacted to request organ/tissue/eye donation
5.2 When a family is contacted to request organ/tissue/eye donation
5.3 Disposition of a referral to Lifepoint including acceptance or rejection by the agency
5.4 “Certificate of Request for Organ/Tissue/Eye Donation”
6. In coroner’s cases (See PH Coroner’s Cases Policy) written or verbal permission must be obtained prior to organ/tissue/eye recovery.
The Coroner’s office will be notified of pending donations.
7. Palmetto Health may use or disclose protected health information to organ procurement organization or other entities in the
procurement, banking or transplantation of cadaveric organs, eyes or tissue for the purpose of facilitating organ, eye or tissue
donation and transplantation. Palmetto Health may use or disclose protected health information for such purposes without obtaining
the patient’s authorization or providing the patient with the opportunity to agree or object in accordance with 45 C.F.R. 164.512(h).
Signature on File
258
Pain Management
P- 17, R-3
September 2009
PHR staff ensures optimal patient comfort through a proactive plan to manage pain which is mutually established
with the patient / family members and with members of the health care team.
1. Evaluation
1.1 All patients will be evaluated for the presence or absence of pain on admission, at least once a shift, after pharmacologic and
nonpharmacologic pain intervention and at discharge.
1.2 Use age and cognitively appropriate pain scale which makes sense to the patient.
1.3 Use the same scale every time with the same patient. Only change scales when the patient’s cognitive ability changes.
1.4 When pain is identified, a more comprehensive pain evaluation is performed and includes:
1.4.1 a detailed pain history including an evaluation of the intensity, quality, location, duration and character;
1.4.2 physical examination emphasizing the neurologic examination;
1.4.3 psychosocial evaluation.
1.5 Using the pain scale with initial evaluation, the patient will be encouraged to identify the pain level that is acceptable to perform
activities of daily living etc.
1.6 When the patient is unable to provide a self-report of the presence of pain, the following evaluation strategies will be used:
1.6.1 consider report from family members or others who are close to the patient;
1.6.2 assess behaviors (i.e. facial expressions, body movements, crying, etc;
1.6.3 consider physiological measures (i.e. heart rate, blood pressure, etc.);
1.6.4 consider developmental and cognitive factors.
2. Re-evaluation
2.1 Re-evaluation includes:
2.1.1 The effectiveness of nonpharmacologic and/or pharmacologic interventions within one hour after each intervention.
2.1.2 Notification to physician if pharmacological or non-pharmacological interventions fail to reduce pain to comfort level
acceptable to the patient.
3. Pain Management Approach
3.1
Believe and accept the patients and families in their reports of pain and relief measures.
3.2 Choose appropriate pain control options, for the patient, family, and setting. Non-pharmacologic interventions (i.e. positioning,
warm/cold compresses, massage, immobilization, etc.) should be considered prior to using pharmacological interventions as
appropriate. Specialized analgesic technologies may be untilized for pain management as appropriate (i.e. PCA, intrathecal, IV,
etc.); refer to the specific policies/procedures.
3.3 Pain interventions should be delivered in a timely, logical, and coordinated manner to ensure optimum pain control.
3.4 Empower patients and their families. Allow choices whenever possible. Enable them to control their course to the greatest
extent possible.
4. Documentation of pain scale, interventions and reevaluation
4.1 Documentation in the medical record will be ongoing.
4.2 The initial pain evaluation will be documented on the admission history database form.
4.3 Re-evaluation, interventions, and responses to interventions will be documented on the following tools as directed in the unit
documentation standards:
•
Nurses notes
•
Flowsheet (paper or computer)
•
Other hospital approved forms/documents
*ALL elements of required documentation must be utilized on the document tool.
4.4 The discharge pain evaluation is documented on the discharge section of the admission history database form.
4.5 Activate Pain Outcome(s) as appropriate.
5. Patient/Family education
5.1 All patients and families have the right to participate in the pain management plan and have
appropriate pain control.
5.2 Instructions to patients and families will include:
5.2.1 How to report pain/discomfort using a pain scale
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5.2.2 The importance of reporting pain promptly
5.2.3 The function, use, and philosophy of pain control pumps, if in use
5.2.4 Splinting, turning, deep breathing, and coughing techniques
5.2.5 Pharmacologic and non-pharmacologic methods available to relieve pain
5.2.6 The need to notify staff for unrelieved pain or side effects
5.2.7 After discharge, when to seek medical attention if pain persists or returns 5.3 Patient teaching tools and aids will be used
wherever available
5.3.1 Visual aids
5.3.1 Department specific teaching aids
6. Staff Education
6.1 All new clinical staff will receive pain education during orientation
6.2 Cultural and age specific considerations of pain management will be incorporated into hospital wide and department specific
staff eduction.
6.3 Staff education will be ongoing. SUPPORTIVE LIT ERATURE:
1. Pain: A complex, subjective response characterized by several quantifiable features, including intensity, time, course, quality, impact
and personal meaning. (AHCPR, 1992a). Pain can be influenced by a number of factors including, but not limited to age, medical
condition, environment, emotional and cognitive state and cultural and spiritual beliefs.
1.1
Acute Pain Attributes
1.1.1. Immediate biological response to inflammatory process, tissue injury, or surgical intervention
1.1.2 Temporary, reversible and usually lasts up to a few days
1.1.3 Protective mechanism
1.1.4 Focuses attention on site
1.1.5 Necessary for survival (alerts to painful stimuli and tissue damage)
1.1.6 Usually has an identifiable cause
1.1.7 If caused by injury, diminishes as healing occurs
1.1.8 Usually describes in terms of sensory qualities
1.2 Chronic Pain Attributes
1.2.1 Persists over time (3-6 months or more)
1.2.2 Persists after the precipitating damage has healed
1.2.3 May cause dysfunction, exhaustion and debilitation
1.2.4 May have organic lesions
1.2.5 Usually has an identifiable cause
1.2.6 Not usually associated with healing
1.2.7 May reoccur over time
2. Pain Management: The alleviation of pain or reduction in pain to a level of comfort that is acceptable to the patient (McClosky and
Bulecheck, 1996).
AGE / GENDER / CULTURAL CONSIDERATION:
3. Age, gender, culture and other factors will be identified and considered when assessing pain, choosing an appropriate pain scale and
managing pain. The pain scale functions as a tool and must be appropriate for the patient’s developmental, physical, emotional and
cognitive status.
3.1 Age Considerations
3.1.1 Neonates/Infants (birth to 1 year)
3.1.1.1 A proactive plan to manage pain is mutually established with the parent (s) when applicable and members of
the health care team.
3.1.1.2 Infants and neonates, pain must be inferred through observation of physiological (i.e. heart rate, blood pressure,
respiration, etc) and behavioral (i.e. facial expressions, body movements, crying, etc.) responses.
3.1.1.3 Neonates and infants have an increased sensitivity to acoustic, visual, tactile, and or vestibular agents. Reduce
exposure to noxious stimuli.
3.1.2 Pediatrics (incorporates neonates to adolescents)
3.1.2.1 A proactive plan to manage pain is mutually established with the child if appropriate, the parent (s) and
members of the health care team.
3.1.2.1 Incorporate the developmental as well as the physiological stage of the child when assessing the pediatric
population for pain.
3.1.2.2 Pain may be inferred through observation of physiological and behavioral responses
3.1.3 Adults (incorporates young adulthood to middle adulthood)
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3.2
3.3
3.4
3.1.3.1 Self-report of pain is the single, most reliable indicator in the adult population.
3.1.3.2 For those adults who may not be able to report verbally, pain may be inferred through observation of
physiological and behavioral responses.
3.1.4 Elderly (late adulthood)
3.1.4.1 Pain evaluation presents unique problems due to physiologic, psychological, and cultural changes associated
with aging.
3.1.4.2 Body size decreases with age, which decreases the volume of distribution of the drug. Therefore, drug
dosage calculations are important.
3.1.4.3 The elderly are at greater risk for drug-drug and drug-disease interactions due to multiple chronic, painful
illnesses and multiple medications.
Gender Considerations
3.2.1 Gender differences may exist in pain tolerance, pain sensitivity, pain threshold, and
responsiveness to analgesics.
3.2.2 Assessing pain from an individual subjective perspective remains the most accurate measure
of pain intensity.
Culture Considerations
3.3.1 Take culture into account in pain evaluation and management. This includes cultural
beliefs/values, pain expressions, pain language, cultural context of suffering, traditional
healers and remedies, and social roles/expectations.
3.3.2 Recognize difference between translation and interpretation.
Other Factors
3.4.1 Patients who are on a neuromuscular blocking agent can still feel pain. Analgesics should be
administered through routine, (not PRN) orders for any procedures, injury, or disease that
cause pain since these patients are unable to communicate their pain through self-report and
behavioral indicators may be masked.
Signature on File
Carolyn Swinton
Chief Nursing Officer and Vice President, Patient Care Administration, Palmetto Health Richland
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Patient Care Orders
Patient Care
Policy No. 8
October 1, 1976
Revised Date: July 2006
Non-routine patient care will be administered only as ordered by the member of the Medical and Dental Staff responsible
for the patient.
GUIDANCE:
1. Orders may be written orders, telephone orders or standing orders.
2. Telephone Orders:
2.1 Of all types may be accepted by an RN or LPN. Orders for respiratory care may be accepted by a respiratory therapist. A
registered pharmacist may accept orders for pharmacy services.
2.2 Will be signed, dated and timed by the person receiving the order and designated as telephone orders (i.e., T.O. Dr. Jones/S. Smith,
RN)
3. When a physician is physically present, verbal orders should be taken only in emergency situations. Verbal orders will be signed,
dated and timed by the person receiving the orders and designated as verbal orders (i.e., V.O. Dr. Jones/S. Smith, RN)
4. Verbal and telephone orders in the following diagnostic and therapeutic categories are to be countersigned by the physician or dentist
within 48 hours:
4.1 administration of blood products
4.2 admission and discharge of patient
4.3 anticoagulant/thrombolytic therapy
4.4 consultation by another physician
4.5 contrast enhance radiology study/invasive procedures
4.6 DNR
4.7 initiation/change in intravenous vasoactive drugs
4.8 intubation/extubation
4.9 schedule II or greater drugs
4.10 transfer of patient to another unit
4.11 ventilator change/paralytic agents.
NOTE:Special requirements associated with restraint orders are addressed in the restraint policy.
5. Standing Orders:
5.1 Must be printed on PRMH physician’s order sheets and have a revision date within the previous 12 months to be valid.
5.2 Are to be reviewed by the Pharmacy Department prior to printing if orders contain drug therapy.
5.3 Are to have no dosages listed for controlled drugs.
5.4 Must be authenticated on the next visit and in any case within 48 hours by the physician or dentist.
6. Orders by medical students are to be countersigned by the attending physician before the orders may be carried out. Telephone
contact with the physician may constitute verification and should be documented as a telephone order.
7. Verbal, telephone or standing orders must be signed, dated and timed by the individual receiving the order. Orders requiring physician
signature will be flagged with a “Please sign, date, and time” sticker. Stickers are to be added at the time the order is transcribed or
during the 24 hour chart checks, if signatures are required. If physician signature/date/time is received, stickers are to be removed
during the 24 hour chart check, if not beforehand.
8. After a verbal or telephone order has been given, the individual receiving the order is to read back the order to the physician to verify
the correct order and is required to write the acronym “V.O.R.B” to verify Verbal Order Read Back.
9. Personnel who carry out physician or dentist orders have the responsibility to verify and/or question for clarification any order that
is not thoroughly understood or is questionable. Such orders are not to be carried out until rewritten or understood by patient care
personnel.
10. Pharmacists will review patients medication profiles every seven (7) days through day twenty-eight (28) and then periodically
thereafter. The pharmacist will consult with the physician or dentist about medication profiles as needed.
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11. The use of “renew”, “repeat”, or “continue orders” is not acceptable.
12. When a responsible practitioner orders that a patient is to receive “nothing by mouth” (NPO), no oral diet, fluids or medications are to
be administered until an order to the contrary is received.
12.1 Oral medications with a small amount of fluid are to be administered if the order is written “NPO except medications”.
13. All preoperative orders will be cancelled after surgery unless otherwise specified by the physician or dentist.
14. Orders are to be rewritten or dictated when patients are transferred from intensive care units.
PROCEDURE:
Responsible Practitioner
1. Write clear, legible, and complete orders which comply with above rules.
2. Sign, date and time all orders when written; countersign, date and
time all telephone orders and standing orders within policy time limit.
Countersign all orders by medical students and authorized allied
health professionals.
Authorized Patient Care Personnel
3. Verify and/or question for clarification any order that is not thoroughly
understood or is questionable.
4. Carry out orders which comply with above rules.
5. Flag order at the time it is transcribed or during the 24 hour chart
check with a “Please sign, date and time” sticker, if needed. When
physician signature, date and time has been executed on chart,
remove sticker.
Pharmacist
6. Monitor medication profiles at specified intervals and consult with
physician/dentist as needed.
Signature on File
Signature On File
Carolyn Swinton
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Patient Concern/Grievance Management
Initial Date of Policy: October 2, 2002
Revised Date: September 2006
Palmetto Health Richland is committed to actively seeking, listening to and responding to the needs, concerns
and complaints of our patients and their families. It is the policy of this organization to encourage patients and
their family members to express their concerns, complaints and suggestions regarding the service they receive;
to provide multiple channels through which a patient may seek resolution to complaints; and, to monitor patterns
of complaints in order to identify opportunities to enhance patient care and service. Presentation of a complaint/
grievance by a patient or a patient’s family will in no way, compromise the patient’s future access to care.
DEFINITIONS:
Concern: A concern is a verbal expression of dissatisfaction with any aspect of care, service or outcome; these are not considered
grievances. A concern deals with an issue(s) that can be immediately addressed and resolved by the clinician(s) or staff present upon
receipt of the concern in a manner that meets with the satisfaction of the person expressing the concern.
