Provena! - The Nurse Agency

Welcome to Provena!
Agency Orientation
Building a Culture of Excellence through our
Mission, Vision, Values:
Provena Health Sponsoring Congregations

Franciscan Sisters of the Sacred
Heart, Frankfort, Illinois

Servants of the Holy Heart of Mary,
Holy Family Province, USA,
Kankakee, Illinois

Sisters of Mercy of the Americas,
Regional Community of Chicago
(Aurora Ministries), Chicago, Illinois
Varied Pasts, Common Present, Shared Future
1843
1876
1889
Mission Statement
Provena Health, A Catholic health
system, builds communities of
healing and hope by
compassionately responding to
human need in the spirit of Jesus
Christ.
Our Values
• Respect – We affirm the individuality of each person
through fairness, dignity, and compassion.
• Integrity – We demonstrate the courage to speak and
act honestly to build trust.
• Stewardship – We use our human and economic
resources responsibly with special concern for the poor
and vulnerable.
• Excellence – We achieve exceptional performance
through continuous growth and development.
Gospel Emphasis
•
•
•
•
•
•
Defend Human Dignity
Whole Person – Body-Mind-Spirit
Care for the Poor and Marginalized
Promote the Common Good
Agents for Justice
Stewardship of Resources
Ethical & Religious Directives
• Pastoral & Spiritual Responsibility of
Catholic Health Care Services
• Professional-Patient Relationship
• Issues in Care of the Beginning of Life
• Issues in Care for the Dying
• Forming New Partnerships with Health
Care Organizations & Providers
The Role of Pastoral Care
• We attend to the medical, emotional and spiritual
needs of all patients, families, and you – the staff.
• We do daily rounding to all floors and electronic
charting of all visits.
• We respond to all codes, traumas, clinical alerts,
and pastoral care pages.
• We educate, initiate and complete advance
directive planning.
• We provide Catholic sacraments and services.
• We advocate for patient rights and ethical concerns
Pastoral Care Documents
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Power of Attorney for Healthcare
Living Will
Healthcare Surrogate Act
DNR Form
Provena Mercy Medical Center
SERVICE:
Measures of Excellent Service
1. Patient Satisfaction
2. Employee Satisfaction
3. Physician Satisfaction
Excellent Service is:
Living our Mission every day
Excellent Service
Creates a Great Place for:
Patients to receive care
Physicians to practice
Employees to work
We serve patients/families, physicians, and
the community
How do we Serve?
By Consistently Practicing
the Standards of Behavior
Standard of Respect
• Definition: Affirms the individuality of each
person through fairness, dignity and
compassion.
– Professionalism: Speaking and acting with
appropriate body language and tone.
– Teamwork: Building trust by providing
support, encouragement and gratitude to
fellow co-workers.
– Communication: Objectively presenting views,
suspending judgment when listening.
Key Words at Key Times
When do you use Key Words?
• To address survey questions/key
drivers
• Tough Questions
• To help the patient or family understand
his/her care – when we need to be
consistent
• Five Fundamentals of Service
Key Words/Key Actions at Key Times
What do our patients need to hear to feel safe…
“Your doctor is excellent; the radiology team
has over __ years of experience.”
To feel cared for…
“I am here for you…I have time for you…what
can I do to make you feel better?…”
5 Fundamentals of Service
Acknowledge – Key Words and Key Actions
– Walk a visitor/patient to his/her
destination
– Knock, touch curtain
– Speak before entering room
– Make eye contact
– Smile
– Stop whatever you are doing so the
customer knows he/she is important
Introduction
• Welcome (standing up when meeting
someone shows respect)
• Say your name
• Give your department
• Tell your role in patient care
• Manage up your skills, experience and
training – why is this important?
Duration
• How long before the test begins
• How long the test will take once begun
• How long before results of the test are
available
• What happens with results
Explanation
• Test or procedure
• Who is involved
• If there will be pain or discomfort and
what will be done to ease either
• Offer to answer questions, address
concerns
• “Is there anything else I can do for you?
I have the time.”
Thank You Key Words and Key Actions
“Thank you for choosing Provena
Mercy Medical Center for your
healthcare needs.”
“Thank you for your patience, while I
___.”
“Do you have any questions that I
can answer for you now?”
Managing the Moment/
Service Recovery
All employees are responsible for identifying
service recovery opportunities when a
patient/family identifies a “less than best
service” experience or an employee is aware
of an unhappy patient/family member as a
direct result of our service.
When an
Incident
Occurs!
On the Road to Excellence…
Service Recovery Decision & Gift Guideline
*Providing “AAA” Service*
Start with an
Apology
It is very important to
us to provide very
good care. I’m so
sorry we did not meet
your expectations
Thank you for bringing
this situation to our
attention. What can
we do to help the
situation?
Please accept this gift
to further express our
apology. Is there
anything else I can do
for you? I have the
time.
Again, it is very
important to us to
provide very good
care.
Determine the
Level of Severity
Level 1-Minor
•Food Late
•Noise Level
•Cleanliness of Room
•Utility Problems
•Cold Food
Level 2-Moderate
•Wait time for schedule
services
•Roommate issues
•Time delay
•Communication
Problems
Level 3-Serious
•Failure to communicate
Increased LOS
Level 4-Severe
•Fall with Injuries
•Medication Errors
•Poor Pain Control
•Loss of Personal Property
•Major Lack of communication
•Issues resulting in Litigation
Apologize &
Acknowledge
Amend
Explain that the problem
will be addressed
immediately and ask for
any necessary information.
Provide Service Recovery Gift
as Appropriate
Notify appropriate persons)
as necessary to correct
situation
Level 1-Minor
Café coupons Dining In
$5 or less
At Serious Level, notify
your manager or director.
If they are not available
contact the patient
advocate.
Level 2-Moderate
Café Coupons /Gift Shoppe
Coupons
Level 3-Serious
Café Coupons or Gift Shoppe
Notify Patient Advocate
Performance
Improvemen
t/Follow Up
Level 4-Severe
Senior Management Notification
Notify Patient Advocate
Corporate Responsibility:
Regulatory Compliance
“Systems that ensure all employees are
aware of laws and regulations and act
in accordance of those regulations”
Corporate Responsibility
Why is this important to me?
Regulatory compliance programs are put
into place to reign in those organizations
that operate outside established laws
and guidelines to turn a profit. It has
become vital that healthcare
organizations implement compliance
program to prevent compliance violations
and reduce the potential for liability
should violations occur.
Compliance Goal
Provena Health is committed to compliance with all
federal and state laws and regulations.
The goal of Provena Health’s compliance efforts is
to ensure all business is conducted ethically,
honestly and in accordance with all rules,
regulations and standards
Office of the Inspector General
• Office of the Inspector General (OIG)
• The enforcement arm of the Department of
Health and Human Services.
• Primary goal is to investigate suspected
health care fraud and abuse, specifically:
Medicare
&
Medicaid
Risk
A large portion of the OIG regulations focus on
Risk Assessment
At Provena Health our highest risk areas are:
• Coding
• Billing
• Documentation/Charting
• Chain of Command issues
• Quality of care-Substandard Care
• Patient/Resident Privacy (HIPAA)
OIG - Recommendations
Due Diligence Recommendations
• Standards of Business conduct education for all
employees
• Senior Oversight of Compliance Programs
• Background checks on all employees, vendors, and
volunteers before hire and biannually
• Create a culture of awareness and establish reporting
mechanisms
• Compliance monitors and audits performed on a regular
basis
• Standards and Compliance procedures for all employees
The Provena Health Corporate
Responsibility Plan
Provena Health’s Standards of Behavior are based on the
Provena Health Values of:
Respect
Integrity
Stewardship
Excellence
It is the expectation of all Provena Health employees that they act with
integrity, honesty, and they approach all customer interactions
ethically and confidentially
The Provena Health Corporate
Responsibility Plan
Due Diligence in Hiring:
Criminal background checks are performed on all new
employees. We additionally check the Excluded Provider list
to assure that our employees, medical staff and vendors
have not been excluded from participating in any federally
funded health care programs.
Employee Awareness and Training:
All Provena Health employees are required to participate in
annual Corporate Compliance training. All employees are
required to receive Corporate Compliance in Orientation.
The Provena Health Corporate
Responsibility Plan
Monitors and Audits:
At Provena Health, systems are in place to continuously
monitor the accuracy of our coding, billing, and
documentation. These systems are designed to
reasonably detect errors and problems.(CHAN -Catholic
Health Audit Network is Provena Health’s internal auditor.)
Discipline:
Any violations of corporate compliance is taken seriously
and appropriate and consistent disciplinary action is
taken for all violations, regardless of title, position, or
affiliation.
The Provena Health Corporate
Responsibility Plan
Alert-Line:
• A confidential and anonymous vehicle to report
compliance issues.
• Outsourced to Global Compliance and reporting is free
of retaliation.
• Our preference is that you initially follow the standard
chain of command when faced with a compliance issue.
Supervisor-->Local Compliance Liaison-->
System Compliance Officer, then to the Alert-Line
1-800-93-ALERT
The Provena Health Corporate
Responsibility Plan
• When errors are detected, we take reasonable
steps to respond appropriately:
– Stop the process, protocol or billing if necessary
– Determine the cause of the error
– Develop a protocol to prevent future errors
– Communicate and implement protocol
– Continuously monitor the protocol
False Claim Act
This Act provides a legal tool to
counteract fraudulent billing turned into
the Federal Government
Claims under the Act are filed by persons with
inside knowledge of the false claim
(“whistle blowing”)
False Claim Act
False claims can occur with documentation issues
that turn a legitimate claim into a false claim.
Problem Areas:
– No documentation
– Incomplete or incorrect documentation
– Documenting on delivery of care that you did not
deliver personally or witness being delivered.
– Missing signatures
– Missing or backdated dates
False Claim Act
Billing High Risk Areas:
• Supplies or services
not delivered
• Services not
medically necessary
• Billing for a noncovered service, as if
covered
• Outpatient services
that should have
been included as part
of an inpatient stay
•Up-coding
•Misrepresenting a
diagnosis to justify
services
•Unbundling
•Duplicate billing
Your Responsibility
Conflict of Interest:
• Arises when anyone has 2 duties that conflict. Staff must not use
their positions for profit or share confidential information for gain.
• Staff must disclose personal or family interests if that business:
– Buys/sells goods or services to/from Provena Health
– Competes with Provena Health
– Is in a position to benefit from patient referrals
Gifts, Honoraria and Gratuities:
Staff is not allowed to except tips, money, gifts, or other items of
value from patients, vendors, or any private party. Generally,
you can only accept gifts of appreciation that can be shared or
used for the common good of the ministry.
Your Responsibility
It is the expectation of Provena Health that
all employees exhibit the Standards of
Behavior, know what is right, and do what
is right.
If you see something that does not look or
feel right, contact your supervisor or the
Corporate Responsibility Liaison or call
the Alert-Line.
Your Resources
• Provena Health Corporate Compliance and
HIPAA Policies can be found on DOVEnet
http://dovenet.provena.org/
• Local Compliance
Liaison
• Alert-Line
Web page photo
HIPAA Standards at
Provena Health