Grievance: A patient grievance is a formal written or verbal complaint (when the verbal complaint about patient care is not resolved at
the time of the complaint by staff present) that is filed with the Patient Relations Department by a patient or their representative. When
the patient contacts Patient Relations before they notify the involved department/staff it will be handled as a concern initially and then as
a grievance if the patient is not satisfied with the outcome. In addition, grievances may also be any complaints involving JCAHO sentinel
and/or DHEC reportable events and/or complaints that a manager, director, and/or physician believes should be taken to the level of
grievance. The patient should have reasonable expectations of care and services and the facility should address those expectations in a
timely, reasonable and consistent manner. (CMS Interpretive Guidelines for Hospital COP for Patient’s Rights, April 2004.)
A written complaint is always a grievance. A grievance requires a written response to the patient or their representative in accordance with
this policy. The hospital shall have a Patient Grievance Committee, which shall have the authority and responsibility to review and resolve
all patient grievances.
GUIDANCE:
1. Notification to patients and others of this policy will be by the following:
1.1 A patient brochure is distributed to each inpatient. Within this brochure are instructions for filing a complaint to the customer
service line or organization. Patients are also informed through the Patient’s Bill of Rights/patient brochure as to their right to
contact a state agency and/or Joint Commission to file a grievance.
1.2 An information sticker is posted on each patient phone advising patients and family members that they can call the Customer
Service Line 24 hours per day if they have questions, concerns, complaints or suggestions. Grievances can also be expressed
through letters, emails, Palmetto Health website, physician order, presentation to the Patient Relations Department, directly to
the caregiver, patient rounds by patient liaison, and patient satisfaction surveys.
1.3 Information about a patient’s right to present a complaint/grievance and how to do so is posted at all patient registration areas.
2. Complaint Intervention/Investigation/Response will occur as follows:
2.1 Patients who express concerns to those directly involved in their care or to those individuals involved in the particular situation
will have their concerns reviewed by those directly involved. If the patient is not satisfied with the resolution, see # 3.
2.2 Complaints involving potential monetary claims, litigation or which in any way involve quality of medical treatment will be
reported to the Risk Manager and Patient Relations.
2.3 Complaints regarding alleged lost belongings (as opposed to valuables) will be referred to Patient Relations for investigation
and follow-up. Reimbursement for the lost/damaged belongings will be made based upon the recommendation and approval
of the director; payment will be made through the Risk Management budget. Refer to the Palmetto Health Richland Valuables/
Belongings policy .
2.4 Complaints regarding physicians will be reported to the physician involved. The concern will be forwarded to the Vice
President of Medical Affairs and the Chief of Staff. Resident physician concern forms will be sent to the Residency Program
Director as well as the Vice President for Medical Education for follow-up.
2.5 Serious allegation of employee misconduct will be investigated and resolved in accordance with Palmetto Health Corporate
Human Resources Policy – Disciplinary Action (045) by the appropriate Vice President and others as appropriate.
2.6 Patient grievances will be investigated and documented within an average of 7 days of receipt.
2.7 Any allegations of HIPAA (breach of patient confidentiality or inappropriate disclosure of protected health information) violations
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will be considered a formal patient grievance. Refer to #3 of this policy as well as Corporate Compliance HIPAA policy “Privacy
Complaints.” The patient is informed of the process of filing a HIPAA concern through the “Palmetto Health Joint Notice of
Privacy Practices” given to the patient upon admission.
3. Grievance Documentation and Reporting will occur as follows:
3.1 Once a concern has become a grievance and is received by the Patient Relations Department, the Patient Representative
shall acknowledge receipt of the grievance upon receipt. The acknowledgement may be by personal visit, telephone call,
electronic mail or letter. All information pertinent to the grievance shall be documented in the grievance management system.
3.2 The Patient Representative shall facilitate the investigation of the grievance. Grievances regarding patient care or hospital
services will be investigated by the appropriate director or designee of that area. The director or designee will be responsible
for performing chart review if appropriate and investigate the grievance. Those investigating the grievance will then send basic
resolution of the grievance to Patient Relations. The Patient Representative is to follow up in writing to the patient or patient’s
representative. The written correspondence must include (1) the name of the hospital contact person, (2) the steps taken on
behalf of the patient to investigate the grievance, (3) the results of the grievance process and (4) the date of completion.
3.3 After business hours and on weekends, grievances will be referred to the administrator on duty who will forward the grievance
to Patient Relations for documentation and/or follow-up.
3.4 The grievance will be investigated and a written response letter provided to the patient or patient’s representative within an
average of 7 days. However, if the investigation is not completed within 7 days, the patient or representative will be informed in
writing that the investigation is ongoing and will be completed as soon as possible but no later than 3 weeks from the receipt
of the grievance. Any grievance that reflects unsafe or endangering conditions to the patient will be addressed immediately by
the department(s) involved.
3.5 The hospital Patient Grievance Review Committee shall have authority over the resolution of all grievances including written
responses. Departments will be responsible for trending grievances and taking actions as appropriate towards continuous
quality improvement. Systemic problems indicated by the grievance will also be addressed at the department level.
PROCEDURE:
Employee
1. Actively seeks, listens to and responds to the needs, concerns and
complaints/grievances of patients and family members and resolves
problem if no intervention is required by other parties.
2. Refers unresolved complaints to Manager/Administrator involved.
Department Director/Manager 3. Actively seeks, listens to and responds to the needs, concerns and
complaints of patient or family, ensures that patients and/or family
receive an appropriate and timely response regarding significant
complaint. Recognizes that follow-up is most appropriately
directed to the patient whenever possible, and not necessarily the
complainant. Encourages patients to file grievances with the Patient
Relations Department if concerns are not resolved at the bedside.
Performs investigation and chart review as appropriate.
Patient Relations
4. Actively seeks, listens to and responds to the needs, concerns
and grievances of patient or patient’s representative. Documents
and forwards all patient grievances to the appropriate parties listed
above and serves as a central repository for all patient grievances.
Responds to grievances in writing to the patient or patient’s
representative in the above mentioned time frame.
Risk Manager
5. Reviews complaints/grievances as referred or as appropriate.
6. Recommends intervention as needed.
Vice President of Medical Affairs
7. Trends grievances concerning Physicians and refers to Department
Chief or Chief of Staff as appropriate.
Signature on File
Effective June 2006
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Patient Identification
Patient Care
October 2006
At least two patient identifiers (neither to be the patient’s room number or location) will be used whenever
administering medications or blood products, taking blood samples and other specimens for clinical testing, or
providing any other treatments or procedures.
GUIDANCE:
1. Patient Care Areas that Use Armbands:
a.
Full name and date of birth will be used as the two identifiers.
b.
Full name and date of birth on the armband are matched to a second source, such as the medical record, MAR, lab label,
physicians order, or referral.
c.
In the event that a patient does not have an armband in place prior to the situations requiring patient identification, accurate
identification must be made and an armband must be placed on the patient.
d.
The patient’s armband must be on the patient’s wrist or ankle. If the armband is found on the IV pole, bed, or other object,
accurate identification must be made and an armband must be placed on the patient’s wrist or ankle.
2. Patient Care and Testing Areas that Do Not Use Armbands:
a.
Full name and date of birth will be used as the two identifiers
b.
Full name and date of birth will be stated verbally by the patient or representative and compared to the name and date of birth
on the medical record, MAR, physicians order, or referral. If the patient or representative cannot state the patient’s name and
date of birth, the staff member will make every effort to verify patient identification using driver’s license, insurance card, or
other written document. Employee will not state the name and / or DOB and prompt the patient to confirm the information.
Signature on File
Stan Hickson
Executive Vice President and Chief Operating Officer,
Effective September 2006
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Signature On File
Carolyn Swinton
Patient Responsibilities
Administration
October 1, 2001
Policy No. E.05
Palmetto Health (PH) considers the patient to be an integral member of the health care team with specific
responsibilities regarding their ongoing health care needs. PH has the right to expect certain reasonable and
responsible behaviors from patients, their family members, and/or designated representatives and visitors.
Whenever possible, the patient will be informed of their responsibilities in advance of furnishing or discontinuing
care.
GUIDANCE:
1. Patients and/or their legal representative have the responsibility to provide complete medical information, including current symptoms,
past illnesses, hospital stays, use of medicines, and other health matters as related to present complaints.
2. Patients and/or their legal representative are responsible for providing feedback to health care providers regarding perceived risks of
treatment, changes in condition, and other concerns pertaining to care planning.
3. Patients have the responsibility to acknowledge understanding of the planned course of treatment, ask questions when they do not
understand information and/or instructions, and to inform physicians when they are unable to follow prescribed treatment.
4. Patients and family are responsible for adhering to prescribed care and are responsible for the outcome if they elect not to follow such
instructions.
5. Patients have the responsibility to keep appointments or inform the physician or hospital in advance of other arrangements.
6. Patients are responsible for being considerate and respectful of the rights of others and for abiding by Hospital Policies and
Procedures regarding patient care, conduct and visitation.
7. Patients are responsible for being considerate of the hospital’s personnel and property.
8. Patients or their legal representatives are responsible for providing information regarding insurance and for promptly meeting financial
obligations incurred during the course of treatment.
Signature on File
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Patients’ Bill of Rights
Administration
October 1, 2001
Revised: September 30, 2004; July 16, 2007 Policy No. E.04
Palmetto Health recognizes and supports the rights of patients and their families/designated representatives. PH
hospitals, physicians, and all other health care professionals are committed to promoting and protecting these
rights. Whenever possible, the patient will be informed of their rights in advance of furnishing or discontinuing care.
GUIDANCE:
1. Individuals will be afforded access to treatment as available and medically indicated regardless of age, sex, race, physical or mental
disability, creed, national origin, or source of payment.
2. Patients have the right to respectful, considerate care with preservation of personal dignity and consideration of psychosocial and
spiritual concerns.
3. Patients have the right to have hospital staff promptly notify a family member/representative and their physician of an admission to the
hospital.
4. Patients have the right to wear appropriate personal clothing and religious or other symbolic items, as long as they do not interfere
with diagnostic procedures or treatment.
5. Patients have the right to participate in and make decisions regarding their care as indicated by the following rights:
5.1 To receive information necessary to give informed consent prior to treatment or procedure(s).
5.2 To be involved in care planning and treatment.
5.3 To obtain complete and timely information concerning the nature of their illness, possible treatment(s), likely outcome, and to
discuss this with their doctor.
5.4 To Be informed about the outcomes of care including unanticipated outcomes
5.5 When unable to give information to the patient, as in the case of a child or incompetent adult, the information should be made
available to the patient’s legal representative. Refer to PH Informed Consent Policy.
6. Patients have the right to know the identity, professional status, and role of those persons providing health care. This includes which
physician is primarily responsible for the patient’s care and if the care giver is a student or trainee or is professionally associated with
other individuals or health care institutions involved in the patient’s care.
7. Patients have the right to expect the health care facility to reasonably respond to requests for appropriate and medically indicated
care and services, within capacity and policies.
8. Patients have the right to expect the health care facility to provide care that optimizes comfort and dignity, regardless of the patient’s
condition, including assessment and management of pain, and regard for psychosocial and spiritual concerns.
9. Within the law, patients have the right to privacy and protection of confidentiality as indicated by the following rights:
9.1 To refuse to talk with or see anyone not directly involved in his or her care.
9.2 To expect that any discussion or consultation involving their care will be conducted discreetly.
9.3 To be cared for in areas assuring reasonable visual and auditory privacy
9.4 To have a person of one’s own sex present during certain parts of a physical examination, treatment or procedure performed
by a health professional of the opposite sex.
10. Patients have the right to confidentiality of information in their medical record, except in cases such as suspected abuse or public
health hazards and/or when reporting is permitted or required by law. Access will be limited to those persons with a “need to know”,
i.e. persons providing patient care and persons involved in financial matters.
11. Patients have the right to access information contained in their medical records within a reasonable time frame and to have the
information explained or interpreted as necessary, except when restricted by law or hospital policy and/or as long as it does not
interfere with treatment.
12. Patients have the right to receive care in a safe setting and to be free from all forms of abuse or harassment.
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13. Patients have the right to be free from restraints of any form that are not medically necessary. For behavior management, all patients
have the right to be free from seclusion and restraints except in the case of an emergency, when there is an imminent risk of an
individual physically harming himself/herself or others, and less restrictive interventions would be ineffective.
14. Patients have the right to an interpreter if they do not speak or understand the predominant language of the community.
15. Patients have the right to access family members and others outside of the health care facility by means of visitation and by verbal
and written communication, unless medically contraindicated or prohibited by law.
16. Patients or their legally qualified representative have the right to refuse treatment to the extent permitted by law and the right to be
informed of the medical consequences of such refusal. The person making this decision is responsible for the consequences arising
from refusal. If, in the opinion of the primary physician, the refusal of treatment prevents the provision of appropriate medical care, the
relationship may be discontinued upon reasonable notice.
17. Patients have the right to consent or decline to take part in research affecting their care. If a patient chooses not to take part, they will
receive the most effective care the health care facility otherwise provides.
18. Patients have the right to have/formulate an Advance Directive/Living Will/Durable Power of Attorney for Health Care. Refer to the PH
Advance Directive Policy.
19. Patients have the right to expect reasonable continuity of care when appropriate and to be informed of realistic care alternatives when
the health care facility services are no longer appropriate.
20. Patients may be transferred to another facility after being informed about the need for, risks, benefits, and alternatives to transfer, if
requested or if medically appropriate and legally permissible. Patients will not be transferred until the other facility agrees to accept
them.
21. Patients have the right to know if PH hospitals have relationships with other health care facilities, educational institutions, or other
outside parties that may influence their care.
22. Patients have a right to examine and receive an explanation of their bill and to know about payment methods, regardless of source of
payment.
23. Patients have the right to express any concern or complaint about their care and to expect a reasonable response and resolution of
such concerns within a reasonable period of time. If patients are not satisfied with this resolution, they may issue a grievance to the
hospital which will be resolved through PH’s grievance resolution process. Refer to PH Patient Grievance Management Policy.
24. Patients have the right to consultation with members of each hospital’s Ethics Committee regarding any ethical questions and
dilemmas related to their care.
25. PH recognizes that children and their families may have special needs and will endeavor to provide resources to meet these needs,
be they social, psychological, educational, or spiritual.
Signature on File
269
Pneumococcal and Influenza Vaccine Administration for
Adults
February 2006
Palmetto Health Richland has established a vaccine guideline that will increase the rate of adult Pneumococcal
and Influenza vaccinations administered in our facility. These guidelines were approved by the Medical Executive
Committee. These guidelines follow the recommendations of federal and state regulations. During the inpatient
admission process, all patients will be assessed for the status of their vaccines including the Influenza and
Pneumococcal vaccines. Patients who are candidates for the Pneumococcal and Influenza vaccines will receive the
vaccine upon admission unless contraindicated, refused, or physician determines the patient will not receive.
GUIDANCE:
1. Persons eligible for the Pneumococcal Vaccine are:
1.1 a.
Anyone 65 years of age or older; anyone who is a resident of a nursing home or chronic care facility, regardless of age;
or
b.
Anyone age 18 – 64 with a history of chronic heart or lung disease, diabetes, or immune compromised state (HIV,
previous chemotherapy, splenectomy, or chronic steroid use).
1.2 Pneumococcal vaccine not indicated (if any of the following):
a.
Previously vaccinated less than 5 years ago (documented date on admission history form). If the patient is uncertain of
his/her immunization status, the nurse must contact the physician or his office for clarification before administering the
vaccine. If clarification is not obtained, the vaccination will be administered unless physician orders that the vaccine not
be administered.
b.
Known sensitivity to pneumococcal vaccine (documented as an allergy)
c.
Patient refuses
1.3 The Pneumococcal vaccine can be given year round.
2. Persons eligible for the Influenza vaccine are:
2.1 Flu Season plus one of the other two indications must be met. Flu Season is month October – February.
a.
Age 50 or greater
b.
Age 18 – 49 with a history of chronic heart or lung disease, diabetes, or immune compromised state (HIV, previous
chemotherapy, splenectomy, or chronic steroid use).
2.2 Influenza vaccine not indicated (if any of the following):
a.
Previously vaccinated this flu season (documented date on admission history form) . If the patient is uncertain of his/
her immunization status, the nurse must contact the physician or his office for clarification before administering the
vaccine. If clarification is not obtained, the vaccination will be administered unless physician orders that the vaccine not
be administered.
b.
Known sensitivity to influenza vaccine (document as allergy)
c.
Known egg allergy
d.
Pregnant by history
e.
Patient refuses
2.3 The Influenza vaccine is given from October through February only.
PROCEDURE:
Licensed Nurse
1. Evaluate patient for Pneumococcal and Influenza vaccine upon
admission and document on admission history.
2. Complete an Adult Vaccination Standing Orders sheet to determine
eligibility.
3. Sign the form and fax to pharmacy.
4. Place form in the orders section of the patient’s chart.
5. Administer vaccination upon receipt from Pharmacy to eligible
patients if MD has not indicated otherwise. Document administration
on the Medication Administration Record and D/C Instruction Sheet.
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Private Duty Nurses
Palmetto Health Richland permits Registered Nurses and Licensed Practical Nurses from approved agencies to do
private duty nursing in approved areas.
GUIDANCE:
1. The Vice President of Patient Care Administration will ensure that all private
duty nurses’ employment processes comply with Policy, Allied Health ProfessionalGuidelines. The Vice President of Patient Care
Administration Nursing will also ensure that an appropriate contract exists between Palmetto Health Richland and any agency that
provides private duty nurses. The Vice President will approve private duty agencies which:
1.1 Establish a mechanism which insures that its personnel are properly qualified and trained;
1.2 Warrant to Palmetto Health Richland that all nurses hold a current license to practice in South Carolina and will furnish proof of
licensure;
1.3 Have or insure that personnel have professional and comprehensive general liability insurance as required by Palmetto Health
Richland;
1.4 Provide staff development and training required by Palmetto Health Richland;
1.5 Insure that personnel have Palmetto Health Richland required health screening;
1.6 Accept responsibility for all financial arrangements and matters related to the services it provides.
1.7 Provide Palmetto Health Richland with copies of. periodic written performance evaluation of personnel as required by Palmetto
Health Richland.
2. There will be no private duty nurses in the following areas: ICU, SIICU, MIICU, NSICU, CCU, CVR, NICLI, Labor and Delivery,
Newborn Nursery, Special Care Nursery, PICLI, PICU, PACU, Operating Room or Psychiatry.
Private Duty personnel may be acquired by the nursing staff for suicide precautions and ventilator weaning. (See Nursing Rules and
Procedures).
3. Private duty nurses may be requested by the patient, the patient’s family, or attending physician.
4. The patient, the patient’s family or attending physician shall contact the nurse on the unit and shall receive a list of approved agencies,
from which they shall select the level of personnel requested and the agency.
5. The nursing unit shall contact the requested agency.
6. The private duty nurse shall report daily to the nursing station and shall sign the private duty request form.
7. Payment of the private duty nurse shall be the responsibility of the family, if not covered by the third party payor. Payment shall be
made to the private duty nurse or to the agency supplying the nurse as may be agreed.
8. The nurse in charge is responsible for the care the patient receives. The private duty nurse is responsible for reporting the condition of
the patient.
9. The nurse in charge will dispense all narcotics to the private duty nurse who will administer them to the patient. (Federal regulations
on narcotics and hypnotics).
10. All physicians’ orders shall be processed by Palmetto Health Nursing Staff.
11. Cancellation of a private duty nurse shall be made by the nursing unit upon the authorization of the family or physician.
12. An RN or LPN who is not from an approved agency but is requested by a specific physician must comply with Allied Health
Professional Policy well enough in advance of a case in order to obtain approval.
13. A private duty nurse whose skills have been documented by the nurse in charge as being substandard will be reported to his/her
agency.
14. Palmetto Health Richland reserves the right to refuse privileges to any private duty nurse.
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PROCEDURE:
Vice President, Patient Care Administration
1. Approves agencies according to predetermined criteria and
maintains a registry of approved agencies.
2. Reports to the approved agency any private duty nurse whose skills
are documented as substandard.
Family/Patient/Attending Physician
3. Requests private duty nurses. Completes request form. Authorizes
cancellation of Private Duty Nurses.
Family/Patient
4. Pays private duty nurse if not covered by third party payor.
Attending Physician
5. Authorizes private duty nurses for patients when medically indicated.
Responsible Nursing Unit
6. Upon authorization of family, patient or attending physician, places
request for private duty nurse with approved agency. Cancels private
duty services upon authorization of family or physician.
Private Duty Nurse
7. Reports daily to the Nursing Station to sign the private duty request
form. If not registered with approved agency, obtains permission
from nursing office and presents current SC license. Abides by all
Palmetto Health policies. Cares for patient according to standing
orders and standards of nursing practice. Reports patient’s condition
to charge nurse. Administers medications to patient as ordered.
Nurse in Charge
8. Ascertains that patient is receiving all necessary care in accordance
with the standards of nursing practice. Requires and receives
reports on the patient’s condition as necessary. Dispenses narcotics
to private duty nurse for administration to patient. Documents
substandard practice.
Signature on File
James E. Lathren
Executive Vice President and Chief Executive Officer, Palmetto Health Richland
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Pronunciation and Certification of Death
Patient Care
August 1, 1977
Palmetto Richland Memorial Hospital provides for pronunciation of death in compliance with South Carolina laws
regarding certification of death.
GUIDANCE:
1. Pronunciation of Inpatient Deaths
1.1 Pronunciation of death is the responsibility and duty of the patient’s physician or an associate designated by the attending
physician.
1.2 If a patient is presumed to have died, the nurse shall contact the patient’s attending physician or the designated associate or a
resident on duty for that service.
1.3 If a patient is presumed to have died, and neither the attending physician, the designated associate, nor a designated resident
can be located or is unavailable, the nurse shall consult the senior Emergency department physician or a resident on duty for
the service concerned and request assistance.
1.4 If a physician other than the patient’s attending physician or a designated associate responds to the request to pronounce
death, the physician may order discontinuance of treatment, authorize announcement of death, and annotate the patient’s
medical records to the fact and time of death.
1.5 At the request of the attending physician or designated associate, nurses designated by department rules may pronounce
death for patients established as “Do Not Resuscitate”, notify next of kin and annotate the patient’s medical record to the fact
and time of death.
2. Certification of Inpatient Deaths
2.1 In order to facilitate completion of the death certificate, the fact and time of death may be certified by the pronouncing
physician immediately after death.
2.2 The death certificate will be prepared by placing the full name of the deceased and date in left side margin on the death
certificate, obtaining from the pronouncing physician the medical certification and physician’s signature, and transmitting the
partly completed certificate, with the Release of Body Form, through Security Services, to the funeral director. (See Nursing
Rules and Procedures D-1)
2.3 If the attending physician or designated associate is not convinced that it is from natural causes, he/she shall request the
Coroner be contacted for the purpose of investigating the cause of death.
2.4 If a nurse pronounces death, a death certificate will not be forwarded to Security Services.
3. Fetal Deaths
3.1 For death certificate purposes, a fetal death is one in which delivery occurs after 20 weeks gestation or the fetus weighs 350
grams or more.
3.2 The Medical Record Department shall complete and file the certificate of fetal death within three days, including disposal
information if PRMH disposes of the remains, and also a supplemental report within 30 days if autopsy is performed.
4. Persons Dead on Arrival
4.1 In the case of a person who is dead on arrival at the Hospital, the Emergency Medical physician who views the body may sign
the death certificate as to the fact of death, provided the patient’s attending physician is unavailable.
4.2 If the Emergency Department physician is uncertain whether or not death resulted from natural causes, the question of cause
of death shall be referred to the Coroner for investigation and for completion of the certificate of death.
4.3 The Coroner shall be informed of all cases in which a patient is dead on arrival or dies in the Emergency Department. See PRMH Policy 6011-19.
PROCEDURE:
Nurses/Hospital Staff
1. Follow rules and procedures for department.
Attending Physician or Designated
Associate or Physician pronouncing death
2. Pronounce and record designated death.
3. Complete appropriate part(s) of death certificate and signs.
Director of Medical Records
4. Complete and file certificates of fetal death.
Emergency Department Physician
5. Follow rules and procedures for department.
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Signature on File
274
Signature On File
Carolyn Swinton
Protected Health Information:
General Uses and Disclosures
Corporate Compliance - HIPAA
Revised: August 10, 2004; October 1, 2007; May 11, 2010
Section IV, Policy Y
Palmetto Health may use and disclose protected health information (PHI) for treatment, payment and health care
operations (TPO) in accordance with applicable state and federal law. This policy provides a general overview
of related PHI terminology as it pertains to Palmetto Health. It provides a foundation for and should be utilized
in conjunction with applicable Palmetto Health privacy policies (refer to Section IV of the Corporate Compliance
Manual).
DEFINITIONS:
Breach: the unauthorized acquisition, access, use, or disclosure of PHI that compromises the security or privacy of such information.
Exceptions to this definition include:
1. disclosures where the recipient of the PHI would not reasonably have been able to retain the information; certain unintentional
acquisition, access, or use of PHI by employees or persons acting under the authority of a covered entity or business associate; as
well as certain inadvertent disclosures among persons similarly authorized to access PHI at a business associate or covered entity.
Refer to Corporate Compliance’s Privacy/Security Breach Notification policy.
Designated Record Set: A group of records maintained by or for Palmetto Health including medical records and billing records about
individuals or the enrollment, payment, claims adjudication and case/medical management records maintained by or for Palmetto Health’s
group health plan. Refer to Corporate Compliance’s Designated Record Set policy.
Disclosure: The release, transfer, provision of access to or divulging in any other manner of information outside Palmetto Health.
Electronic Health Record: an electronic record of health-related information on an individual that is created, gathered, managed and
consulted by authorized health care clinicians and staff.
Health Care Operations: Any one of the following activities of the covered entity to the extent the activities are related to providing
health care:
1. Conducting quality assessment and improvement activities, population-based activities relating to improving health or reducing health
care costs, protocol development, case management and care coordination, contacting of health care providers and patients with
information about treatment alternatives and related functions that do not include treatment;
2. performance, health plan performance, conducting training programs in which students, trainees, or practitioners in areas of health
care learn under supervision to practice or improve their skills as health care providers, training of non-health care professionals,
accreditation, certification, licensing or credentialing activities;
3. Underwriting, premium rating, and other activities relating to the creation, renewal or replacement of a contract of health insurance or
health benefits, and ceding, securing, or placing a contract for reinsurance of risk relating to claims for health care;
4. Conducting or arranging for medical review, legal services, and auditing functions, including fraud and abuse detection and
compliance programs;
5. Business planning and development, such as conducting cost-management and planning-related analyses related to managing and
operating the entity, including formulary development and administration, development or improvement of methods of payment or
coverage policies; and
6. Business management and general administrative activities, including, but not limited to:
6.1 management activities relating to HIPAA Compliance;
6.2 customer service;
6.3 resolution of internal grievances;
6.4 the sale, transfer, merger, or consolidation of covered entities; and
6.5 creating de-identified health information or a limited data set, and fundraising for the benefit of Palmetto Health.
Minimum Necessary: Uses and disclosures of PHI must be limited to the minimum amount of information necessary to satisfy the
request or to complete the task; however, minimum necessary does not apply in certain circumstances (refer to Corporate Compliance’s
Minimum Necessary policy).
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Payment: The activities undertaken by a health plan or by a health care provider to obtain premiums determine or fulfill it’s responsibility
for coverage and provision of benefits or to obtain or provide reimbursement for the provision of health care, including but not limited to:
1. determining eligibility or coverage and adjudication or subrogation of health benefit claims;
2. risk adjusting amounts due based on enrollee health status and demographic characteristics;
3. billing, claims management, collection activities, obtaining payment under a contract for reinsurance, and related health care data
processing;
4. review of health care services with respect to medical necessity, coverage under a health plan, appropriateness of care or justification
of charges;
5. utilization review activities, including pre-certification and pre-authorization of services, concurrent and retrospective review of
services; and
6. disclosure to consumer reporting agencies of any of certain PHI relating to collection of premiums or reimbursement.
Protected Health Information (PHI): Encompasses all individually identifiable health information created, received, transmitted or
maintained in any form or medium. It is information relating to the past, present or future physical health, mental health or condition of an
individual. PHI either identifies or could be used to identify the individual.
Request: When any person affiliated with Palmetto Health asks for health information from a person or entity outside of the organization,
or when Palmetto Health is asked for health information by a person not affiliated with the organization.