• Protect patient rights by giving access to their
confidential Health information and control over how
this information is used.
• Protect the physical security of resident and patient,
confidential health information.
Privacy and Security Standards
Privacy Standards:
– ensure that patients have access and control over
how their health information is utilized.
– these standards deal with patient expectations of
how we use that information.
Security Standards:
Ensure that we keep patient health information, safe
and secure. This includes all health information that is
stored physically and electronically.
What HIPAA is Not
HIPAA is not a reason to withhold or discuss a
patient’s condition with a family member.
“I cannot tell you what is going on with your
loved one due to HIPAA”
What should be done is to verify the identity of the
caller or visitor and ask verbal permission to share
information with the family member.
HIPAA Privacy
Breeches in Confidentiality
• 1 out of every 5 Americans believe that
their health information has been used
inappropriately.
• 1 in 6 Americans report that they have
provided inaccurate information to a
health provider because they feel it would
not be kept confidential.
What happens when patients don’t
trust us?
Protected Health Information (PHI)
Name, address, city, county, zip code,
fingerprints, names of relatives, name of
employer, date of birth, telephone number,
social security number, fax number, photos,
medical record or account numbers, and
license number.
Any information that can be used to
identify and individual.
Shared in any form, verbal, written, or
electronic.
Vital Behaviors to Protect PHI
• Only share information on a need to know basis and
accessing and disclosing information as specifically
required by your duties.
• When engaging in verbal conversation, keep your
voice down, close doors or curtains.
• Never discuss patient information in elevators or
other public places (ex. Cafeteria)
• Patient’s charts are stored out of public view.
• Reduce all patient information that could be visible to
the general public.
Vital Behaviors to Protect PHI
• When announcing a patient overhead, use of
name is OK, however the patient/resident or
family member should be referred to a reception
desk or other non-specific location.
• When leaving information on answering
machines limit information to:
– Name of the facility or physician
– Time of appointment
– If necessary to discuss treatment or procedures,
leave a call back number
PHI – Access & Control
Notice of Privacy Practices:
– It is not the intent of HIPAA to stand in the way of the
using information for normal operation: Treatment,
Payment or other Health Care Related Operation.
– This document informs our patients how we use and
disclose their protected health information.
Authorization Form:
– HIPAA Standards state that Patients have a right to view
or obtain a copy of their medical record. This is done
through the Authorization form.
Employees/Families as Patients
Sharing is
not caring
Provena Health has a HIPAA Corrective
Action Policy. Willful or intentional
violations will result in immediate
dismissal.
HIPAA Security Standards
Not only are we responsible for
access, control and
confidential handling of patient
information, we are also
responsible for the physical
security of that information.
Provena Health Security Measures
• Provena Health takes a 3-pronged
approach to protect confidential health
information:
– Administrative Safeguards – specific policies
and procedures that ensure HIPAA Security is
a priority.
– Physical Safeguards – protective software,
firewalls and controls.
– Technical Safeguards – encryption, password
protection.
Workstation Management
Workstation = any electronic computing
device
Not only are you responsible for the
content you send and receive, but also
the physical care of that
equipment
It is your professional responsibility to
maintain and care for these devices.
Workstation Management
All devices have password protection:
– You are professionally responsible for
your password and must never share it
with anyone – for any reason.
Password development:
• Make your password at least 6 characters
long.
• Include numbers and special characters.
• Use upper and lower case characters.
Electronic Applications
Sending PHI Electronically:
Before you send PHI, you must get your
immediate supervisors approval, approval
from the patient and password protect all
documents.
Electronic Applications
Faxes:
• Fax from a machine in a secured area.
• Include a cover sheet with the confidentiality
statement.
• Double check the phone number:
– Before entering on the key pad
– After entering on the key pad
• Pick up documents after sending.
• Retrieve confirmation sheet after sending.
• Call and make sure another qualified person is there
to retrieve the fax.
Quality Management:
Regulatory Bodies
What is the Joint Commission?
www.jointcommission.org
Who is CMS?
www.medicare.gov
www.hospitalcompare.hhs.gov
Who is IDPH?
www.idph.il.state.us
Survey Process
• Surveyors can present at any time-usually
unannounced
• Can come based on complaint
• Patients, families, employees can report
concerns to any regulatory body
• Code 777 is announced overhead
• Tidy up and continue your normal routine
• Surveyors will be escorted by Administration
• Answer honestly, politely
Public Reporting and what
that means to me…
• Soon, almost everything we do will be
accessible to the public-the good, bad and ugly
• Check out Minnesota Patient Adverse Events
• Check out www.FloridaHealthfinder.gov
• Public may not know how to
interpret the results on the internet
• There is no perfect hospital
Info Available on the Web
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Patient Satisfaction scores
Mortality rates
Adverse events such as suicide, falls, abductions
Core Measures
– Heart failure
– Heart attack
– Pneumonia
– Surgical Care
• Nursing Hours
Performance Improvement (PI)
& Measurement
• What is PI?
• PI is ongoing, continuous improvement ALL the
time
• Can be
– Improving outcomes (no infection, no harm, live birth,
no readmission)
– Improving process (wait times, accuracy, efficiency,
documentation)
When something goes wrong
• We investigate so that we can learn and prevent
reoccurrence-gather the people involved
• Identify the ‘root cause’ of the event and analyze it
(Root Cause Analysis-RCA)
• RCAs are non-punitive and confidential
• What is the goal? TO LEARN
• How do RCA’s come about?
– Variance Reporting(Incident Reports): one of the most
valuable tools a hospital has for identifying areas where
adverse events are occurring or have the potential to
occur; DO NOT chart that you have filled out a variance
in the patient’s record
On the main desktop click
on the Internet Explorer
icon
Click here to begin Variance Reporting
Select the type of variance
•Fall Variances and Medication Variances are
patient related.
•Other Variances are visitor related or patient
related such as delayed testing, left AMA, etc.
Each screen includes the
• Main information
screen
Follow the
onscreen instructions for
• The Legend
completing the report.
• Help
Patient Safety & Risk Management:
Overview
• 1999 IOM Report – Up to
100,000 preventable deaths in
U.S. Hospitals per year
• 1.3 million Americans are
injured and more die each year
from medication errors
• Hidden epidemic of life
threatening infections killing
tens of thousands of patients
each year
Who we are
• Hospitals are high hazard organizations (along
with aviation, nuclear power production, chemical
manufacturing, military). Why?
– Errors that we make lead to death or injury
– We deal with ethical, legal, moral issues unlike any
other business or enterprise
– Intense scrutiny by the public and regulators
How Do We Ensure Safety?
• With proper organization of people,
technology and processes, hospitals
can handle complex and hazardous
activities at acceptable levels of
performance
• Support those who are Caring for
the Patient
– Decision making migrates to the
person best capable of making it,
even if not the highest in rank
What we must do
Create a Culture of Safety
– Encourage error reporting (Variance Reports)
• Non-punitive system
• No tolerance for avoidance or cover-up
• Support any employee involved in a serious error
– A culture of safety is about changing the
environment from one of blame, to one where
we ask, why did this happen, and what can we
do to prevent it from happening again?
Systems Issues as
Opposed to People Issues
• Understand that humans make errors,
especially when tired, stressed, and they feel
unsupported.
• Ask “why” an error occurred, rather than “who”
made the error
• Moving past “blame and shame” mentality
• Every “incident” or error would be viewed as a
System Problem, not an Individual Problem.
Good Documentation is Key
• Patient charts document the quality of patient
care
• Communicate the care of the patient to all
caregivers
• Is used by attorneys to determine whether they
will file a lawsuit
• Juries rely on the chart as the authoritative
account of what transpired
What Are We Doing at PMMC to Create
This Culture?
• Blame and shame behaviors are not tolerated
• Errors and unanticipated events are viewed
with an eye toward systems issues, not human
ones
• Teamwork and communication is emphasized
• We encourage the reporting of all adverse
events and near misses
PMMC Safety Initiatives
• Fall prevention program
• Education and training of all staff (patient
identification, suicide assessment,
communication of critical lab values, etc.)
• Patient and Staff Safety surveys
• Restraint Reduction
Patient Rights &
Responsibilities
Every patient upon registration, receives a
brochure detailing their RIGHTS:
– Be free from abuse, neglect, inappropriate
behavior
– Be treated with courtesy and respect
– Have personal privacy respected
– Know the identity and professional status
of individuals providing care
Staff with Concerns about Patient Safety
• Any employee who has concerns about the
safety or quality of care provided at PMMC
may report these concerns to The Joint
Commission.
• There will be NO retaliation or discipline on
the part of PMMC for any report made by an
employee.
• The Joint Commission may be reached at
630-792-5000.
Safety & Security
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24/7 operation - E.D. & BHS offices
ID Badges
Access control
Suspicious persons/circumstances
Valuables, lost & found, patient meds
Escort employees to vehicles
Vehicle assistance – lock outs, jump starts
Who is Responsible for Safety?
All of us. Be aware of your
surroundings, notify Security of
suspicious or dangerous
persons or circumstances.
Dial 1111.
Id Badges
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•
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Worn at all times while on duty
Worn above waist
Unobstructed w/name & photo clearly visible
No pins, stickers, etc. on badge
Used for Kronos time clock & door access
Wear your Agency badge and we will give
you a PMMC contractor badge when you sign
in
Code Red = Fire
• R.A.C.E. = Rescue Alarm Contain Evacuate
• P.A.S.S. = Pull Aim Squeeze Sweep
describes the proper use of a fire
extinguisher.
– Use for small fires
– 15 – 25 seconds operation time
– Meant to slow the fire’s spread
Code Green
• Dial 1111
• Utilities Failure
• Red outlets/plugs are for required
patient support equipment
• Await instructions from supervisor
Code Orange
• Hazardous Material Spill
• Dial 1111 and have Environmental
Services notified
• Take necessary precautions, i.e.
evacuate, keep others away
• Contact supervisor
Code Gray
• Bomb Threat
• Dial 1111 to report a bomb threat or
suspicious package
• Prepare for evacuation
• Assist response team with search
Code Black
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•
•
•
•
Tornado warning - within 20 miles
Do not use elevators
Close all doors and window coverings
Move patients away from windows
Move ambulatory patients into hallway
Code Purple
• Prepare to evacuate patients and
visitors
• Wait for instructions for evacuation
Code Adam
• Infant or Child abduction
• Newborn to 1 year: Use “Code Adam.”
• 1 year and up: State the age and gender
as, for example: “Code Adam, male, 8
• Do not allow anyone in or out of your area
• Watch elevators, stairs and exits
• Immediately contact security to report