Treatment: The provision, coordination or management of health care related services by one or more health care providers, including the
coordination or management of health care by a health care provider with a third party, consultation between health care providers relating
to a patient or for the referral of a patient for health care from one health care provider to another.
Unsecured PHI: PHI that is not secured through the use of a technology or methodology, specified by the Secretary of the Department
of Health and Human Services.
Use: The sharing, employing, applying, utilizing, examining or analyzing individually identifiable health information within Palmetto Health.
Workforce: Employees, volunteers, trainees and other persons whose conduct, in the performance of work for Palmetto Health, is under
the control of the organization.
GUIDANCE:
1. Palmetto Health will inform patients of their rights through the provision of its Joint Notice of Privacy Practices. Individuals may
exercise these rights through the processes outlined in the specific Palmetto Health policies addressing each of these rights.
2. It is sometimes necessary to allow medical equipment vendors to be in patient care areas, such as the surgical suite, in order to
provide the highest quality patient care. In order to inform patients of the possibility of this occurrence, Palmetto Health has included
information to this effect in its Surgery Consent form. Additionally, the patient’s physician should specifically inform the patient when it
is apparent a vendor will be present during a procedure.
3. Palmetto Health shall not directly or indirectly receive remuneration in exchange for any protected health information of an individual
unless a valid authorization has been obtained. The authorization must also specifically state whether the PHI can be further
exchanged for remuneration by the entity receiving PHI of that individual. However, this statement does not apply if the PHI is
exchanged for the following purposes:
3.1 public health activities,
3.1 research,
3.2 treatment of the individual,
3.3 healthcare operations,
3.4 exchanges with a business associate,
3.5 exchanges with the individual who is the subject of the PHI, or as otherwise specified by the Secretary of the Department of
Health and Human Services.
4. The following Palmetto Health corporate policies should also be consulted when handling PHI related to these areas:
4.1 Abuse and Neglect
4.2 Confidentiality
4.3 Coroner’s and Medical Examiner’s Cases
4.4 Human Remains
4.5 Involving Other’s in a Patient’s Care/Notifying Next of Kin
4.6 Media/Public Request for Patient Information (Formerly, Release of Information Policy)
4.7 Medical Record Information Release
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4.8 Organ and Tissue Donation
4.9 Reporting of Illegal Drug Use During Pregnancy
4.10 Research Uses and Disclosures of Protected Health Information
REFERENCE:
HIPAA Federal Regulations 45 C.F.R. 164.500-164.530
Signature on File
Effective May 11, 2010
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Rapid Response Team
Patient Care
The Rapid Response Team brings critical care consultation and expertise to non-critical care areas when patients
exhibit signs and symptoms of physiologic instability, or when a clinician has a nonspecific concern about a
patient, visitor, or staff member. The goal of the Rapid Response Team is to improve in-patient outcomes by
providing a means for rapid and timely intervention of a declining patient.
GUIDANCE:
1. The Adult Rapid Response Team is composed of a critical care charge nurse and respiratory therapy supervisor. Additionally, a
member of the RRT may call the internal medicine resident on the critical care rotation if needed. The Pediatric Rapid Response Team
will include a PICU nurse and respiratory therapist. The senior pediatric resident may be called by a member of the RRT if needed.
2. The Rapid Response Team may be activated by any RN, RT, MD, or ancillary staff member by calling the operator at “6222” and
saying “I need to activate the rapid response team.” The operator should be given the patient’s exact location including room number.
If the Rapid Response is being activated for a visitor or staff member, the caller should be as specific as possible about the location
and should indicate that it for a non-patient.
3. The operator activates the Rapid Response Team by paging all beepers in the Rapid Response Team in-hospital network.
4. The goal for the Rapid Response Team is to arrive at the victim’s location within 5 minutes of the page.
5. The role of the RRT is to help assess and stabilize patients, assist with communication, provide education and support to staff, and
assist with transfer to a higher level of care if necessary. The RRT does not assume care of the patient from the primary nurse or
attending physician.
6. Criteria for activating the RRT are:
a.
Adult:
1.
Acute change in vital signs and/or patient is symptomatic
2.
Acute change in oxygen saturation despite supplemental oxygen (<90%)
3.
Altered mental status
4.
Acute chest pain
5.
The caregiver has concerns about non-specific changes in patient condition
b.
Children:
1.
Acute change in vital signs
2.
Acute change in oxygen saturation despite supplemental oxygen (<90%)
3.
Respiratory distress, threatened airway, change in breathing pattern
4.
Altered mental status or acute changes in neurological status
5.
Caregiver has concerns about non-specific changes in patient condition
7. Condition Help: Family and Patient Activated RRT:
a.
Patients and families are encouraged to communicate with their health care team about serious concerns related to patient
condition or care.
b.
In the event of persistent, unresolved concerns, family and patients may call for assistance via the Condition Help line at 434-8999.
c.
The operator will ask the nature of the call.
1. Calls of a service nature such as food, room temperature, environmental services will be referred to the appropriate department and
the nursing unit will be notified of the Condition Help call.
2. Calls of any clinical or patient care nature will be paged to the Rapid Response team for assessment and evaluation as per protocol
and designated on the page as Con H RRT. The nursing unit will be notified of the Condition Help call.
d.
Calls to Condition Help will be evaluated by the Guest Services Department.
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8. Coverage is as follows:
a.
Medical Intensive Care Unit and Surgical Trauma Intensive Care Unit: All medical surgical floors 3rd floor and above in the main
hospital on a rotational basis.
b.
Emergency Department: All calls on second floor and below in Medical Park 5 and calls on Atrium level and below in Medical
Park 6. On arrival if the client is an inpatient, they will notify the AOD for transfer of care to the appropriate RRT.
c.
d.
e.
Pediatric Intensive Care Unit: All areas in Medical Park 7.
Heart Hospital Coronary Care Unit: Heart Hospital above atrium level with the exception of Hartwell Suites.
Heart Hospital Cardiovascular Intensive Care Unit: Hartwell Suites
9. If a second Pediatric Rapid Response occurs while the RRT is at another pediatric Rapid Response call, the hospital operator will call
the PICU directly and provide information for the need for assistance at the 2nd Rapid Response. A designated Pediatric Respiratory
Therapist II attends the 2nd RRT.
10. If a second Adult Rapid Response occurs while the RRT is at another Rapid Response call, the first RN RRT responder will call their
designated Intensive Care Unit partner for assistance at the 2nd Rapid Response.
a.
MICU will call STICU at Ext. 6846
b.
STICU will call MICU at Ext. 7133
c.
CCU will call CVICU at Ext. 5010
d.
CVICU will call CCU at Ext. 5020
A designated Respiratory Therapist II attends the 2nd RRT.
11. Upon receiving the page, a representative from Transportation will bring a stretcher to the location of all non-patient RRT locations
during the hours of 0700 – 2330. From 2330 – 0700, a representative from the ED will provide a stretcher.
12. Care of the Patient:
a.
Inpatient: Upon arrival of the RRT, the primary nurse will give a brief report to the RRT nurse using SBAR. The primary nurse
who activated the RRT maintains overall responsibility for the coordination of care and communication with the physician.
Using SBAR, the primary nurse is responsible for notifying the attending physician that a Rapid Response has been called
and what interventions have been taken. The RRT nurse will be available to assist the primary nurse in relaying information to
the physician as needed. In conjunction with the primary nurse, the RRT nurse and Respiratory Therapist will utilize the Adult
Rapid Response Team Protocol sheet and ACLS protocol to stabilize inpatients until orders are received from the attending
physician.
If the patient is in one of the ED areas of response, the ED RRT nurse will respond and notify the AOD for transfer of care to
the appropriate Rapid Response Team.
b.
Non-inpatients: The RRT responders will assess ABC’s and transport the patient to the ED by stretcher as soon as possible. If
the non-inpatient refuses treatment, the RRT nurse will document refusal on the RRT record.
13. If a physician is needed at the bedside of an adult patient immediately, the Pulmonary Critical Care Resident should be paged at 3520288.
14. The RRT patient should be relocated to a higher level of care if their status has not improved in 45 minutes.
15. Documentation:
a.
The RRT Nurse will complete:
1.
The Rapid Response Team Record and place it in the progress notes of the patient’s medical record.
2.
The Adult Rapid Response Team Protocol sheet and place it in the physician orders section of the patient’s medical
record.
3.
The Rapid Response Team evaluation form. The RRT nurse places the Rapid Response Evaluation Form and a copy of
the completed Rapid Response Team Record in the Rapid Response book located in the responding ICU.
b.
The floor nurse will complete:
1.
The Rapid Response Evaluation and fax it to 434-7761 (Quality Review Analyst, Critical Care).
2.
Documentation that the physician was notified in the “Ad Hoc” Consultation/Notification section of Epicenter, or as
customary in the paper record.
3.
Documentation in Epicenter to include all pertinent information surrounding the RRT as it relates to systems
assessment changes and interventions taken.
4.
Documentation in Epicenter under Ad Hoc Charting / Hospital Events form with the date / time of the RRT event in the
section titled “Hospital Procedures / Events.”
5.
Documentation of post procedure vital signs, in Epicenter or paper record, as outlined in Policy P-9, R-6, Nurses
Manual, if patient does not transfer to a critical care unit.
Signature on File
Signature On File
Carolyn Swinton
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Red Rules
Patient Care
It is the policy of Palmetto Health Richland (PHR) to follow established Red Rules. To accomplish this policy, all
PHR employees and those who provide services on behalf of PHR make a personal and organizational commitment
to be guided by patient safety. All employees are accountable for compliance with Red Rules. Red Rules are
established to ensure the safety of all who trust us to provide their care.
DEFINITIONS:
Red Rules: critical elements associated with an activity or procedure. Red Rules must be adhered to 100% of the time to prevent harm.
PHR Red Rules are:
1. Patient Identification – a minimum of two patient identifiers are used to identify a patient when administering medication, blood, blood
products, obtaining blood samples, or performing any test/procedure.
2. Verification of correct test/procedure is made prior to performing the task.
1. Patient Identification
1.1. When armbands are used:
1.1.1. Full name and medical record number will be used as the two identifiers
1.1.2. Full name and medical record number on the armband are matched to a second source, such as the medical record,
eMAR, MAR, lab label, physician’s order, or referral.
1.1.3. The patient’s armband must be on the patient’s wrist or ankle. If unable to place an armband on the patient’s wrist or
ankle, the armband must be placed elsewhere on the patient.
1.1.4. Exception: in the ambulatory setting, the staff uses the patient name and the date of birth.
When armbands are present but not visible:
1.1.5. In the event the armband is not visible (ex. Patient draped for surgery), positive identification is made prior to draping
the patient using the positive identification process, and then a patient id label is placed on the person.
1.1.6. Blood bands may be moved when the arm will not be visible during the procedure. If a blood band is moved, first
confirm the patient identification using the positive identification process, then cut the band, place in the extender
and place blood band on another body part. The person moving the blood band must not leave the patient until the
process is complete.
1.2. Where armbands are not used:
1.2.1. Full name and date of birth will be used as the two identifiers
1.2.2. Full name and date of birth will be stated verbally by the PATIENT or representative and compared to the name and
date of birth on the medical record, eMAR, MAR, physician’s order, or referral.
1.2.3. If the patient or representative cannot state the patient’s name and date of birth, the staff member will make every effort
to verify patient identification using driver’s license, or other written document.
1.2.4. Employee will NOT state the name and/or date of birth and prompt the patient to confirm the information.
2. Confirming correct test/procedure prior to performance of the test/procedure
2.1.1. Patient care staff will review the physician’s order/requisition form/eMAR/MAR immediately prior to performing test/
procedure.
3. Failure to comply with any Red Rule results in disciplinary action
3.1 First violation, at minimum written warning
3.2 Second violation, at minimum suspension
3.3 Third violation, termination
Signature on File
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Reporting of Illegal Drug Use during Pregnancy
October 1, 2001
Policy No. B.14
Revised: August 10, 2004Section IV, Policy OO
Palmetto Health complies with Ferguson v. City of Charleston, S.C. Code Ann. 20-7-50 and Whitner v. State of S.C.
1) The U.S. Supreme Court in Ferguson held that a maternal drug test without consent of the mother and reporting
positive test results to the police is unconstitutional. 2) S.C. Code Ann. 20-7-510 requires health care professionals
to report to the Department of Social Services (DSS) if the person has reason to believe that a child’s physical or
mental health or welfare has been or may be adversely affected by abuse and/or neglect. Palmetto Health may use/
disclose protected health information to comply with these requirements without the authorization of the patient
and without providing the patient the opportunity to agree or object, pursuant to 45 C.F.R. 164.512(a). For the
purposes of this policy, suspected cases of illegal drug use by a pregnant woman (24 weeks gestation or greater)
are considered cases of suspected abuse and should be reported to DSS. 3) The South Carolina Supreme Court
in Whitner holds that a “viable fetus” of twenty-four (24) weeks gestation is a “child” for purposes of the S.C. Child
Protection Act. Therefore, maternal drug testing and reporting the results to the police cannot be done without the
mother’s consent. However, if the mother consents to testing or the baby is tested after birth because of medical
necessity, then the health care professional would report suspected cases of illegal drug use by a pregnant woman
(24 weeks gestation or greater). The absence of drug testing does not eliminate responsibility for mandatory
reporting.
DEFINITIONS:
1. Child: includes fetus of 24 weeks gestation or greater.
2. Child Abuse: includes use of illegal drugs by a pregnant woman of 24 weeks gestation or greater.
3. Illegal Drug: includes but is not limited to cocaine, heroin, LSD, non-prescription amphetamines, marijuana and their derivatives.
4. Mandatory reporters: includes but is not limited to physicians, nurses, social workers, and other allied health professionals who
believe that a child’s physical or mental health or welfare has been or may be adversely affected by abuse and/or neglect.
GUIDANCE:
The following procedure is to be followed when mandatory reporters suspect drug abuse including a viable fetus or newly born child.
1. Assessment
1.1 Assessment findings (history, interview, self-report, physical exam) may support the need for maternal and/or newborn drug
testing to be ordered by the physician.
1.2 The decision to order a test by a physician should be based on sound clinical judgment weighing all factors relevant to the
particular patient.