suspicious persons
Mr. Speed – Dial 1111
•
•
•
•
Aggressive/Disruptive Person
CPI trained staff respond
Show of force is important
If in doubt, call it out
Code Silver
• An aggressive or agitated person armed
with a firearm (handgun, rifle, shotgun)
Call 1111
• Report location to operator
• Close all doors and remain with most
critical patients
• Non-clinical staff evacuate from public
areas of the hospital to a safe location
Code Blue/Code Blue Pediatric
•
•
•
•
Cardiac and/or Respiratory Arrest
Dial 1111
Remain with the patient and start BLS
Code Blue team will respond
Code Blue Team
• Patient’s RN: responsible for
providing history
• ED or other physician: runs
the code
• ED RN: documents and runs
the crash cart
• ICU RN: starts lines and
administers medications
• Anesthesia
• Respiratory
• Pharmacy
• Pastoral Care
• Security
• Director/Coordinator/
Nursing Supervisor
– Directs &/or dismisses
team as needed
– Assures Physician & family
notified
– Arranges for transfer
– Completes Code Quality
Review Form in nonpatient areas or directs
others
Expectation of Staff
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•
•
•
•
•
•
Assess ABCs
Initiate CPR
Call a Code
Bring Code cart
Remove
roommate/visitors
Clear space
Staff off floor: return
Start documentation
Set up suction
Assist as directed
Primary Nurse
• Give report to Code
Team
• Assist with
documentation on
Cardiopulmonary
Resuscitation Record
• Ensures Code cart is
exchanged
Rapid Response
• If there is concern for patient condition or signs
of deterioration
• Responders: ER RN, ICU RN, Respiratory
Therapist, the Nursing Administration
Supervisor, Clinical Nurse Manager if available
and Clinical Nurse Specialist/APN if available.
• Any person can call a Rapid Response including
patients, family, or visitors
Brain Alert
• Suspected Stroke
• 1st call a Rapid Response for further
evaluation
• Inpatients sent to ED for further
assessment and/or treatment
• Stroke patients are then
transferred/admitted to 4th floor or ICU
Equipment Management
A Medical Device is any item that
is used for the diagnosis,
treatment, or prevention of a
disease, injury or other condition
and is NOT a drug or biologic.
Inspecting Medical Equipment
• Inspecting Medical Equipment for safety and correct
operation before its use, is the responsibility and
requirement of each of us as end users of a device.
• ALL new medical equipment must be inspected by Clinical
Engineering prior to use.
• It is critical to the safe use of medical equipment that
before it is used, that it be inspected for safety and
correct operation.
• This needs to be done each and every time it is used.
– Are the cords frayed
– Is the device functioning the way it is supposed to
function?
Reporting Equipment Failure
• To report a failure or to submit a work request for a
piece of medical equipment call extension 3100. This
will open a work order for the Biomedical Engineering.
Please no not use the on-line work order system as this
is for non-medical equipment failures.
• Have the CEID number (Clinical Equipment ID Number)
ready, as this will help us locate the correct device.
The 3100 extension goes to a live operator at TriMedX.
These operators will then dispatch a service engineer. This
includes normal and after hours needs.
Hazardous Communication Plan
The Materials Safety Data Sheets
(MSDS):
Is a vehicle that is used to allow
employers to provide employees with
information about hazardous chemicals
and materials that the employee may be
exposed to in the workplace.
Hazardous Communication Plan
Where to Find the MSDS at PMMC:
• On PMMC’s Intranet-materials used in each
department is available on line via 3E’s Healthcare
MSDS Database. A guideline on how to access 3E by
intranet or phone will be kept in all departments (a
burgundy colored binder)
• The Emergency Department houses the master file of
the MSDS, excluding those pertaining to Pharmacy and
Laboratory chemicals, which will be housed in the
respective department manuals.
The Hazardous Communication Plan can be found in our on-line policies. The
policy number is II-03-3.5
Emergency Management
What is Emergency Management?
An overall strategy developed in order to
successfully handle large numbers of
casualties and/or disruption to normal
hospital operations.
Goals of Emergency Management
• To provide safe, effective patient care during an
emergency
• Staff roles are defined, and they are trained in their
responsibilities
• Priority emergencies for the organization are
assessed, prioritized and planned for
• It allows staff to easily adjust to changes in volume,
acuity, work procedures
• It outlines who our work partners are within the
community at times of emergency
What is the Emergency
Operations Plan (EOP)
• An all-hazards response that outlines what to do
in an emergency situation or event
• Fundamentals: receive direction from supervisor
– “1111”
– Code Triage Levels
– Departmental Roles & Responsibilities
– Surge Capacity
– Other related policies
EOP Fundamental: Code Triage Levels
• Divides emergency into 3 levels based
on number of patients anticipated
– Code Triage Level 1 (1-10 patients)
– Code Triage Level 2 (11-20)
– Code Triage Level 3 (21 or more)
• A red Disaster/Surge manual is kept in
every department outlining roles at
every level
EOP Fundamental: Surge Capacity
Policy
• Plan where to place overflow patients
• Takes what we already do & places it in a written
format; Drawn on experience of our senior staff
• IDPH mandate is to prepare for 20% over our
licensed operating capacity
• Activated after we reach Peak Census
Diversity:
Diversity Definitions
• Diversity – Recognizing and respecting
similarities and differences
• Cultural Diversity – A dimension of diversity
within society which includes country of origin,
ethnicity, race
• Workplace Diversity – A dimension of
differences within the work environment
including job level, occupation, department, FTE
status, exempt vs. non-exempt, benefited vs.
non-benefited, etc.
What is Diversity?
Diversity is about inclusion of
differences and the respectful
involvement of all people, calling
forth the gifts from each person’s
cultures, perspective and
background.
What is Inclusion?
Inclusion is:
• Welcoming the uniqueness of the talents,
beliefs, backgrounds, capabilities and ways of
living of individuals and groups when joined in a
common endeavor
• Welcoming differences to create a culture of
belonging
• Practicing behaviors that leverage and honor the
uniqueness of people’s different talents, beliefs,
and ways of living
Diversity in the Workplace
Valuing diversity means creating a
workplace that respects and includes
differences, recognizing the unique
contributions that individuals with many
types of differences can make, and
creating a work environment that
maximizes the potential of all
employees.
Our Commitment
Provena Health is committed to diversity. We
believe that respecting, leveraging, and
celebrating the diversity of our workforce, our
patients and their families, and our communities
create value. We practice inclusion because it’s
central to our mission and values and enables
us to respond to the diverse needs of those we
serve.
Accessing Policies
Harassment
We are committed to providing a professional, respectful
and safe working environment that is free from
discrimination or harassment.
Harassment
Visual
Verbal
Physical/Sexual
Harassment =
Unwelcome conduct, based upon…
Gender
Color
Race
Ancestry
Religion
Age
Disability
Veteran
Status
Citizenship
National
Origin
Marital
Status
Sexual
Orientation
What Do You Do?
• Discuss with your Immediate Supervisor if
appropriate, or your Manager or Director.
• If your Immediate Supervisor is not available you
may contact the Nursing Administrative
Supervisor (5549), Human Resources or call the
Alert-Line at 1-800-93-ALERT.
Smoke Free Campus
• To establish and maintain the safest possible
environment in which to deliver quality health
care.
• Includes all tobacco products.
• Includes PMMC campus building/structures,
property, parking lots, and vehicles.
• Applies to all Employees, Medical Staff,
Patients, Visitors, Students, Vendors,
Contracted Personnel, Volunteers, Tenants and
other invitees of PMMC.
Meal Periods & Rest Breaks
• Meal Periods: Non-exempt, (hourly), employees scheduled to
work a shift of 7½ continuous hours or more are provided a 30
minute unpaid uninterrupted meal period.
• Time keeping system automatically deducts an unpaid 30 minute
meal period for those non-exempt employees who work 5 hours
or more.
• Non-exempt employees must be paid for all time worked. In
those rare situations when an employee is not able to take or
complete an unpaid meal period without interruption, he/she
must notify their leader before completion of the shift and
complete a “Missed Unpaid Meal Period” form and enter “no
lunch” in Kronos.
• IF YOU DO NOT THINK YOU WILL RECEIVE A LUNCH,
NOTIFY THE CHARGE NURSE AND THE NURSING
SUPERVISOR OR YOU WILL NOT BE PAID FOR IT
Workplace Safety
Work-Related Injury
• An injury during the course of doing your job
• All injuries are investigated and evaluated
• Not all injuries that happen in the work place are
work-related
• If you are injured while working:
– Notify Charge RN and RN supervisor
– Fill out the paper Injury Report
– Notify your Agency
What Governing Body Regulates Safety
within Our Institution
Occupational Safety and Health
Administration (OSHA):
OSHA was created in 1971 under the Occupational
Safety and Health Act. It’s mission is to “prevent
work-related injuries, illnesses, and deaths.
Since the agency was created in 1971, occupational
deaths have been cut by 62% and injuries have
declined by 42%.”
Back Safety
•
•
•
•
•
•
•
•
•
•
Get close to the object
Face the object squarely.
Make sure you are balanced
Squat, bending your knees, Keep your back straight
Tighten your stomach muscles
Bring the object close to you
Grip the object firmly
Look straight ahead or up
Use your legs to stand
Keep the movement smooth and controlled
Back Safety
•
•
•
•
•
•
•
•
•
•
Prepare: Is your footing solid?
Clear the movable objects out of the way
Know where the unmovable objects are and how to get around them
Do not lift objects over your head
Do not twist
Do not reach over an obstacle to lift
Follow the safety guidelines of the workplace
Wear supportive shoes that are not slippery
When lowering an object follow the same steps
Lifting guidelines apply to all job tasks-shoveling, pushing, pulling,
sweeping, etc.
• These guidelines also apply to patient transfers
Minimal Lift Program
•
•
•
•
WHY USE LIFT
EQUIPMENT?
Prevent care giver
injury
Prevent patient injury
Prevent patient fall
Corporate policy
WHO USES LIFT
EQUIPMENT?
• All care givers who
transfer or reposition
patients
•
•
•
•
•
Nursing staff
Transporters
Therapists
Radiology
Surgery
What Equipment Do We
Have and Where Is It?
•
•
•
•
•
EQUIPMENT TYPES
Equipment is available to
move most patients.
Minimal assist-Stedy
Extensive assist-Encore
Total assist-Tempo
Bariatric-Tenor
Lateral transfersmaxislides or Patrans or
Hover Matt
•
•
•
•
•
•
•
LOCATIONS
3rd floor
4th floor
5th floor
Hope Unit
Radiology
Emergency
Department
Surgery
Infection Control
HAND HYGIENE:
the biggest piece of the puzzle
2 ways to Wash your hands
1.Soap and Water Method
2.Waterless Method (Alcohol-based hand rub)
Hand Washing
• Before and after work shift
• After using washroom, before eating, drinking,
or handling food
• After your skin comes in contact with blood,
body fluids, mucous membranes, non-intact
skin, secretions, excretions, and contaminated
items
• Whenever hands become visibly soiled
Effective Hand Washing
1. Wet hands first with water (avoid HOT water)
2. Apply 3 to 5 ml of soap to hands
3. Rub hands together for at least 15 seconds
4. Cover all surfaces of the hands and fingers
5. Rinse hands with water and dry thoroughly
6. Use paper towel to turn off water faucet
Hand Sanitizing
When?
• Entering and Exiting a patient room
• Before putting on and after removing gloves and other PPE
• After blowing your nose, covering a sneeze/cough
How?
• apply 1.5 to 3 ml of an alcohol gel or rinse to the palm of one
hand, and rub hands together
• cover all surfaces of your hands, including fingernails
• continue rubbing hands together until alcohol dries
It should take at least 10 -15 seconds of rubbing before
your hands feel dry
Advantages of Alcohol-Based Hand Rub:
– take less time to use
– can be made more accessible than sinks
– cause less skin irritation and dryness
– are more effective in reducing the number
of bacteria on hands
– making alcohol-based hand rubs readily
available to personnel has led to improved
hand hygiene practices
Artificial Nails
• These are not permitted for direct patient caregivers and
outpatient care settings
• Not permitted for individuals whose responsibilities
include the handling of patient care supplies/ equipment or
food
• Glitter, appliqués, and cracked nail polish also
harbors organisms and contributes to the spread of
infection in the health care setting
Infection Chain
THREE ELEMENTS
1. Organism
3.
2. Susceptible
Host
Organism
• Bacteria
• Viruses
• Fungi
Susceptible Host
– Very old or young
– Unvaccinated
– Weakened immune system
– Malnourished
– Chronically ill
Modes of
Transmission
Contact
• Direct
• Indirect
Many DRUG RESISTANT
ORGANISMS
Airborne
•Tuberculosis
•Chickenpox
•Smallpox
•Measles
Droplet
• Flu
• Some types
of
Meningitis
Vector / Vehicle
– VECTOR BORNE
• West Nile Virus
• Malaria
• Plague
– VEHICLE BORNE
• Food Poisoning
Breaking the Chain
– Good hand hygiene is the single most
effective means of breaking the chain
– Receive immunizations
– Adhere to isolation precautions and utilize
appropriate PPE
– Don’t come to work if you are ill
Isolation Precautions
•
•
•
•
•
AIRBORNE
DROPLET
CONTACT
CONTACT WITH MASK
NEUTROPENIC
• SPECIAL = AIRBORNE + CONTACT
AIRBORNE Precautions
Requirements:
• Negative Pressure Room
• N95 Respirator Mask on family and care providers
• No children visitors
Organisms:
– Tuberculosis
– Measles
Tb Risk Factors:
• Foreign Born
• High Risk Occupations
• Suppressed Immune System
• HIV Infection
• Substance Abuse
• Resident of
• Correctional Facility
• Nursing Home
• Homeless Shelter
Signs & Symptoms Tb Disease
• PERSISTENT, PRODUCTIVE COUGH (more than 3
weeks)
• Hemoptysis (bloody sputum)
• Chest pain
• Fever, chills and night sweats
• Loss of appetite and weight loss
• Easy fatigability
• Upper lobe infiltrate
• History of having TB in past or being exposed
Susceptible Host: EVERYONE
Tb Infection vs. Disease
INFECTION
Organism is
INACTIVE
Patient is NOT SICK
but could become
sick later
NOT INFECTIOUS
Positive PPD skin test
DISEASE
Patient is SICK
INFECTIOUS
Needs to be Isolated
BREAK THE CHAIN
PATIENT CONTROL
–Use tissue when coughing
–Transport only when necessary
–Place mask on patient when leaving
room
DROPLET Precautions
Requirements:
• Surgical Mask
Organisms:
• Bordetella pertussis
• Neisseria meningitidis
• Mumps
• INFLUENZA
CONTACT Precautions
Requirements: Wear gowns and gloves for all
interactions that may involve contact with the patient
or the patient's environment
Organisms:
– MRSA
– VRE
– ESBL
– RSV
CONTACT Precautions
MASK not Required
• Use for Infections :
• Adds DROPLET
Precautions
WOUNDS
• Use if Drug Resistant
URINE
Organism is in the
STOOL
SPUTUM or Patient
• Use for
has a Respiratory
COLONIZATIONS
Infection
With MASK
Special Precautions
Requirements:
– Gown
– Gloves
– Soap and Water Handwashing
Organisms:
– C. Difficile
– Norovirus
– Acute Viral Gastroenteritis
– MDR Acinetobacter
Clostridium difficile
Protocol:
– Use SOAP and WATER
– Manual removal of spore
– Place Sign outside door and laminated sign
in room over hand gel pump.
Documentation and
Communication
1. Patient Face Sheet
2. Status Board
3. Ticket to Ride
Bloodborne Pathogens
–Human Immunodeficiency
Virus
–Hepatitis B Virus
–Hepatitis C Virus
OSHA Standard
• Effective since 1992
• Requires that hospitals minimize or
eliminate occupational exposures to
blood borne pathogens
– EXPOSURE CONTROL PLAN
Exposure Control Plan
EXPOSURE DETERMINATION
– Category I job- everyone who has the job is
at risk for exposure
– Category II- only some people who have the
job have duties that put them at risk for
exposure
– Category III - no one who has the job is at
risk for exposure
What Can You Do?
Engineering Controls
•
•
•
•
SHARPS CONTAINTERS
NEEDLELESS SYSTEMS
SAFETY DEVICES ON SHARPS
BIOHAZARD SIGNAGE
Work Practice Controls
• Proper Hand Hygiene
• Standard Precautions
• Use appropriate PPE & Isolation
Precautions
• Restrict eating, drinking, applying
cosmetics, handling contact lenses in
areas where exposure might exist
• Not recapping needles, scalpels
Standard Precautions
• Assume that everyone is infectious
• Includes:
– Blood
– Body fluids
– Secretions
– Excretions
– Non-intact skin
– Mucous membranes
Standard Precautions
– Sweat only body fluid excluded (unless visibly
contaminated with blood)
– If it is wet, use barrier precautions
– PPE
•
•
•
•
Gloves
Gowns
Masks
Eyewear
What else can YOU do to
minimize EXPOSURE risks?
• GET YOUR VACCINATIONS
• INFLUENZA
• HEPATITIS B
• CHICKENPOX
• GOOD HOUSEKEEPING
POST EXPOSURE
• WASH / FLUSH
• REPORT IMMEDIATELY to Supervisor
• Evaluation & Testing done through
OCCUPATIONAL HEALTH
ED on off-shifts
• CONFIDENTIAL evaluation & follow-up
Needs of a Dying Patient
• Physiological: good symptom control
• Safety: a feeling of security
• Love: expression of affection/human contact
(touch)
• Understanding: explanation about symptoms
of disease and the opportunity to discuss the
process of dying
Needs of a Dying Patient
• Acceptance: regardless of mood and
sociability
• Self-Esteem: involvement in decision
making, particularly as physical
dependency on others increases
• The opportunity to give as well as to receive
Disruptive and Impaired Licensed
Independent Practitioners
Provena Health’s Commitment
Consistent with its Mission, Vision, Values and Ethical
and Religious Directives for Catholic Health Care,
Provena Health is committed to providing a safe
environment of care for patients and an optimum
practice environment for physicians and all other
clinicians.
What is disruptive behavior?
Disruptive behavior is defined as a “chronic” pattern
of contentious, threatening, litigious behavior that
deviates significantly from the cultural norm of the
peer group, creating an atmosphere that
interferes with the efficient function of the health
care staff and the institution.
This behavior may be, but is not necessarily, related
to substance abuse/dependency.
Disruptive Physician Defined
The disruptive physician often lacks the
ability of self observation.
The disruptive physician views:
– Themselves as Clinically superior
– Other members of the health care
team as less competent or
incompetent, weak and/or vulnerable
– Themselves as champions for their
patients
Disruptive actions cause:
• A distraction from the goal of providing optimum
patient care
• A decrease in morale
• Increase level of workplace stress
• Inordinate time spent by staff appeasing or
avoiding the physician
• Increased potential for malpractice litigation
Recognizing Impairment
Drug and/or alcohol impairment should be ruled out
prior to addressing the issue as purely negative
behavior
• Physical appearance
• Personality or behavior changes
• Deterioration of hygiene or appearance
• Frequent or unusual accidents
• Multiple prescriptions
What Can You Do?
Organizational staff, including
hospital employees, who observe
or are subjected to, inappropriate behavior by
a physician are responsible for
communication with their supervisor about
the incident
Abuse & Neglect
Abuse
• Physical: An act that results in bodily harm, injury,
impairment or disease
• Hitting, slapping, striking, sexual coercion/assault, incorrect
positioning of the elder, forced feeding/ medicating, improper use
of restraints
• Psychological: Inflicts emotional pain or distress
• Verbal scolding, harassment, intimidation, threatening
punishment or deprivation, isolation
• Financial
– Taking control of resources of another through
misrepresentation, coercion or outright theft for personal
gain
Child Abuse/Neglect
• Abuse
– Unexplained or
questionable scars, burns,
welts, bruises or fractures
– Unnecessary confinement
– Witnessed beatings
– Sexual abuse
– Emotional abuse
– Withdrawn, angry or
unusual behavior exhibited
by the child.
• Neglect
– Malnourishment, failure to
thrive and grown
– Lack of medical care
– Filthy or unsafe
environment
– Poor hygiene and personal
care
– Absence of
parents/appropriate
supervision
– Irregular school attendance
Adult Abuse/Neglect
• Abuse
–
–
–
–
Witnessed beatings
Emotional abuse
Sexual abuse
Unexplained or
questionable scars, welts,
bruises or fractures
– Unexplained or
questionable burns
– Signs of unnecessary
confinement
– Financial exploitation
• Neglect
– Hazardous housing
– Failure to administer
prescribed medications or
seek medical care for the
adult
– Any situation where there
is failure to provide for the
needs of the adult that
result in physical harm to
that person
Neglect
• Physical: Failure to provide goods/services necessary
for the health and well being
• Withholding adequate meals/hydration, therapy,
hygiene, failure to provide physical aids or safety
precautions
• Psychological: Failure to provide social stimulation
• Leaving someone alone for long periods of time, failing
to provide companionship or links to the outside world
• Financial: Failure to use available resources to sustain
or restore health and security
• Improper level of care when resources available to
provide the proper level of care, sudden transfer of
assets
Mandated Reporter
• Mandated reporters are professionals who, in the
ordinary course of their work and because they have
regular contact with children, disabled persons, senior
citizens, or other identified vulnerable populations, are
required to report (or cause a report to be made)
whenever financial, physical, sexual or other types of
abuse has been observed or is suspected, or when there
is evidence of neglect knowledge of an incident, or an
imminent risk of serious harm
• These professionals can be held liable by both the civil
and criminal legal systems for intentionally failing to make
a report but their name can also be said unidentified.
• The Illinois Abused and Neglected Children's
Reporting Act ("ANCRA")
Resources Available
• PMMC/PHS Policies
• Internal Resources
– Social Work
• Diane Feltes x 5695
– Nursing Supervisors, Managers, Directors
– Case Management Department
• Colleen Morley-Wines, Mgr. X2620
• Community Resources
Community Resources
•
DCFS (age birth to about 18
years)
– 800-252-2837
•
•
– >60, Senior Services 630-8974035
– <60, OIG 800-368-1463 (may
not take report)
Office of Inspector General
(disabled, 18-59)
– 800-368-1463
•
Senior Services (if from home or
independent living)
– Hotline: 800-252-8966
•
IDPH (if from nursing home)
– Hotline: 800-252-4343
Self-Neglect
•
Mutual Ground (Domestic
Violence, Rape 18-59)
– No mandated reporting for this
population
• Hotline: 630-897-0080
• Sexual Assault: 630-897-8383
• Advocacy: 630-897-8009
Provena Health’s Mission, Values & Vision
Catholic Directives/Medical Ethics
Patient Rights
Advance Directives
Standards of Business Conduct
Patient Safety
Code Blue/Facilities Alert/Weather Alerts
Pain Management
Employee Incident, Safety Concerns Reporting
Interpreting Services
HIPAA
Patient Confidentiality
Policy & Procedures
Information Services
Quality Improvement Process
Approved Forms of Identification
Disaster Alerts/Codes
Responding fire Drill/Fire Extinguishers
Code Pink (Infant/Child Abduction)
Code White (Aggressive/Disruptive Crisis)
Operation Alert (Bomb Threat)
Infection Control
Restraints
Code Orange /Code T
Customer Service RISE
Severe Weather
Service Excellence
Color Codes
Proper Body Mechanics/Patient Handling Lift Equipment
Equipment Management
Utilities Management
Hazardous Materials/ Handling Spills
* Bolded items reflect changes/corrections in 2008
Emergency contact numbers:
Dial 333 for any hospital code emergency.
Security x5220
Engineering x5251
Infection Control x5689
Occupational Health x5555
Risk Management x5682
PSJH AlertLine (confidential) 1 800 93 ALERT
1
2
3
4-5
6-7
8-10
11
12
13
14
15
16
17
18
19
20
21-23
24-25
26
27
28-29
30-31
32
33
34
35
36
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39-40
41
42-43
PROVENA HEALTH’S MISSION, VALUES AND VISION
Our Mission
Provena Health, a Catholic health System, builds communities of healing and hope by
compassionately responding to human need in the spirit of Jesus Christ.
Our Values