1.2.1 Newborn drug testing may be done without parental consent if determined medically necessary by physician.
1.3 The absence of drug testing does not eliminate responsibility for mandatory reporting.
2. Reporting
Mandatory reporters who have reason to believe that a child has been exposed to illegal drug use (as defined by this policy) must
immediately contact the on-call social worker who will make the report to the appropriate county DSS office where the mother
resides. However, the ultimate responsibility to ensure reporting to DSS lies with the mandatory reporter.
3. Documentation
The mandatory reporters shall document the following in the medical record:
3.1 Assessment findings that support suspicion for illegal drug use
3.2 Drug tests and consents of mother for maternal testing
3.3 Referral to social worker
3.4 Report to DSS by the social worker
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4. Release of Written Information
All requests for medical record information must be routed through the hospital Health Information Management department. Only
Health Information Management may release relevant information to the county DSS office. This includes the history and physical,
health care professional’s notes and the results of the newborn’s drug test. (Medical information from previous hospitalizations may
not be released.) Release of results will not be made without consent or proper warrants.
Signature on File
Howard P. West
Senior Vice President and General Counsel
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Signature On File
President and Chief Executive Officer,
Palmetto Health
Restraint for Non-Violent / Non-Self Destructive Behavior
Effective:12/28/2010
Revised:10/17/2011
Name of Associated Policy: Restraint for Non-Violent / Non-Self Destructive Behavior, Restraint/ Seclusion for Violent/ Self Destructive
Behavior
RESPONSIBLE PERSONS:
»» Physician
»» Physician Assistant/PA
»» Nurse Practitioner/NP
»» Second Year Resident or Higher Residency
»» Registered Nurses
EQUIPMENT NEEDED:
Restraint as ordered by Physician, NP, PA, Second Year or Higher Resident
1. Initiation of restraint
1.1. A description of the patient’s behavior, symptoms, and any alternatives/interventions to prevent the use of restraint shall be
documented in the medical record.
1.2. The patient’s family or primary contact will be notified by the nurse as soon as possible and the notification will be documented
in the medical record.
1.3. When all attempts have failed, and following a comprehensive patient assessment, a RN may initiate restraint as follows:
1.3.1. The admitting Physician(s) shall be notified within 2 hours after the application of restraint and a written/electronic
or verbal/telephone order obtained. Failure to obtain an order within 2 hours is viewed as an application of restraint
without an order. Notification of physician (s) is documented in the medical record.
1.3.2. If the attending/“on call” physician did not order the restraint, then he shall be notified preferably as soon as possible;
but not to exceed one’s scheduled shift.
1.3.3. If the patient’s behavior represents a significant change in his/her condition, the RN shall immediately notify the
physician.
1.3.4. If an emergent situation warrants restraint, the physician shall be notified immediately.
1.3.5. Only RNs may obtain the verbal/telephone order.
1.3.6. The order shall meet criteria as defined in Physician’s Orders.
1.3.7. RNs, LPNs, and non-licensed personnel may apply and release restraint during supervised patient care without an
additional order.
2. Physician Orders for Restraint
2.1. A written or electronic order shall be obtained immediately, but no later than 2 hours of initiation of the restraint from an
authorized physician, NP, PA or Second Year or Higher Resident.
2.2. The restraint order sheet/electronic order for “Non-Violent / Non-Self Destructive Behavior” is completed as follows:
»» Time limit – Order is valid for a maximum of “one calendar day”
»» Reason for restraint including patient behaviors and related causes
»» Type & number of restraint(s)
2.3 A restraint order will not be written as a standing order or on an “as needed” or PRN basis.
2.4 A new restraint order is required “no less than once each calendar day.”
2.5 The physician shall conduct an in person exam of the patient within 24 hours.
2.6 A new order is required if restraints have been discontinued and the patient’s behavior re-escalates, even if it occurs in the
original time frame. Staff cannot discontinue a restraint intervention and re-start under the same order. This does not include
temporary direct-supervised release of restraint to provide patient care.
2.7 The restraint must be discontinued at the earliest possible time, regardless of the length of time identified in the order.
2.8 Physicians, NPs, PAs and Second Year or Higher Residents authorized to order restraint shall have a working knowledge of
hospital policy regarding the use of restraint.
3. Application of Restraint
3.1. Use/apply restraint according to manufacturer’s instructions (package insert). Exception: for vest restraint package insert, omit
use of shoulder straps and discard the shoulder straps.
3.2. Use discretion when placing restraint over wounds, catheters, IV sites, dressings, drains, or tubes.
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3.3.
3.4.
3.5.
Apply restraint in a manner which maintains proper body alignment and insures the patient’s comfort. Elevate head of bed at
least 30 degrees if a vest is applied and ensure patient has adequate head movement capability.
Dispose of all restraints except the Leather type restraint after patient use and DO NOT send home with the patient.
Clean Leather type restraint with Cavicide after use.
4. Plan of Care
4.1. Assessment:
4.1.1. Asses the patient for confusion or disorientation.
4.1.2. Assess if a decrease in level of consciousness (LOC) is due to medications, sedation, or clinical conditions (hypoxemia,
electrolyte imbalance, septicemia, etc).
4.1.3. Assess the patient for unstable ambulation, limited ROM, or altered cognitive function.
4.1.4. Assess for presence of indwelling medical device(s) or other potential irritants.
4.1.5. Assess the patient for pain or other discomfort.
4.2. Plan:
4.2.1. Determine level of supervision/observation needed.
4.2.2. Evaluate medication regime for interactions/toxicity.
4.2.3. Determine a need for pain and/or other symptom relief.
4.2.4. Evaluate for appropriate diversionary activities.
4.2.5. Collaborate with physician to determine need to continue indwelling medical device and/or correct clinical conditions.
4.3. Interventions:
4.3.1 Provide a welcoming and comfortable environment.
4.3.2. Create a culture in which patient can participate in decision-making.
4.3.3. Be respectful of patient’s rights and dignity.
4.3.4. Move patient to a room closer to the nursing station. Suggest family member/significant other can be present if
available.
4.3.5. Increase level of supervision/observation.
4.3.6. Continue monitoring change in LOC and follow physician orders to treat
agitation, restlessness, or combative behavior.
4.3.7. Activate bed alarm/alert system if available.
4.3.8. Arrange for diversion when possible.
4.3.9. Treat pain/other discomforts.
4.3.10. Camouflage or cover devices (i.e. hide IV tubing in sleeve of gown, overdress or pad sites, use binders, etc).
4.3.11. Remove irritating stimuli, including indwelling medical devices as soon as possible.
4.3.12. Follow physician orders in attempting to correct abnormal assessment findings (i.e. hypoxia, electrolyte imbalances,
sepsis, etc.).
5. Monitoring and Documentation
5.1. Physicians, NPs, PAs, Second Year or higher Residents and registered nurses can assess and monitor patients in restraints.
All trained personnel can monitor patients in restraints.
5.2. At a minimum, skin care shall be provided in the am and pm, with restraints being
fully removed and skin care provided and documented by the RN/LPN/unlicensed personnel.
5.3. The RN/LPN/unlicensed personnel are required to monitor and document on the
restraint monitor tool at least every 2 hours. The frequency of assessment and monitoring should be individualized, taking
into consideration variables such as the patient’s condition, cognitive status, risks associated with the use of the chosen
intervention. (EXCEPTION: Hyperbaric Oxygen Department – continuous visual observation is required when the patient is in
the chamber.)
5.4. When the restrained patient must leave the unit for testing or a procedure EITHER:
»» The restraint is permanently discontinued and a new order obtained if the behavior re-escalates upon return to the unit, OR
»» A trained staff member accompanies and remains with the patient unless a handoff occurs with another trained staff member.
5.5. The plan of care is reviewed and updated per hospital policy.
5.6. Vital signs for restrained patients are taken a minimum of every 8 hours unless the patient condition warrants more frequent
monitoring of vital signs.
6. Discontinuation of Restraint
6.1. The authorized physician or trained RN has the authority to discontinue the restraint.
6.2. Restraint use is ended at the earliest possible time. Criteria utilized for the release of restraint will be a reduction in the
behavior(s) that led to the restraint usage.
6.3. The RN documents the change in patient behavior that leads to discontinuation of restraint on the restraint flowsheet or in the
medical record.
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6.4.
A new order is required if restraint has been discontinued and the patient’s behavior re-escalates, even if it occurs in the
original time frame. Staff cannot discontinue a restraint intervention and re-start it under the same order.
7. Restraint Data Collection
7.1. Palmetto Health uses performance improvement processes to identify opportunities to reduce risks associated with the use of
restraint.
7.2. Upon the death of a patient in restraint, the RN caring for the patient must notify the physician and the Administrator on Duty
(AOD)/Supervisor.
7.3. Data is collected and reported by telephone to the Center for Medicaid and Medicare services by the Administrator on duty/
Supervisor for:
7.3.1. Each death that occurs while a patient is in restraint.
7.3.2. Each death that occurs within 24 hours after the patient has been removed from restraint.
7.3.3. Each Death known to the hospital system that occurs within one week after the restraint was used when it is
reasonable to assume that the use of the restraint contributed directly or indirectly to the patient’s death.
8. Critical Care Airway Protection Restraint Guidelines
8.1. To maintain a safe and secure patent airway (intubation or tracheostomy) and prevent self-extubation or dislodgement of an
artificial airway, critical care airway protection restraint may be ordered.
8.2. Each airway protection guideline order encompasses one intubation event; therefore, there is no longer a need for a daily order
to continue the restraint.
8.3. In the event of planned extubation and re-intubation, a new restraint order will be obtained from the Physician, NP, PA or
Second Year or Higher Resident.
8.4. In the event restraints are removed during the intubation event, a new order must be obtained if restraints are re-applied.
8.5. A copy of the airway protection guideline will be placed in the patient’s chart/medical record.
9. Restraint Training and Education
9.1 Individuals providing staff training shall be qualified as evidenced by education, training and experience in techniques used to
address patient behaviors necessitating the use of restraint.
9.2 All direct care staff members shall be trained and will demonstrate competency in the application of restraint, monitoring,
assessment (RN), and providing care for a patient in restraint at orientation, prior to utilizing restraint and on an annual basis.
9.3 Palmetto Health shall document in staff personnel records that restraint training and demonstration of competency were
successfully completed.
REFERENCES:
The Joint Commission “Revised 2009 Accreditation Requirements as of March 26, 2009 – Hospital Accreditation Program”.
42C. F. R. 482.13 (2008) Health Care Financing Administration, Chapter IV-Centers for Medicare and Medicaid Services, Department of
Health and Human Services: Hospital Conditions of Participation: Patient’s Rights.
DHEC Licensing Standards Hospitals and Institutional General Infirmaries Section 404.2 Use of Safety Precautions
Sponsoring Department: Nursing
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Restraint and Seclusion for Violent and/or Self-Destructive
Behavior
Effective: December 28, 2010
Name of Associated Policy: Restraint for Non-Violent / Non-Self Destructive Behavior; Restraint and Seclusion for Violent / Self
Destructive Behavior
»» Physicians
»» Physician Assistants (PAs)
»» Nurse Practitioners (NPs)
»» Second Year or Higher Residents
»» Nursing Staff
»» Security officers
EQUIPMENT NEE DED:
»» Soft restraint
»» Leather restraint
»» Posey vest
»» Mittens
»» Papoose
»» Seclusion room
1. Initial Assessment and Initiation of Restraint and Seclusion
1.1. The Physician,NP, PA, Second Year or higher Resident or RN must do an initial clinical assessment of the patient to evaluate
patient’s need for restraint/seclusion. The Agitation Protocol may be used to complete this assessment. Findings of this
assessment will be documented in the patient’s medical record. Note: Restraint and seclusion may only be used as a last
resort after alternatives are exhausted and determined to be ineffective or inappropriate to prevent injury to the patient or to
others.
1.2 All staff members should consider the following potential negative patient effects of using a restraint:
»» Dehydration
»» Choking
»» Circulatory and skin problems
»» Loss of strength and mobility
»» Incontinence
»» Psychological trauma
»» Physical injury or death due to patient actions or improper application of restraint
1.3. A registered nurse or other qualified, trained staff members under the direction of a RN may initiate the use of restraint/
seclusion before an order is obtained from the Physician, NP, PA, Second Year or Higher Resident because restraint and
seclusion use is limited to emergencies in which a Physician NP, PA, Second Year or Higher Resident may not be immediately
available.
1.4. Restraint/Seclusion is used and continued pursuant to an order by the Physician, NP, PA, Second Year or Higher Resident
who is primarily responsible for the individual’s ongoing care and is authorized to order restraint or seclusion by hospital policy.
If the initial assessment is conducted by a trained RN, the attending physician, NP, PA, Second Year or Higher Resident that
is responsible for the care of the patient must be consulted within a few minutes after completion of the evaluation. Note:
Restraint and seclusion are never written as a standing order or on as needed basis.
1.5. The RN will notify the Physician, NP, PA, Second Year or Higher Resident regarding:
1.5.1. The initiation of restraint or seclusion
1.5.2. The nursing assessment – patient’s physical and psychological condition
1.5.3. Obtain an order for restraint or seclusion. The order must be obtained as soon as possible (within a few minutes) after
the initial use of restraint/seclusion.
1.6. The Physician, NP, PA, Second Year or Higher Resident provides the following guidance:
1.6.1. Reviews with the RN the physical and psychological status of the patient.
1.6.2. Determines whether restraint or seclusion should be ordered.
1.6.3. Supplies staff with guidance in identifying ways to help the patient regain control so that restraint or seclusion can be
discontinued.
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1.7.
The Physicians, NP, PA, Second Year or Higher Resident gives a time limited order for restraint/seclusion.
1.7.1 4 hours for individuals ages 18 and older
1.7.2. 2 hours for children and adolescents ages 9 to17
1.7.3. 1 hour for children under age 9.
1.8. Time-limited orders do not mean that restraint or seclusion must be applied for the entire length of time for which the order is
written. Restraint or seclusion is to be discontinued as soon as the individual meets the behavior criteria for its discontinuation.