Respect
Integrity
Stewardship
Excellence
Our Vision
Provena Health, an integrated delivery system, is a leader in redefining Catholic health
care. In partnership with our communities, we are committed to improving health status
by providing consistent outcomes and creating value.
1
CATHOLIC DIRECTIVES
The Ethical and Religious Directives for Catholic Health Care Services are as follows:
The primary purpose of the relationship between medical science and Christian faith is for the common
good of all human persons. Health care professionals share in carrying forth God’s life-giving and healing
work by:
 Defending human dignity
 Respecting the sacredness of every human life from the moment of conception until death
 Protecting and respecting the person’s health problem or social status
The Catholic health care institution is a community of healing and compassion, embracing the physical,
physiological, social and spiritual dimensions of the human person.
Medical Ethics
Ethics is a process of choosing the best way of acting in a situation. Provena Saint Joseph Hospital’s
Medical Ethics Committee meets on a regular basis to discuss ethical dilemmas, and to develop policy.
Access to appropriate resources are available to manage ethical conflicts in your healthcare decisionmaking by calling the Chaplain-On-Call or the Pastoral Care Department at Ext. 5767.
2
PATIENT RIGHTS/RESPONSIBILITIES
Each patient receives a written statement of his or her rights. These statements can be found in the
“Patient Handbook” or “Flyer.”
Admission to the hospital can be a frightening and confusing experience for patients, making it difficult for
them to understand and/or exercise their rights. It is our duty to assure patients of their rights. This may
mean you will read them their rights, or ask an interpreter to inform them of their rights in their primary
language. The on-call chaplain is available for assistance by calling the operator and having the chaplain
paged.
All Patients Have the Right to:
 Privacy, Confidentiality, Security
 Receive an Explanation of Billing
 Disclosure of Hospital and Business Relationships
 The Resolution of Complaints
 Pastoral Care and Other Spiritual Services
 Communicate
 Be Involved in all Aspects and Decisions Regarding their Care
 Informed Consent
 Make Advance Directives
 Know their Caregivers’ Names
 Refuse Treatment or Request Treatment Elsewhere
 Informed about the outcomes of care treatment and services
 File a complaint with the state authority
3
ADVANCE DIRECTIVES
A Time for Decisions…
Everyone has the right to make decisions about their healthcare, including the right to receive
information about his/her condition, treatments and the expected outcome, the right to discontinue
medical treatment when the treatment extends living without offering reasonable benefits or quality
of life. It is each individual’s right to express in writing his/her wishes about health care.
How can a person pre-determine how they wish to be medically treated in case they become unable
to make decisions regarding care and treatment? They may initiate two legal documents, which will
provide for their care. These two documents are called the Living Will and the Durable Power of
Attorney for Health Care.
What is a Living Will?
A Living Will is a written directive in which you state your choices for medical treatment if you should become
terminally ill. Through this document, you are saying to your physician that if you develop an incurable and
irreversible condition (“terminal condition”), and there is no reasonable chance of recovery, you want those
procedures withheld or withdrawn that serve only to prolong the dying process. A Living Will does not take
effect until you have a terminal condition, documented by your physician.
4
ADVANCE DIRECTIVES (Con’t)
What is the Power of Attorney for Health Care?
The Power of Attorney for Health Care is a written directive, which designates another person to make health
care decisions on your behalf if you become unable to make such decisions. This person is known as your
“agent”.
Any competent adult at least 18 years old may act as an agent. You should discuss your wishes with your
agent personally and make sure he/she understands your wishes.
The Power of Attorney for Health Care is broader than the Living Will because it allows your agent to make
health care decisions for you in any situation where you are unable to do so and is not limited to situations
where you have a terminal illness.
What if I have not signed any Advance Directive of any kind?
The Illinois Healthcare Surrogate Act applies to this situation. If your attending physician determines that you
do not have the ability to understand and appreciate the nature of, or consequences of a decision regarding
your medical treatment, then the attending physician will pick someone to make medical decisions for you. The
person/surrogate picked shall make decisions based on what they feel you would have done under the
circumstances.
The hospital Chaplains are available to answer questions or provide further information to assist with these very
important decisions. Call Pastoral Care at ext 5767 or dial “0” to have the on call Chaplain paged.
5
STANDARDS OF BUSINESS CONDUCT
Standards of Business Conduct is a program designed to support our employees in making workplace
decisions which reflect the Mission of Provena Health in all of our words and actions. These
standards apply to:
 All employees of Provena Saint Joseph Hospital

All outside individuals, agencies, organizations and vendors who act on our behalf in any way.

The Provena Health AlertLine is a simple, risk-free way for you to report activities that may
involve ethical violations or safety risks.

AlertLine (1 800 93 ALERT)
In our Standards of Business Conduct training, employees are encouraged to follow the supervisory
chain of command for advice and assistance, or to contact the Provena Saint Joseph Hospital
Corporate Compliance Liaison.
Any and all questions and concerns related to business conduct are considered valid and employees
are encouraged to freely discuss them with the appropriate supervisory or management staff person.
6
STANDARDS OF BUSINESS CONDUCT (Con’t)
Our training includes the following directives to employees:
You are responsible for the decisions and the results of the decisions you make. When you have questions
regarding the right thing to say or do in any situation, it is your responsibility to ask for help. Your words and
actions should be guided by our Business Conduct Standards and your own personal standards and values.
Should a conflict arise between the two, it is your responsibility to seek help in making an appropriate decision.
Before you make a decision that involves your conduct in the workplace, you should ask yourself the following
questions:

Is safety at risk?
Provena Saint Joseph Hospital’s first priority must be the safety of our patients and employees.

Does it comply with Provena Saint Joseph Hospital and/or Provena Health policies?
We are expected to follow the intent, letter and spirit of the law. Employees are responsible for knowing and following
all policies and procedures.

Is it consistent with Provena Health Mission and Values?
Our behavior is expected to reflect the Mission and Values of the organization we represent.

If my decision were made public, how would I feel?
We are expected to know and do what is right. If we follow our Standard guidelines, we will be proud of the decisions
we make.
IF YOU DON'T KNOW, ASK!
7
Patient Safety Program – The “ABCs”
A. Your Patient Safety Officer is Julie Lyons. Julie can be reached by calling Extension 5682.
B.
Provena Saint Joseph Hospital recognizes that compliance with the Joint Commission’s National Patient Safety Goals is
essential for its goal in building a culture of safety. The new requirements for 2008 are in bold print below:
(Please note: The numbers and letters of the Goals and Requirements are not consecutive because the Joint Commission makes annual
changes but generally retains the original designations.)
Goal 1 – Improve accuracy of patient identification.
1A PSJH uses patient name and date of birth as the two patient identifiers.
Goal 2- Improve the effectiveness of communication among caregivers.
2A Write down then read back verbal & telephone orders and critical test results.
2B Use only approved abbreviations
2C Improve the timeliness of reporting results from critical tests and critical values/results.
2E Implement a standard approach to “hand off communications, including an opportunity to ask and respond to
questions”.
Goal 3 – Improve the safety of using medications
3C Prevent errors with look-alike/sound alike drugs.
3D Label all medications, medication containers (e.g., syringes, medicine cups, basins), or other solutions on and
off the sterile field in perioperative and other procedural settings.
3E Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.
8
Patient Safety Program (Con’t)
Goal 7 – Reduce the risk of health-care associated infections.
7A Follow the CDC guidelines for hand hygiene.
7B Deaths/disabilities from health-care associated infections are considered sentinel events.
Goal 8 – Accurately and completely reconcile medications across the continuum of care.
8A This process for comparing the patient’s current medications with those ordered for the patient while under the
care of the organization
8B Communicate to the next provider the list of patient’s medications when patient transfers. Also provide a
complete list to the patient.
Goal 9– Reduce the risk of patient harm resulting from falls.
9B Implement a fall reduction program and evaluate the effectiveness of the program.
Goal 13 – Encourage patient’s active involvement in their own care as a patient safety strategy.
13A Define and communicate the means for patients and their families to report concerns about
safety and encourage them to do so.
Goal 15 – The organization identifies safety risks inherent in its patient population.
15A The organization identifies patients at risk for suicide. [Applicable to psychiatric hospitals and
patients being treated for emotional or behavioral disorders in general hospitals.]
9
Patient Safety Program (Con’t)
Goal 16 – Improve recognition and response to changes in the patient’s condition.
16A The organization selects a suitable method that enables health care staff members to directly
request additional assistance from a specially trained individual(s) when the patient’s condition
appears to be worsening.
C.
Variance Reports are used to document unexpected events, which may occur. Unexpected events are “any
situation that is not consistent with routine operation of the facility or routine care of the particular patient.”
Variance reports are also used to document incidents involving visitors. Variances should be entered into the
MIDAS module found on the Home Page of our Intranet site. All variance reports must be completed before the
end of your shift, and preferably at the time of the detection of the incident. Information from variance reports is
tracked, trended and used in improvement activities related to patient care and safety.
A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the
risk thereof. Serious injury includes loss of limb or function. Such events are called “sentinel” because they signal
the need for immediate investigation and response. We conduct a root cause analysis-a process for identifying
the basic or causal factor(s) that underlie variation in performance-following a sentinel event in order to prevent
similar occurrences in the future.
10
Code Blue
A code blue is announced from any hospital care provider to communicate an actual or potential
medical emergency. As a response, trained responders from the code blue team will report to the
area and administer associated medical attention.
Facilities Alert
A code facilities alert is announced to report any situation requiring general hospital staff assistance.
Example conditions include emergency campus surveillance, monitoring of any potential risk to the
campus or grounds, security assistance or notification of a large-scale condition potentially impacting
the operations of Provena Saint Joseph Hospital. Upon alert, hospital staff should be prepared to
send any available staff to the scene of the called alert. The security department will provide all
responders with appropriate instruction.
Weather Alerts
Code Gray: Severe weather watch. Severe weather conditions which could possibly produce
tornadoes.
Code Black: Severe weather alert. Very severe weather which have produced a funnel cloud within
area counties.
11
PAIN MANAGEMENT
Interdisciplinary pain assessment criteria:
 On admission:
 Pain is assessed using the appropriate pain scale (Numeric Pain Intensity Scale [0-10], Visual Pain
Analogue [Faces].
 The patient’s acceptable level of pain is assessed and documented.
 If patient is unable to report pain, non-verbal assessment can be used (i.e., vital signs, behavior
changes).
 If the pain score or greater than the acceptable level of pain, then pain intervention must be
initiated and documented.
 If intervention through medication, the sedation score is assessed and documented (S-1-2-3-4).
 Reassessment is mandatory, and follows any intervention and must be documented.
 If pain score is less than the patient’s acceptable pain goal, pain assessment is done every shift or
as indicated.
 Pain score will be documented on discharge.
12
EMPLOYEE INCIDENT REPORTING
Employee incident reporting is an important part of PSJH’s goal to provide a safe working environment for
employees.
Employee incident reporting and investigation does not place blame, punish or find fault. It is a process that
focuses on the collection of information for the maintenance of a safe working environment for all employees.
When an accident occurs, complete the Occupational Injury/Illness Incident Report. Injured employees
should be seen by Occupational Health or ED. Reporting an injury promptly may lessen the severity of the
injury. Also, prompt reporting will initiate a thorough investigation of the circumstances and define corrective
action to be taken to prevent future accidents.
When the accident involves a needle puncture or exposure to blood or body fluids one of the following forms is
to be completed immediately: Fill out Form #462-570-7601 report of Work Injury and Form #463-570-7615
Needle Stick/Body Fluid Exposure.
*NOTE: If you observe someone doing something that will put someone at risk, contact a member of the
Environment of Care Committee or your manager.
Reporting Safety Concerns


All employees of Provena Saint Joseph Hospital are required to consistently monitor their specific work
area for any safety related issues or concerns.
Any identified safety concern is to be directed to the specific department manager for review of the
proper routing, and or action plan.
To report unresolved safety issues, employees may utilize the following:
PSJH AlertLine 1-800-93 ALERT (confidential)
JCAHO Safety Hot Line #630-792-5000
13
INTERPRETING SERVICES
Interpretation services available through hospital staff can be accessed by calling the Interpreter at
5192 or Pastoral Care at extension 5767 or Human Resources at ext 5505 or the House Supervisor
when Pastoral Care or Human Resources are closed. Phone interpretation is available 24 hours a
day, 7 days a week for all languages via the AT&T Language Line. The staff person needing
interpretation would dial 1-800-874-9426, follow the prompts using our 6-digit organization ID
#206069, and your personal code number which will be your 4 digit telephone extension. The
interpreter then comes on the line.
Hearing Impaired
Patients who are hearing impaired will be provided qualified sign language interpreters Call Human
Resources or Nursing Supervisor. TDD (Telephone Device for the Deaf) units are available from the
switchboard. The television sets can be modified to provide close caption viewing. There is no
charge for this service.
14
Health Insurance Portability and Accountability Act
HIPAA stands for the “Health Insurance Portability and Accountability Act”. Originally called the Kennedy
Kesslebaum Act, the Department of Health & Human Services (DHHS) issued the final Privacy Regulation
requires compliance by: April 14, 2003

Protect patient’s rights by giving them access to their health information and control over how it will be
used.
 Improve the quality of care by restoring trust in the health care system
 Protect the security & privacy of all medical records that is used or shared in any form
 Privacy Standards-deal with patient’s expectations of providers in terms of the way health information is
used. (Information released on need to know basis only)
 Example-limiting who has access to their records
 Security Standards-deal with measures that covered entities can take to keep their information safe
 Example-Encrypting information before it is sent over the internet
15
“THE END”
CONFIDENTIALITY
PATIENT CONFIDENTIALITY means that every employee must keep private all personal
information disclosed by the patient while receiving care. This includes the patient’s:
 Identity
 Physical or psychological condition
 Emotional status
 Financial situation
All employees and volunteers in the healthcare facility are responsible for patient confidentiality.
Guidelines:
 All requests for patient records should be referred to Health Information Management (Medical Records). If
Medical Records is closed refer requests to the Nursing Supervisor.