1.9. As early as feasible in the restraint or seclusion process, the patient is made aware of the rationale for restraint or seclusion
and the behavior criteria for its discontinuation. Staff should provide assistance to patients in meeting behavior criteria for the
discontinuation of restraint or seclusion.
1.10. If a patient is removed from either restraint or seclusion, and needs to be placed back in seclusion/restraint, the nurse again
completes an evaluation of the patient and obtains a new order as soon as possible.
1.11. If the individual has consented to have the family kept informed regarding his or her care and the family has agreed to be
notified, staff will contact the family to inform them of the restraint or seclusion episode.
2. Documentation
2.1 Documentation – Initiation of Restraint or Seclusion
2.1.1. The behaviors exhibited by the patient which may necessitate restraint/seclusion.
2.1.2. Less restrictive measures that were taken to assist in de-escalating the patient’s behavior, including patient’s reaction to
the intervention.
2.1.3. The rationale for the type of physical intervention selected.
2.1.4. Pre-existing medical condition or any physical disabilities, limitations that would place the individual at greater risk
during restraint or seclusion.
2.1.5. Any history of sexual or physical abuse that would place the individual at greater psychological risk during estraint or seclusion.
2.1.6. Physician, NP, PA, Second Year or Higher Resident order for restraint or seclusion for each episode of use.
2.1.7. Patient and family were informed of hospital policy regarding restraint and seclusion and that family was notified of
event as appropriate.
2.2 Documentation – While in Restraint or Seclusion
2.2.1. Behavior criteria for discontinuing restraint or seclusion.
2.2.2. Informing the patient of behavior criteria for discontinuing restraint or seclusion.
2.2.3. Any assistance provided to the patient to help him or her meet the behavior criteria for discontinuing restraint or
seclusion.
2.2.4. Any Physician, NP, PA, Second Year or Higher Resident orders (telephone, verbal, written).
2.2.5. Each face-to-face evaluation and re-evaluation by the Physician, NP, PA, Second Year or Higher Resident or RN.
2.2.6. A staff member who is trained and competent to monitor patients in restraint or seclusion must document the following
findings every 15 minutes. Findings are reported to the RN.
»» Signs of injury associated with the application of restraint or seclusion – skin condition every 15 minutes.
»» Correct positioning of restraint – every 15 minutes.
»» Nutrition/hydration – offer food and fluids every 15 minutes.
»» Circulation and range of motion in the extremities – restraint rotated and joint exercised if appropriate to restraint
every 15 minutes. Note which joint exercised.
»» Vital signs – every 15 minutes.
»» Hygiene and elimination – hygiene as needed, bathroom every 15 minutes.
»» Physical and psychological status and comfort – every 15 minutes, and
»» Readiness for discontinuation of restraint or seclusion every 15 minutes.
2.2.6.1. If any of the above information or interventions cannot be provided, the reason why must be documented in
the patient’medical record.
2.2.7. Debriefing of the patient with staff.
2.2.8. Any deaths that occur within 24 hours after the patient has been removed from restraint or seclusion or within one
week after being in restraint or seclusion and it is reasonable to assume that the use of the restraint or seclusion
contributed directly or indirectly to the patient’s death.
3. Monitoring Patients in Restraints or Seclusion
3.1 Patients who are either restrained or secluded must be continually monitored:
3.1.1 Secluded patients are to be face-to-face monitored by competent, trained staff for one hour. If seclusion is to be
continued, the patient can then be monitored by simultaneous monitoring by video and audio equipment, if this is
consistent with the individual’s condition or wishes.
For example, it may be more helpful and less disruptive to the individual if
staff is not monitoring him or her by physically sitting in the seclusion room or watching through the window in the
seclusion room.
287
3.1.2 Restrained patients will have one-to-one, continuous monitoring and observation whether in or out of seclusion
3.1.3 Patients in a physical hold, will be observed by a second staff person while being held.
4. Continual Assessment
4.1. The Physician NP, PA, Second year or higher resident or RN reevaluates the patient in seclusion or restraint face to face at 1
(one) hour after the initiation of the restraint or seclusion. If the evaluation was completed by the RN, the MD, NP, PA, Second
Year or Higher Resident is consulted and given information about the evaluation of the patient.
4.2. If the individual is not ready for restraint or seclusion to be discontinued, the RN re-evaluates the efficacy of the individual’s
treatment plan and works with the individual to identify ways to help him or her regain control.
4.3. If reassessment indicates the need for continued restraint or seclusion at the time the order expires, a new order from the
patient’s MD, NP, PA, Second Year or Higher Resident is received.
4.4. If the patient’s Physician is not the Physician, NP, PA or Second Year or higher Resident who gives the order, the patient’s
Physician should be notified of the individual’s status if the restraint or seclusion is continued.
4.5. When the RN continues restraint and seclusion based upon a new order by the Physician, NP, PA, Second Year or Higher
Resident , the RN or the Physician, NP, PA, Second Year or Higher Resident conducts an in person re-evaluation at a
minimum of every
•
hour and consults with the Physician, NP, PA, Second Year or Higher Resident for children under 9 years of age.
•
2 hours and consults with Physician, NP, PA, Second Year or Higher Resident for children ages 9-17 years of age, and
•
4 hours and consults with Physician, NP, PA, Second Year or Higher Resident for adults 18 years and above.
4.6. If restraints or seclusion are continued, the Physician, NP, PA, Second Year or Higher Resident must conduct a face-to-face
evaluation within 24 hours of initiation.
4.7. If restraint or seclusion are discontinued before the order expires, the Physician, NP, PA, Second Year or Higher Resident must
evaluate the person face-to-face within 24 hours.
4.8. The charge nurse will report any restraint or seclusion for violent or self-destructive reason to the Nurse Manager on call
and the Nursing Supervisor immediately. If the patient is in restraints or seclusion for more than 12 hours or experiences
2 or episodes of restraint or seclusion of any duration within 12 hours, contact the nurse manager on call and the nursing
supervisor again. Thereafter, clinical leaders are notified every 24 hours if either of these conditions continues.
5. Debriefing
5.1. When the patient is taken out of seclusion/restraint, a debriefing with the patient and if appropriate, the patient’s family will be
arranged to discuss the restraint or seclusion episode. Debriefing occurs as soon as possible when the patient is emotionally
and physically in control, but no longer than 24 hours after the episode. The debriefing is documented and should be used to:
5.1.1 Identify what led to the incident and how it could have been handled differently.
5.1.2. Ascertain that the individual’s physical well-being, psychological comfort, and right to privacy were addressed.
5.1.3. Counsel the individual for any trauma that may have resulted from the incident.
5.1.4. Modify the treatment plan when indicated.
6. Performance Improvement
6.1. At the end of each shift that the patient is either in seclusion or restraint, the charge nurse will insure that the QI monitoring
tool has been completed and turned in to the Nurse Manager. Restraint and seclusion are monitored as part of an ongoing
performance process on each behavioral care unit.
6.2. The P.I. process continuously assesses the reasons for using restraint and seclusion. The monitor assists the staff in evaluating
whether policies and procedures are being followed.
6.3. The P. I. process includes the following:
6.3.1. Analysis of trends regarding the use of restraint and seclusion.
6.3.2. Evaluation of whether changes in clinical practice can decrease the use of restraint or seclusion.
6.3.3. Special review of any instances of multiple episodes of use for individual patients.
6.3.4. Data analysis during the monthly Performance Improvement Committee where areas of concern are shared.
6.3.5. Performance Improvement data regarding restraint and seclusion is presented to physicians at the Medical Staff Meeting.
7. Staff Training and Competency
7.1. Staff are trained and competent to minimize the use of restraint and seclusion.
7.2. Staff must be trained and able to demonstrate competency in safely applying restraints, implementing seclusion, monitoring,
assessing, and providing care for a patient in restraint or seclusion before performing these actions. This training occurs as
part of their orientation, and annually thereafter.
7.3. The hospital must require appropriate staff to have education, training and demonstrated knowledge based on the specific
needs of the patient population in at least the following:
7.3.1. The techniques to identify staff and patient behaviors, events, and environmental factors that may trigger circumstances
that require restraint or seclusion.
288
7.4.
7.5.
7.6.
7.3.2. The use of non-physical intervention skills.
7.3.3. The ability to choose the least restrictive intervention based on an individualized assessment of the patient’s medical or
behavioral status or condition.
7.3.4. The safe application and use of all types of restraint or seclusion used in the hospital.
7.3.4.1. Handcuffs, shackles, mace, or pepper spray will not be used as forms of restraint.
7.3.5. The knowledge to recognize and respond to signs of Physical and psychological distress.
7.3.6. The knowledge and clinical skill to recognize specific behavioral changes that indicate that restraint or seclusion is no
longer necessary.
7.3.7. The knowledge and clinical skill to monitor the physical and psychological well-being of the patient who is restrained or
secluded.,. This includes but is not limited to respiratory and circulatory status, skin integrity, vital signs, and any special
requirements specified by hospital policy associated with the 1-hour face to face evaluation.
7.3.8. The knowledge of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required
periodic recertification.
7.3.9. Debriefing techniques used with patients involved in the situation, families, staff, and other patients on the unit who
witnessed the event.
Individuals providing staff training will be qualified as evidenced by education, training, and experience in techniques used to
address patients’ behaviors.
A record of completed training and demonstration of competency in Behavior Management and safe intervention techniques
will be documented in each staff’s education file (actual file and/or computer). RN staff will also have documented evidence of
BLS certification.
The viewpoints of patients who have experienced restraint or seclusion are incorporated into staff training and education to
help staff better understand all aspects of restraint and seclusion.
Restraints and Seclusion for Violent/Self-Destructive Behavior
FLOWCHART
Child under 9
Child 9-17
Adult 18 and over
RN completes initial
assessment
assessment
assessment
RN gets order (lasts 1 hour) RN gets order (lasts 2 hours) RN gets order (lasts 4 hours)
RN re-evaluates pt. at 1 hour
and consults with physician,
NP, PA, Second Year or
Higher Resident
Higher Resident
Higher Resident
RN gets new order if needed
when first order expires
If continues, RN re-evaluates
at least every hour and
consults with the physician,
Higher Resident
at least every 2 hours and
Higher Resident
at least every 4 hours and
Higher Resident
If continues, MD must
evaluate face to face within
24 hours
24 hours
24 hours
1. The charge nurse will report any restraint or seclusion that occurs to the Nurse
Manager on call and Nursing Supervisor immediately.
2. If the patient is removed from restraints or seclusion before the order expires, the
physician, NP, PA, Second Year or Higher Resident must see the patient within 24 hours
of initiation.
3. If patient is in restraints or seclusion for more than 24 hours, or 2 times in 12 hours,
contact the nurse manager on call again as well as the nursing supervisor. After first 24
hours notification, contact clinical leadership at least every 24 hours.
REFERENCES:
Centers for Medicare & Medicaid Services: ww.cms.hhs.gov, 2010
The Joint Commission. Provision of Care, Treatment, and Services, 2010
National Association of Psychiatric Health Systems: www.naphs.org, 2010
Murphy, Tim and Bennington-Davis, Maggie, Restraints and Seclusion: The Model for Eliminating Their Use in Healthcare, HCPro,
Inc.,Marblehead, MA, 2005
Sponsoring Department: Nursing
289
Restricting Uses and Disclosures of Protected Health
Information
Reviewed:
October 1, 2008
Revised: August 10, 2004; October 1, 2007; May 11, 2010; December 1, 2010; December 1, 2011
Name of Associated Policy: HIPAA Privacy Policy
DEFINITIONS:
N/A
N/A
EQUIPMENT NEEDED:
Workforce Members
1. Palmetto Health must permit an individual to request that Palmetto Health restrict:
1.1. uses and disclosures about the individual to carry out treatment, payment or health care operations (TPO).
1.2. Permitted uses and disclosures are allowed in:
1.2.1. the Palmetto Health Directory PGR; and
1.2.2. Palmetto Health’s Involving Others in a Patient’s Care/Notifying Next of Kin policy.
2. Palmetto Health is not required to agree to a restriction. If Palmetto Health does agree to a restriction, Palmetto Health may not use
or disclose PHI in violation of the restriction except if the individual who is requesting the restriction is in need of emergency medical
treatment and the restricted PHI is needed to provide that treatment or as required by law. Palmetto Health may use the restricted
PHI itself or disclose it to a health care provider to provide such treatment. Palmetto Health must request that the health care provider
not further use or disclose the PHI. A restriction agreed to by Palmetto Health does not prevent:
2.1. uses or disclosures from being made to the individual for inspection and copying of their PHI;
2.2. the individual from obtaining an accounting of disclosures of PHI (unless restricted by law);
2.3. the individual’s inclusion in the facility directory; or
2.4. uses and disclosures for which authorization or opportunity to object is not required.
3. Palmetto Health MUST comply with a patient’s request to restrict disclosures of his/her PHI when the disclosure is to a health plan
for payment or healthcare operations purposes and if the patient has paid in full for the services out of their own pocket. The claim
cannot be submitted for insurance reimbursement at all.
4. Palmetto Health may terminate its agreement to the restriction if:
4.1. the individual agrees to or requests the termination in writing;
4.2. the individual orally agrees to the termination and the oral agreement is documented; or
4.3. Palmetto Health informs the individual that they are terminating the restriction. Such termination is only effective with respect to
PHI created or received after Palmetto Health has informed the individual.
5. All requests for restrictions of PHI should be documented on the Restriction Request form and directed to Health Information
Management or the specific department maintaining the PHI.
6. Palmetto Health will document and retain any agreed upon restriction for a period of six years from the date if its creation or the date
when it was last in effect, whichever is later.
REFERENCES:
HIPAA Federal Regulation 45 C.F.R. §164.522
290
Care of Psychiatric Patients in an Acute Care Environment
(In-Patient Units)
Policy No. S-15 R-7
March 2009
Identification of individuals at risk for suicide while under the care of or following discharge from a health care
organization is an important step in protecting at-risk individuals (The Joint Commission, 2008). For the protection
of patients at risk for harming themselves or others, the following guidelines are implemented.
RULES:
1. When a patient’s verbal or non-verbal behavior indicates risk of threatening behavior to self or others, the attending physician will be
notified immediately and the following precautionary measures will be implemented:
1.1 Patients at risk for suicide will be placed on one-to-one observation immediately.
1.2 All potentially destructive articles, such as belts, ties, scissors, glass objects, jewelry, pencils, pens, pins, knives, coat hangers,
plastic bags, paper clips, appliances with cords, soft drink cans, medications, etc. will be removed from the patient and the
patient’s environment by a licensed staff member.
2. Any known or suspected suicidal patient will have a consultation performed by a member of psychiatric services. If psychiatry
deems the patient is at risk for suicide (and the patient is deemed medically stable) transfer to an in-patient psychiatric facility will be
arranged. The patient will be placed on one-to-one observation until transferred.
3. Patients deemed suicidal or agressively threatening to others and are not medically stable for transfer require the following:
3.1 Continuous one to one observation
3.2 The patient and the room will be searched for actual or potentially destructive objects each shift.
3.3 Ancillary staff will not approach the patient without prior approval from nursing or the patient’s physician.
3.4 Suicide precaution status will be documented on the plan of care and communicated to all pertinent health care workers.
Place “Suicide” orderable in Epidenter.
3.5 Visitors will be limited.
3.6 Patients in Critical Care units, i.e. STU, MICU, CVICU, CCU and PICU, who are
chemically or medically incapacitated, do not require a sitter when under the direct supervision of a licensed nurse.
4. If an outside agency sitter is used, the sitter will report to the unit charge nurse for a review of suicide precautions and expectations at
the start of the shift.
4.1 Unit nursing staff will provide staff relief any time the agency sitter or the staff member takes a break.
4.2 The sitter will not read, study, socialize, sleep, make use of a telephone or attend to anything but the patient, even when the
patient is sleeping.
4.3 The sitter will remain at arms length from the patient at all times. The sitter will be stationed between the patient and the door
to the room and will accompany patient to the restroom.
4.4 The sitter will document on the Close Observation Record.
5. The unit Charge Nurse/Nurse Manager is responsible for the following:
5.1 Provide information to agency and sitter personnel regarding policy, expectations and documentation.
5.2 Ensure patient remains under one-on-one observation at all times.
6. Continued observation of patient behavior will be documented every ten minutes. All levels of nursing staff and the agency sitter will
record observations. The patient’s RN or LPN will document evaluation of patient condition and behavior at least once per shift;
including a review of the Close Observation Record.
6.1 The following will be documented by nursing:
6.2 Patient behavior, statements, and circumstances that prompted the nurse or staff to perceived the patient to be at risk for
suicide or harm to others.
6.3 Notification to physician of patient behavior
6.4 Implementation of the physician’s orders related to suicide precautions and/or related care (limitation or restrictions on number
and type of visitors).
6.5 The search for and removal of any actual or potentially destructive objects (document where the removed articles are secured).
6.6 Ongoing assessments of patient behavior, affect, speech and orientation.
6.7 Transfer of patient to a psychiatric unit or facility with appropriate escort.
291
7. Suicide precaution measures will be maintained until discontinued by physician order.
PROCEDURES:
1. Licensed Nurse:
1.1 Notifies attending physician of patient behavior
1.2 Initiates precautionary measures as indicated
1.3 Coordinates transfer to Psychiatric unit or facility as ordered
1.4 Acquires staff member/agency sitter for patients as indicated by Rule 4.
1.5 Schedules staff relief for staff member/staff as indicated by rules 4.1.
1.6 Documents as indicated by Rules 6.1. Documents on Close Observation Record at end of shift.
1.7 Posts sign “Please check at nursing station before entering patient room”.
1.8 Notifies Administrator on Duty
2. Sitter/staff member
2.1 Reports to charge nurse for review of suicide precautions and expectations
2.2 Records observations on Close Observation Record
2.3 Arranges break/relief with staff
2.4 Licensed staff member performs search of patient and room after each visitation
3. Unit Secretary
3.1 Notifies Patient Placement of patient status
Signature on File
Carolyn Swinton
Chief Nursing Officer and Vice President, Patient Care Administration, Palmetto Health Richland
Effective November 1976
292
Transporting Patients
Policy No. 4, R-2
March 2003
It is the policy of Palmetto Health Richland to provide safety measures and the appropriate level of care when
transporting patients from one environment of care to another.
GUIDANCE:
1. A nurse will assess the patient condition, prior to travel off unit or floor for procedures, to determine the level of care required during
transport. Documentation of the assessment must be reflected in the patient’s record and/or on the transport checklist.
1.1 The patient’s chart, including vital signs and medication record is sent with each patient.
1.2 All patients must have appropriate patient identification.
1.3 All monitoring equipment, respiratory support, intravenous fluids, pumps and other ordered equipment will be maintained
unless discontinued by physician order.
1.4 Critical Care Nurse will carry emergency drugs during patient transport.
2. The respiratory therapist’s assessment will include ventilation parameters and airway status/stability. A respiratory therapist must
accompany to and from the unit/floor all patients receiving mechanical ventilation. The primary nurse or department nurse is required
to stay with the patient during the procedure.
A respiratory therapist should be consulted to evaluate, prior to transport, any patients receiving oxygen concentration greater than
50 percent.
3. Selected patients receiving rehabilitation may travel to the rehabilitation department accompanied by rehabilitation personnel or by
family members if ordered by the physician.
4.
Patients undergoing sleep lab diagnostic testing will be accompanied by a respiratory care/sleep lab technologist.
5. Stable patients from telemetry units may have telemetry discontinued according to unit policy and remain unmonitored until return
to room at the completion of the diagnostic study as ordered. The transport personnel will notify the nursing staff immediately upon
returning patient to his/her room.
6. All patients meeting the level of care for critical care (Level II) will be accompanied by the primary nurse or transport nurse, respiratory
therapist, and/or physician for transport to and from off-unit procedures.
6.1 Noncritical care patients occupying unit beds do not meet the critical care criteria for Level of care (Level II) and may be
transported with the Level of monitoring appropriate for the noncritical care area.
6.2 Transport/Transfer of a patient from a critical care unit to a noncritical care area does not require Level II monitoring, unless the
patient requires monitoring on the regular floor.
6.3 Transport/Transfer of a patient from a noncritical care area or the Emergency Department to a critical care area requires Level II
monitoring.
7. Radiology department nurses will monitor and care for critical care patients for Special Procedures on a daily basis and after hours. A
licensed nurse will accompany the patient during transport to and from the department. Any significant change in the patient’s status
will be communicated between unit and radiology nurse before and/or after procedure as applicable.
8. Non-licensed transport personnel will present a transport checklist, which is to be initialed by licensed personnel prior to transport
and upon return of patient to the unit of origin. The minimum data set for the transport checklist will consist of:
8.1 LEAVING UNIT OF ORIGIN: time, items to accompany patient (ID bracelet, MAR, Code Status, Allergies); most recent vital
signs (T,BP, P, RR,SaO2), nurse initial, and transporter’s name.
8.2 RETURNING TO UNIT OF ORIGIN: time, safety measures provided, vital signs if patient has had change in condition/status or
invasive procedure, transporter’s name and nurse’s initials.
9. The following safety measures will be applied when patient is returned to unit of origin:
9.1 Transporter will use patient call system at bedside to notify unit personnel of patient return. Transporter will remain with the
patient until relieved by unit personnel. Should relief exceed a five-minute period, transporter will call for the Charge Nurse,
who may delegate another staff member to receive the patient.
293
9.2
9.3
9.4
9.5
9.6
Transporter will assist or move patient to bed as needed.
Transporter will ask for assistance as necessary based on the patient’s mental or physical condition, i.e. mental confusion,
obesity.
The nursing staff will ensure the bed will be placed in lowest position, with side-rails up as appropriate.
The nursing staff will ensure vital signs will be obtained on all patients after invasive procedures and/or those with observed
changes in condition or status.
The nursing staff will ensure bedside articles and call light will be placed within reach of patient.
10. RN/LPN must sign back of travel transport checklist indicating receipt of patient and responsibility for care.
11. Transporter must sign patient in/out in the logbook on unit of origin if applicable.
PROCEDURE:
Physician
1. Provide orders, when indicated, concerning transport care and
monitoring.
Nurse, Unit of Origin
2. Determine if patient can be transported off unit and the level of care
required during transport.
3. Determine type of personnel required to accompany patient.
4. Determine equipment to be maintained during transport.
5. Complete “Transport Checklist” when appropriate.
6. Provide report of patient’s status according to above guidelines.
7. Provide required care and monitoring when remaining with patient
during procedure.
Respiratory Therapist
8. Provide assessment, monitoring and care for patients with artificial
airways, mechanical ventilation, portable oxygen, pulse oximetry and
capnography according to above guidelines.
Transporter
9. Assure “Transport Checklist” is completed when indicated.
10. Follow all applicable safety guidelines in transfer and transport of
patients.
11. Complete appropriate section of “Transport Checklist” and unit log
book.
Nurse/Caregiver, Procedure Department
12. Provide required care and monitoring when nurse from unit of origin
does not remain with patient.
13. Provide report to unit of origin according to above guidelines.
14. Complete “Transport Checklist” when appropriate.
Physical Therapist/Occupational Therapist/Speech Path.
15. Designate patients who can travel to department unaccompanied or
accompanied by family.
16. Coordinate transport activities with nursing staff.
Signature on File
294
Signature On File
Carolyn Swinton
Transportation Level Requirements
Nonmonitored (Level I)
Monitored (Level II)
Neurological
Unchanged from Baseline or No Acute Changes
Moderate, severe, or acute change from baseline (Lethargic,
combative, decrease responsiveness over past 24 hrs and patient
assessed recently by physician). Requires 1:1 care due to extreme
agitation, violence, suicide or physical condition.
Respiratory
Not Supplemental Oxygen Dependent. Have
ability to maintain own patent airway. Oxygen
concentration less than (<) 50 % (to be determined
by respiratory therapy, unit nurse and physician
prior to patient leaving the unit).
Requires suctioning every 2 hours or more. Unable to call or
alert nurse or aide for respiratory needs. Bipap/CPAP and O2
concentration >50%. Endotracheal Tube. Mechanically ventilated
and/or weaning. Trach less than 72 hrs.
Vital Signs
Vital Signs stable or normal for patient; Vital signs
every 2 hr or greater.
Vital Signs unstable or requires monitoring more often than every
2 hours. Requires continuous intensive assessment and/or
intervention for life threatening situations and complex physiologic
needs for at least 2 hours. Includes CODE situation.
Noninvasive
Monitoring
Routine telemetry monitoring.
Pulse Oximetry where 02 Sat stable for 24
hr>93% and dependent on < (less) 50% 02 (*see
Respiratory Level I criteria).
Requires cardiac monitor, apnea monitor, hypothermia blanket, fetal
monitoring, or Oxygen saturation monitoring unstable for 24 hr or
02 sat >50%.
None
CVP, temporary pacemaker, femoral sheath, intraventricular drain,
intra-arterial hepatic lines, or lumbar drain, etc.
None or routine IV which does not require
constant monitoring or adjustments e.g. routine
Heparin, PCA, Renal dose Dopamine, non-titrated
Nitroglycerin drip
Vasopressor drugs and other IV drips or medications which require
frequent montoring q 2 hr or >; arterial lines for infusions; Patient
requires maintenance of 3 intravenous lines/drips. Also includes
hourly IV fluid replacement for stabilization or epidural catheter
infusion.
Sedation
None or routine pain medication. No Moderate
Sedation.
Moderate or Deep Sedation.
Transport
Hospital escort, tech or aide
RN and/or MD, and or Respiratory Therapist
Care
Tech or nurse’s aide
RN, MD and/or Respiratory Therapist
Invasive Monitoring
IV
295
TRANSPORT CHECKLIST
Time Leaving Unit of Origin:___________a.m. p.m.
Please denoted by checkmark these items accompany patient:
ID Bracelet MAR
Code Status Allergies
Most recent VS:
T
BP
P
RR
SAMPLE
SaO2
Nurse Initial (for transport)
Transporter’s Name:
Invasive Procedure Transport
New orders on chart: Yes_____ No _____
VS (Invasive Procedure):
T
BP
P
RR
SaO2
VS (Post invasive procedure or changes in condition/status)
T
BP
P
RR
SaO2
Comments: Nurse/Tech Initial
Received from Transport:
Time Received: ____________ a.m. / p.m.
Safety Measures Provided: Yes_____ No _____
Comments: Transporter’s Name: Nurse’s Initial Receiving Patient: 296
Verification of Invasive/Surgical Site
June 2004
Revised: January 30, 2006
Preoperative identification of an extremity, side of the body and/or surgical site will be a collaborative process
among the surgical team (Surgeon, Registered Nurses, Surgical Technologists (ST), and Anesthesia Care Provider),
as well as RN staff from patient care areas. This identification process of verification of correct surgical site is done
in order to prevent wrong site/wrong patient surgery.
Note: This protocol is applicable to all operative and other invasive procedures that expose patients to harm, including
procedures done in settings other than the Operating Room.
The patient and/or the patient’s legally authorized representative will be involved, to the extent possible, in the verification of correct
surgical site in order that the invasive/surgical procedures are consistently performed on the correct site.
Surgical Team: Surgeon, Anesthesia Provider, RN, ST, PA, NP
PROCEDURE:
Pre-Operative Verification:
1. Preoperatively, the RN will verify the patient and the invasive/surgical procedure by review of the following and document accordingly
in nursing notes:
a.
Informed consent
b.
Surgical schedule
c.
Physician’s orders
d.
Medical record review, armband verifying patient name and medical record number, H&P, and preoperative assessment
e.
Direct observation of marked surgical site
f.
Verbal communication with the patient and/or family members/significant others.
g.
Verbal verification of correct site with each member of the surgical team
2. To the extent possible, the invasive/surgical site will be verified verbally by the patient and/or the patient’s legally authorized
representative prior to the invasive/surgical procedure in the preoperative preparation area (for outpatients and admitted patients) or
on the patient care unit (for inpatients scheduled for surgery). Verification of the invasive/surgical site by the patient and/or the patient’s
legally authorized representative should match the H&P, surgical consent, and the OR schedule.
3. If the patient and/or the patient’s legally authorized representative is unable to communicate or unable to identify the surgical site,
the surgeon should be notified and requested to identify the invasive/surgical site based on H&P, surgical consent and in conjunction
with available family members or patient’s legally authorized representative. If the family is not available in person, phone verification is
acceptable. (refer to Informed Consent Policy) The RN will never mark the surgical site.