Medical information should only be accessed by those who need to know in order to care for the patient.
Prior written consent from the patient is required for information to be shared with insurance companies,
attorneys, police, and sometimes, even the patient’s family members.
 All media representatives should be referred to the Marketing Department, or evening or night Nursing
Supervisor.
16
POLICIES AND PROCEDURES
Policies and procedures that direct hospital operations are developed, approved, and stored online
through the Provena Saint Joseph Hospital Intranet. Policies are available to Provena Saint Joseph
Hospital staff at all times for reference.
In addition to our Provena Saint Joseph Hospital Institutional Policies and Departmental Policies, we
have Corporate Policies that govern our entire system. These system-wide policies can be found on
our Provena Health Intranet.
17
INFORMATION SERVICES
In accordance with Corporate Compliance, HIPAA regulation, the Joint Commission and auditing,
policies regarding network standards and usage have been developed and are available on DOVEnet:





Access and Disclosure of Electronic Mail
Information Security Policy Statement
Internet/Intranet Policy Statement
Software Usage Policy Statement
Standard Software Policy Statement
Beyond the Information Services Institutional policies, the following are a few I.S. safety rules to
follow:
 Do not share your network login/password with anyone.
 Always log off the network and application sessions before leaving your workstation.
 NEVER leave patient specific information displayed on a workstation or in view of nonauthorized personnel.
18
CONTINUOUS QUALITY IMPROVEMENT PROCESS
Problem or process change identified
Recognize Excellence/Best Practice
Organize a team
Validate knowledge
Evaluate causes
Negotiate improvements
Act/Accountability
 What are we trying to accomplish?
 How will we know that a change is an improvement?
 What changes can we make that will result in improvement?
Rapid Cycle PDSA
Act

To hold gains

To abandon change

To determine next
steps
Plan

Process
changes

Data
Collection
Study

Were changes
implemented as
planned?

Outcomes/results

Lessons learned
Do

Process
changes

Data collection

Data analysis
19
APPROVED FORMS OF IDENTIFICATION
Approved forms of identification are always to be worn above the waist and must be visible at all times while on
duty.
The approved form of employee identification is a Matrix Badge. Badges provide picture identification and
verify the right to access job-related information. The strip on the matrix badge gives authorization for
employees/persons to be at Provena Saint Joseph Hospital.
The color strip on Matrix Badges indicates:
 Blue-employees of PSJH.
 Green-Out Source employees.
 Pink-Volunteers of PSJH.
 Red-Physicians/Contracted persons working for an extended period of time who are not employees. They
are authorized to use computers and access patient information as needed.
 Yellow-Students/Interns of PSJH.
 Purple-Family Birth Place employees
Other approved forms of identification:
Patients must wear ID bracelets at all times.
At least two identifiers must be used (neither to be a patient’s room number) whenever taking blood samples or
administering medications or blood products.
All Vendors must sign in at the Security office and receive a temporary identification badge.
All construction contractors must sign-in at the Facilities Management office and receive a
temporary I.D. badge.
20
DISASTER ALERTS/CODES
EMERGENCY TELEPHONE NUMBER
Just like calling 911 for an emergency in the community, at PSJH we have one emergency number.
DIAL 333 FOR ALL EMERGENCIES
ANYWHERE IN OR ON PSJH’S CAMPUS.
Code Red
Code Blue
Code Pink
Operations
Alert
Rapid Response
Room # or
Location
Code
White
Emergency Announcement Procedures
The 333 emergency telephone number rings at PSJH’s switchboard. Tell the operator the location and
code description (in case of a fire, state the severity of the fire). Do not hang up until you are told to do
so. The operator will announce the code name and the location of the emergency and notify the
appropriate emergency response team.
21
DISASTER ALERTS/CODES (Con’t)
TYPES OF EMERGENCY REPONSES
EXTERNAL/INTERNAL DISASTER (Operation Alert)
An internal disaster occurs when conditions are such that the ability of the ED to process and care for patients are
compromised by conditions such as hospital explosions or gas-emission events, utility interruption or fires. The
ability to handle such situations utilizing on-duty personnel is determined by the emergency physician on duty, the
ED charge nurse, and the ED director/inpatient administrative director/nursing supervisor.
An external disaster requires a health care facility to admit and treat many casualties, but there is no damage to the
facility itself. All Provena Saint Joseph Hospital employees are required to learn the Departmental Emergency
Response Plan associated within their work area(s).
PHASE I
0-9 patients admitted through the ED. Request assistance from support areas as necessary. Notify
Administration
PHASE II
10-19 patients admitted through ED. ED call list activated to support internal departments
PHASE III
20 or more patients admitted through ED.
Ed treatment/triage areas established as required.
22
DISASTER ALERTS/CODES (Con’t)
EXTERNAL/INTERNAL DISASTER ANNOUNCEMENT CODES
The operator will announce: “Attention please!
We have an external disaster phase ____.”
Operations Alert
Phase I
On-duty personnel will most likely handle such a situation.
Operations Alert
Phase II
Such a situation might require calling additional help. If additional help is required, the call plan would be
implemented.
Operations Alert
Phase II
All department disaster plans in effect. Call in off duty staff.
If on-duty when the announcement is made:
Remain in your work area unless pre-assigned to a Disaster Center. (Refer to your department’s specific
Emergency Preparedness Plan.)
If reached through the Department Call List:
Report to the hospital via the north entrance and proceed
to the Volunteer’s Lounge.
Medical Equipment:
Wheelchairs and carts should be sent to the Emergency Department immediately.
All Provena Saint Joseph Hospital employees are required to learn the Departmental Emergency Response Plan
associated within their work area(s).
23
RESPONDING TO A FIRE OR DRILL
Know where fire alarms, extinguishers and exits are located in your work area before a fire or drill.
If you discover a fire follow the R.A.C.E. method:
Rescue those in immediate danger.
Activate the closest alarm and dial 333.
Contain the fire by closing all the doors.
Extinguish a fire only if it is safe to do so.
Fire Announcements:
CODE RED
Code Red exists when Fire, smoke or evidence of burning materials.
DIAL 333, State “CODE RED” and give location.
CODE RED: Staff Response at the scene of the fire
In addition to R.A.C.E. and P.A.S.S. procedures, all employees of Provena Saint Joseph Hospital are required to
learn their specific rolls during a code red event. These procedures are reviewed during departmental
orientation and reflected in the zone specific “red frame”.
HORIZONTAL EVACUATION (contained within immediate working area)
All staff must review their work areas to determine the appropriate direction of horizontal (smoke compartment)
movement in the event of a fire. Smoke compartments within patient care areas are identified with the letter
“S” above doorways. Staff are reminded to relocate into contiguous horizontal smoke compartments identified
with the “S” indicator whenever moving away from the scene of a fire.
VERTICAL EVACUATION (fire stairwells)
All staff must review their work areas to determine the appropriate direction of vertical (fire compartment)
movement in the event of a fire. Fire compartments serving patient care areas are identified with the letter “F”
above doorways. Staff are reminded these exits are to be used for the evacuation of patients/staff/visitors
during a full evacuation. Elevators are not to be used unless approved by the fire department.
ROLES OF STUDENTS/MEDICAL STAFF DURING CODE REDS
Students and medical staff are reminded to participate in concert with area specific staff during code red
announcements and as directed by hospital Leadership. Further instructions will be provided as details of
advanced evacuations are developed.
24
FIRE EXTINGUISHERS
Read the operating instructions on the fire extinguishers located in your work area(s) before a fire happens.
Extinguishers have different contents to put out different types of fires. Extinguishers are labeled according to
the class of fire they are designed to extinguish. Most extinguishers in the hospital are multipurpose and can be
used on any fire.
Learn to P.A.S.S.
Pull
Aim
Pull the pin. Provena Saint Joseph
Hospital’s extinguishers use a plastic
cord to hold the pin in place. Before
you are able to remove the pin, the
plastic cord needs to be broken. To
break the cord, simply twist the pin.
Aim the extinguisher nozzle at the base of
the fire.
Squeeze
Squeeze or press the handle.
Sweep
Sweep from side to side at the base of the
fire until it goes out. Shut off the
extinguisher. Watch for reflash and
reactivate the extinguisher if necessary.
Foam and water extinguishers require
slightly different action.
REMEMBER:
Horizontal Evacuation: The relocation of patients and staff from a compromised smoke compartment to the next adjacent
compartment (behind smoke doors) on the same floor.
Vertical Evacuation: The relocation of patients and staff from a compromised smoke compartment using vertical fire exit
stairwells.
25
CODE PINK
Calling a Code Pink
Immediately report an attempted infant or child abduction or any unusual or suspicious behaviors to Security.
 Dial 333, you will be connected to the operator.
 Tell the operator Code Pink, location and any identifying traits of the suspected abductor or abductor’s
vehicle.
 The operator will contact Security and announce overhead Code Pink and location.
Responding to a Code Pink Announcement
When a Code Pink is announced, all employees have the responsibility to monitor their areas for visitors,
patients or staff who may be, without permission, transporting a child or infant. Such an individual may also be
transporting a large package, which may contain a child or infant patient. Staff members should never attempt
to use physical force to detain a suspected abductor. Staff members should report the person to Security and
follow the person (if safe to do so) until Security arrives. Most Code Pink situations are crimes of stealth and
deception, and drawing attention loudly to the suspected abductor is a good way to not only alert your coworkers, but possibly change the plans of the abductor as well (leaving the child and fleeing, etc.).

Know unit/department specific Code Pink procedures and where to respond during a code Pink.

Know Provena Saint Joseph Hospital’s Code Pink policy.
26
CODE WHITE
Learning to recognize early warning signs of potentially aggressive, disturbed behavior and knowing how to deescalate a potentially violent situation helps to ensure safety of the staff, the person acting out and the other
people in the area. Be observant of behaviors that have the potential to escalate into violence.
One of the most important ways to avoid violence is to know how to respond if you are faced with someone
whose words or actions frighten you. Take all threats seriously and report all threats immediately. Verbal
intervention and control of the environment are the first interventions utilized to control the situation. Other
patients and visitors are to be removed or restricted from coming into the area of confrontation.
During an aggressive or disruptive crisis your professionalism is on display for all visitors, patients, volunteers
and employees to see. You need to respond to the crisis in an appropriate way. To learn de-escalation
techniques, attend the Nonviolent Crisis Intervention class sponsored by CPI and offered throughout the year by
certified instructors on staff at the hospital.
Staff members who plan to become physically involved in any code white situation should take this training.
Other staff members may respond to a code white situation to assist with access and crowd control, etc but
only CPI certified staff should interact with an action out person.
27
OPERATION SEARCH (Bomb Threat)
If a threat is received by telephone:
 Be calm, listen and attempt to prolong the conversation as long as possible.
 If possible, have someone else call 5220 while the conversation is still in progress.
 Be alert for distinguishing background noises, e.g., music, aircraft, and other noises.
 Note voice characteristics such as accents, etc.
 Try to determine exactly where the device is located and any timeliness for activity.
 Note if the caller appears to have knowledge of the hospital's floor plans or is familiar with staff.
 Complete the Variance Report and/or Threatening/Obscene Call Sheet (refer to PSJH policy “Bomb
Threat/Potential Concealed Weapons of Destruction” under the Management of the Environment
of Care chapter).
Prepare for a possible evacuation of the area.
28
OPERATION SEARCH (Bomb Threat) (Con’t)
If you hear a Operation Search announcement:
 You will know that a bomb threat has been received by the hospital.