4. If the patient is a minor or unable to verify the information, the parent, authorized legal guardian, or health care proxy will verify the
correct surgical site. (refer to Informed Consent Policy)
5. Any conflicting information regarding the correct patient, correct procedure, or correct invasive/ surgical site will cause the process to
cease until all issues are resolved. The surgeon will be notified of the issues.
6. The discrepancy and resolution shall be documented in the medical record.
Marking the operative site:
7. The invasive/surgical site will be marked preoperatively at or near the incision site. The invasive/surgical site should be marked by
the surgeon. However, if this is impractical, the invasive/surgical site may be marked by an authorized physician assistant (PA), nurse
practitioner (NP) or resident provided they are a member of the surgical team who is fully informed about the patient and the intended
procedure. The mark will be made with a hypo-allergenic, latex-free ink pen, (e.g., a surgical marker) which will be clearly visible after
the site is prepped and draped.
The surgical site shall be marked “YES” to ensure the site marking is unambiguous and the method and type of mark is consistent
throughout the organization. In cases of eye surgery, the correct eye will be identified by marking above the operative eye. Site
marking of sensitive areas (e.g., genitalia) will involve marking the hand of corresponding laterality.
297
a.
b.
c.
d.
e.
f.
All cases involving laterality, multiple structures (digits, lesions), and multiple levels as in spine surgery, must be marked prior to
being transferred to the OR. Note: In addition to preoperative skin marking of the general spinal region, special intraoperative
radiographic techniques are used for marking the exact vertebral level. If two procedures are being done sequentially on the
same patient by different surgeons, the second surgeon is not required to mark in the holding area but may mark in the OR at
the completion of the first procedure.
Note: In the Gamma Knife Center, when treating Trigeminal Neuraligia the patient marks the site of the pain in the presence of
the physician. This eliminates the need for the physician to mark the site.
If the patient is scheduled for multiple procedures, the patient and/or the patient’s
Legally authorized representative will verify all sites prior to the invasive/surgical procedure.
When the surgical site involves an internal organ, e.g. kidney, whose laterality affects the incision site, the site will be marked.
Do not mark any non-operative site(s) unless necessary for some other aspect of care.
Patients have the right to refuse the site being marked. Team members need to be aware of these situations and the
Registered Nurse assigned to that patient must make a detailed entry in the notes clearly documenting the patient’s
objections.
Local procedures with no sedation involved may be marked in the OR.
Exemptions:
8. Exceptions to marking surgical sites are:
a.
Wire marked or methylene blue injected breast
b.
Vascular surgery where the site has been marked by the vascular lab
c.
Emergency surgeries
d.
Teeth, but indicate operative tooth name(s) on documentation, or mark the operative tooth (teeth) on the dental radiographs or
dental diagram.
e.
Premature infants, for whom the mark may cause a permanent tattoo.
f.
Surgeries where surgical site not predetermined (e.g. vein harvest site for CABG). Interventional cases for which the catheter/
instrument insertion site is not predetermined (e.g., cardiac catheterization).
g.
Single organ cases (e.g., Cesarean section, cardiac surgery)
9. The surgeon will verify all imaging data.
Time Out:
10. A timeout process will be initiated just prior to start of procedure and involve the verification of the correct patient, correct side and
site, correct invasive/surgical procedure, correct patient position, and as applicable any required implants and special equipment
or special requirements. This is done by reading aloud the informed consent, noting the patient’s identification, and observing for
the properly marked site, if applicable. The communication process needs to be active, not passive, and involve all personnel in
attendance (to include at minimum the surgeon, anesthesia provider, nurse and surgical technologist) just prior to the start of
the procedure. This process will be documented on the perioperative record for quality control initiatives.
11. Invasive/surgical procedures in which the individual doing the procedure is in continuous attendance with the patient from the time of
the decision to do the procedure and consent from the patient, through to the conduct of the procedure, may be exempted from the
site marking requirement. The requirement for a “time out” final verification still applies.
Approved by MEC: Date: 298
Visitors for Patients
Patient Care
Policy No. 6
October 1, 1976
Revised Date: July 20, 1999
Palmetto Richland Memorial Hospital permits visitors to patients and provides general guidelines to assure patient
welfare, respect of patient rights and uninterrupted patient care activities.
GUIDANCE:
1. Signs indicating general visiting hours are placed at the visitor information desk. Special visiting hours are displayed in the appropriate
patient lobby on the corresponding floor and in the visitor information brochure.
1.1. General visiting hours are 11: 00 a.m. until 8:30 p.m.
1.2. Patients will have visitors restricted as appropriate for patient care, patient privacy and patient welfare.
1.3 Visiting rules for special care, intensive care, and behavioral health units may differ from the general visiting rules.
2. Children (under 13 years of age) are permitted to visit under the following conditions:
2.1 Children may visit immediate family during normal visiting hours.
2.2 No child with a communicable disease may visit with any patient.
2.3 Children will be attended by an adult (non-patient) at all times.
2.4 Children may visit patients in isolation only if capable of following correct isolation procedures.
2.5 Children are not permitted to visit in the third, fifth or sixth floor lobbies of 5 Medical Park.
3. One parent or guardian may stay with the hospitalized child at all times. Other patients may have overnight visitors only as long as
patient rights are respected, patient welfare is assured, and patient care is not interrupted.
3.1 Overnight visitors may use recliner chairs in the patient’s room.
4. Signs on doors of patients in isolation will provide visitors information for proper precautions while visiting.
5. Seeing Eye and Hearing Ear dogs are the only animals that may be brought into the hospital.
6. Visitors whose actions, in the opinion of staff, show lack of respect for patient rights, threaten patient welfare or interrupt patient care
will be referred to Security Services.
7. All entrances must be secured in the evening except for the Emergency Department entrance which will remain open 24 hours per
day.
PROCEDURE:
Information Desk
1. Gives direction and assistance to visitors. Requests permission from
Nursing regarding exceptions for visiting rules.
Security Officers
2. Gives direction to visitors. Notifies Nursing of visit after normal visiting
hours.
3. Patrols floors on a regular basis and enforces visiting regulations.
Visitor
4. Observes visiting hours and other regulations.
Administrative Personnel
5. Enforces visiting regulations.
Signature on File
Signature On File
Carolyn Swinton
299
Warfarin Monitoring
Initial Policy: February 12, 2009
To assure the safety and timeliness of warfarin anticoagulation for the acute care setting.
GUIDANCE:
Policy and Procedure: Warfarin Monitoring
Purpose: To assure the safety and timeliness of warfarin anticoagulation for the acute care setting.
POLICY:
1. Warfarin administration in the acute care setting requires that an INR is obtained no less than every 72 hours during an acute
admission.
2. Warfarin is to be administered at 1800. A physician can overwrite the administration time according to clinical judgment.
PROCEDURE:
1. This policy applies to acute care areas.
2. Expectations:
»» A baseline INR will be obtained for all patients receiving warfarin upon admission and or initiation of warfarin therapy during
admission prior to receiving the first dose of warfarin.
»» Upon ordering warfarin, an order for INR every 72 hours will be placed unless a more frequent order has been written (i.e. daily).
»» The most recent INR will be reviewed prior to each warfarin administration.
»» For INRs less than or equal to 3.5, the ordered warfarin dose will be administered at 1800.
»» For INRs greater than 3.5, the physician will be contacted prior to the scheduled dose to clarify that the ordered dose should
be administered unless patient is receiving concomitant therapy with argatroban. Documentation of the communication with
the physician should follow hospital policy. For patients receiving a stabilized warfarin regimen for greater than 28 days, routine
monitoring of INR every 72 hours can be discontinued per physician discretion.
300
Withholding or Withdrawing Resuscitative Services in the
Absence of a Living Will (No Code or Basic Life Support
Orders)
Patient Care
November 1, 1989
The decision to withhold or withdraw resuscitative services will be the result of a responsible medical, legal and
ethical process, with due respect for the patient’s rights to privacy and self-determination. It is acceptable to
consider withholding or withdrawing resuscitative services in the event a patient is irreversibly comatose or whose
death will occur in a reasonably short period of time or for whom treatment would be futile or prolong the act of
dying. In the absence of a known living will or other advance directive, this policy will be the guide for withholding
or withdrawing resuscitative services, otherwise referred to as the No Code Policy. This policy has been developed
by Administration in consultation with health care and legal professionals and is in compliance with the South
Carolina Adult Health Care Consent Act. It has been adopted by the Medical Staff and approved by the Governing
Body.
GUIDANCE:
1. Definitions
1.1 For the purpose of this policy, Withholding or Withdrawing Resuscitative Services is defined as:
1.1.1 Not applying any stimulation, massage or pumping action to the heart by manual, mechanical or electrical means;
1.1.2 Not providing any assistance to respiration by oral (mouth to mouth) or mechanical means. This does not preclude
maintenance of airway by suctioning.
1.2 For the purpose of this policy, a Basic Life Support code is defined as providing manual CPR only; no electrical, mechanical or
pharmacological stimulation or intervention. Ordered routine medications should continue to be administered as prescribed
2. Procedure Statement
2.1 A No Code Order is appropriate if the following conditions are fulfilled:
2.1.1 The attending physician has determined that the patient is irreversibly comatose or that death will occur in a reasonably
short
period of time or that treatment will be virtually futile or prolong the act of dying.
2.1.2 The attending physician enters a properly authorized No Code Order under one of the following situations:
2.1.2.1 Competent Patient - When a patient is competent and informed of the consequences of his/her actions and
has authorized the entry of a No Code Order.
Competent to Consent - A patient is considered competent when he/she is able to appreciate the nature and
implications of his /her condition and proposed health care and can make a reasoned decision concerning
the proposed health care and communicate that decision in an unambiguous manner.
2.1.2.2.Incompetent Patient - When two physicians have examined the patient and determined that the patient is not
competent as described in 2.1.2.1. and there is no advance directive or other clear indication of the patient’s
desire, authorization to enter a No Code Order may be made by another person as provided for in the South
Carolina Adult Health Care Consent Act.
2.1.2.2.1. See RMH Policy 8200-37, Informed Consent, Rule 4.2, for the procedure to follow in obtaining
consent to authorize the No Code Order for the incompetent patient.
2.1.2.2.2. The No Code Order may be written after the attending physician has informed the person acting on
behalf of the incompetent patient of the consequences of the No Code Order and that person has
authorized entry of the order.
2.1.2.2.3. Attending physician may authorize entry of No Code Order if none of the above are available and
a second physician has examined the patient and certifies that the patient is unable to consent
and that all criteria for a No Code Order have been met. Both physicians must document. See 2.4
below.
2.2 Although nurses and other professional members of the health-care team do not participate in the actual decision making,
the health-care team participates in the actual implementation of the No Code Order. The health-care team shall monitor and
report to the physician relevant patient changes which may indicate that a review of the appropriateness of the No Code Order
is warranted.
301
2.3
2.4
2.5
Resolving Conflict in Decision-Making
2.3.1 Conflicts regarding the decision to withhold or withdraw resuscitative services may arise between the physician,
patients and family, legal representative or agent.
2.3.1.1 Competent Patient - The physician may honor the competent patient’s wish to have services withheld or
withdrawn despite objections from family members.
2.3.1.2 Incompetent Patient - In the absence of a known living will, the physician may honor the wishes of the
person authorized to consent for the incompetent patient despite objections form other family members. The
physician uses his/her judgement in deciding for the incompetent patient whether to initiate or continue a No
Code Order if substantial family conflict is present. In circumstances where conflicts exist, the parties will be
encouraged to access the resources available through the various hospital ethics committees in accordance
with the Hospital’s Medical Ethics Committee policy or other hospital resources, such as Pastoral Services.
In accordance with the South Carolina Adult Health Care Consent Act, if persons of equal priority disagree,
any person interested in the welfare of the patient may petition the probate court for an order determining
care or appointment of guardian.
Documentation of Withholding or Withdrawing Resuscitative Services
A decision to withhold or withdraw resuscitative services shall be documented by the attending physician in the patient’s
medical records. Documentation shall include an order that the resuscitative services, as defined by this policy, are to be
withheld or withdrawn. (If the intent is to withhold only a portion of the resuscitative services in addition to those included in
the definition of resuscitative services, the Order shall state these modifications so the intent is clear.) An entry in the progress
notes is also indicated, which should include the following information.
2.4.1 A description of the factors utilized in making the medical determination that the patient is irreversible comatose or that
death will occur in a reasonably short period of time or that treatment is virtually futile or prolongs the act of dying.
2.4.2 A reference to the patient’s competence or incompetence. Competence in this context refers to the ability of the adult
patient to understand the consequences of the No Code Order and communicate his/her desire for a No Code Order.
See Policy 8200-37. Informed Consent, Rule 4.
2.4.3 A reference to communication with the competent patient or the legal representative, agent or responsible family
member of the incompetent patient; in particular, a reference to a discussion of the consequences of, and authorization
for, the entry of the No Code Order.
Policy for Implementation of a Living Will: For patients with a Living Will, refer to the policy for the implementation of Living Will.
PROCEDURE:
Physician 1. Determine that treatment will not reverse imminent death.
2. Seek the decision of the appropriate family member or legal
representative if the patient is unable to make his/her own decision
for a No Code or Basic Life Support Order.
3. If a family member or authorized representative is not available or a
consensus cannot be reached, obtain a second physician’s consultation
to determine that the criteria for a No Code Order has been met.
4. If a consensus cannot be reached among the parties, utilize hospital
resources available through the various ethics committees and other
resources, such as Pastoral Services.
5. Document the decision for a No Code or Basic Life Support Order
on the Physician’s Order Sheet and in the progress notes, stating
factors utilized in making the decision, reference to competency and
communication with person authorizing the No Code Order.
Respiratory Therapist
6. Participate in the comfort care of patients on mechanical ventilation.
Nurse
7. Participate in the implementation of the No Code or Basic Life
Support Order.
8. Notify physician when the patient’s condition warrants a review of the
No Code or Basic Life Support status.
302
Signature on File
Signature On File
Carolyn Swinton
303
SM
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