You may be required to send a representative from your department/unit to the designated
meeting place.

All staff will prepare to search their units for unusual or out-of-place packages in the department.

Follow the directions of individuals leading the search activity.
If a suspicious item is discovered:
 Isolate the area and notify Security
 Close all doors and open windows, if possible.
 Evacuate patients, visitors and all other personnel if ordered by Administration.
29
INFECTION CONTROL
Sharps Containers
DISPOSE SHARPS IN PUNCTURE PROOF “SHARPS CONTAINERS”:
 This includes sharps, syringes, scalpels, needles, lancets, blood tubes, slides and cover slips.



Do not leave sharps for others to dispose.
Do not overfill sharps containers.
Activate sharps safety device before placing in puncture proof container.
Biohazard Waste
Use red bag to dispose biohazard waste. Biohazard waste includes:
 Any material saturated with blood or blood components.
 Body tissue, organs or body parts including body fluids that are removed during medical procedures like
surgery and autopsy.
 Cultures and stocks from laboratories.
 Add Red Z to all potentially infectious liquids before disposing in the red bins.
Respiratory Masks
An N-95 is a special mask worn by all staff who enter a negative pressure room for airborne isolation. Fit
testing is required before using this mask.
Act
Study
Latex Allergy
Prevention Points
DPo lan
 Minimize exposure. Continued exposure to latex allergens increases sensitization and worsens allergic
reactions.
 Recognize symptoms. Dermatitis, hives and nasal congestion, to asthma, food cross reactions and
anaphylactic shock. (Currently there are policies for the latex allergic patient and the latex allergic HCW. To
access these policies go to the PSJH policy section on the Intranet under “Management/Environment of
Care”.)
 Know the high-risk groups. Healthcare workers, persons with spina bifida, persons with histories of multiple
surgeries or allergies.
 Medic alert bracelets and emergency medical supplies should be available for persons with allergy.
 If you are latex allergic be your own advocate.
30
INFECTION CONTROL (Con’t)
Hand washing before and after patient contact and after contact with potentially infectious items or
surfaces is the single most effective infection control practice in the hospital.
Alcohol hand gel can be used instead of soap and water except when the infection is clostridium
difficle diarrhea, then soap and water is required.
Consider all human blood, body fluids, mucus membrane, non-intact skin and moist body surfaces to be
potentially infectious. Therefore:

Use standard precautions regardless of the diagnosis.

Wash hands before and after patient contact.

Use personal protective equipment (PPE):
GLOVES-FOR HAND PROTECTION
Goggles & face shield-for face and eye protection
Gowns-for protection from soiling
Masks-for respiratory protection

Use transmission based precautions:
Airborne Precautions for pulmonary TB, Chicken Pox, disseminated shingles or measles. With SARS, monkey pox,
smallpox, Avian flu, N-95 mask and goggles are required also airborne and contact precautions. (Mode of spreaddroplet nuclei from respiratory secretions) Negative pressure rooms are 212,214,312,314,412,414,ICU 8.
Droplet Precautions for influenza and other communicable respiratory infections where the mode of spread is
droplets from respiratory passages.
Contact Precautions for communicable diseases spread by direct contact with blood or body fluids and multi drug
resistant pathogens such as MRSA, VRE,ESBL and C-Difficile diarrhea.
Multiple signs when a patient has a resistant organism in the respiratory tract ie MRSA. Contact and Droplet will
be used in combination.
V.I.P. status: For patients with resistant organisms such as MRSA,VRE and ESBL. The V.I.P. status is not removed so the
patient can be placed in isolation on readmission and rescreened. If a patient, is MRSA positive by history they can be
rescreened and if negative removed from isolation. However, they will be rescreened with every subsequent admission. If
they are on Mupirocin intranasally they cannot be rescreened and need Contact isolation. For VRE and ESBL, the patient
must be off antibiotic treatment for the organism and 3 negative screens done 1 week apart are necessary to remove a
patient from isolation.
For C.Difficile diarrhea, the patient is placed in Contact and treatment started. To remove the patient from isolation, the
treatment must be completed and no s/s of diarrhea for 48 hrs after treatment. No negative specimens are needed.
* Food/beverages in the workplace: When transporting food or beverages from the cafeteria to be consumed in an
established break room it MUST be covered. No food or beverages are allowed in the nurses station, med carts in the
hallway, etc.
31
RESTRAINTS
Philosophy of Restraints:
Provena Saint Joseph Hospital respects the rights and dignity of its patients and employs preventive
and alternative strategies to reduce restraint episodes. PSJH staff delivering care to the patient will
use alternative means whenever possible to protect the patient’s health, well being and safety prior to
the use of restraint and/or seclusion while complying with agency standards and statutory
regulations. Seclusion/restraint is only used in those situations when its use is essential to protect the
patient from harming himself/herself and/or others.
Restraint is defined as any method of applying involuntary restrictions on a patient’s bodily
movement (or access to his or her body areas) in order to protect the patient or others from harm.
Seclusion is involuntary confinement of a person alone in a room where the person is physically
prevented from leaving.
Note: You need to know the frequency of care for behavioral vs. medical use of restraints.
32
Code Orange
A code orange is announced from the emergency room or other specified department to
communicate a potential risk of exposure to chemicals/weapons of mass destruction. As a response,
staff should contact the alerting department to identify risk measures and general conditions prior to
responding. In situations of actual conditions, only trained staff members should respond following
directions from Emergency Services leaders.
Code T
A code T is announced to communicate the imminent arrival of one or more multiple trauma patients.
Only designated staff members should respond and follow directions from Emergency Services
leaders.
33
R.I.S.E
As employees of Provena Saint Joseph Hospital, we are required to incorporate the RISE concept
in all facets of patient contact:
Respect – We affirm the individuality of each person through fairness, dignity, and compassion.
Integrity – We demonstrate the courage to speak and act honestly to build trust.
Stewardship – We use our human and economic resources responsibility with a special concern for the poor and
vulnerable.
Excellence – We achieve exceptional performance through continuous growth and development.
All employees of Provena Saint Joseph Hospital are required to sign an agreement stating they will reflect the
RISE standards at all times as a provision of employment.
Respect
Integrity
Customer
Service
Excellence
Stewardship
34
SEVERE WEATHER WARNING
A severe weather alert is announced from the switchboard to communicate pending or current
weather conditions requiring response from the general staff. A severe weather watch (Code Gray) is
announced when severe weather conditions could present strong winds, tornado, severe lightening or
hail within our area. A severe weather Alert (Code Black) is announced when service weather
conditions are sighted presenting strong winds, tornado severe lightening or hail within our area.
In actual conditions staff members are encouraged to monitor each working area for specific risks
and possibly relocate from window areas to hallways or common corridors. Patients are to be
relocated to areas of safe refuge including hallways, common corridors or other identified areas.
35
SERVICE EXCELLENCE
All employees of Provena Saint Joseph Hospital are required to reinforce the five fundamentals of
customer
Service. These are defined as follows:
THE FIVE FUNDAMENTALS OF SERVICE (AIDET)
ACKNOWLEDGEMENT
 Eye Contact
 Smile
 Stop whatever you are doing so your customer knows they are important
INTRODUCTION
 Welcome
 State your name
 State your department
 State your role in the customers care
DURATION (TIME EXPECTATION)
 Explains how long before the test starts
 Explain how long the test itself will take
 Explain after the test – report process
EXPLANATION
 Explain test or procedure
 Explain who is involved in providing your customers care
 Explain if the test will cause pain or discomfort, or if any post procedure instructions are necessary
 Offer to answer any concerns, questions, or resolve any complaints
THANK YOU
 Say “Thank you for choosing Provena Health for your healthcare needs.”
36
Provena Saint Joseph Hospital Emergency
Color Codes
Code Green
Utilities Failure
Code Red
Fire Emergency
Code Pink
Infant abduction/alert
Code Blue
Medical Emergency
Code White
Patient restraint/assistance
Code Orange
Weapons/chemicals mass
destruction response plan
Code T
Mass causality response
Facilities Alert
Response/assistance needed
Code Gray
Severe weather watch
Code Black
Severe weather alert
Operations Alert
External/internal disaster
Operation Search
Bomb threat plan
37
Proper Body Mechanics for Employees
Body mechanics refers to the correct use of the body as a tool for locomotion and manipulation. Proper positioning, movement techniques,
maintaining balance and use of gravity are the key components for implementation of proper body mechanics. Using the proper body
mechanics is essential to maintain safety and to avoid acute injury when lifting or moving objects. It can also be important over time to
prevent and reduce postural dysfunction, chronic strain and degenerative changes in yourself.
1. Plan every move or lift in advance to ensure safety. Remember to anticipate obstacles-maintain clear pathway. Make use of available
equipment and assistive devices.
2. Try to maintain a proper “neutral” alignment of the head and spinal curves throughout the lift. Your shoulders, hips, knees, ankles
should be flexed and ready to lift.
3. Attain a proper base of support by keeping your feet apart and aligned with your hips and shoulders. This posture ensures balance and
prevents falling forward or backward.
4. Avoid bending over at the waist, and avoid twisting motion of the spine. This is especially true if you are sitting. Use extra care when
lowering something to the floor or when reaching with even light loads.
5. Position objects being moved as close to your body as possible. This process helps you maintain your balance and reduces strain on
your back and arms.
6. When you begin the lift or move, keep your knees bent and back straight. Tighten your abdominal muscles to stabilize the low back,
but do not hold your breath.
7. Demonstrate competency with the use of equipment that facilitates movement of objects.
8. Remember, most back injuries can be prevented through good habits and common sense. Serious injuries can occur suddenly, even
when lifting small objects if you are in the wrong position.
Patient Handling Lift Equipment
Provena Health requires that any employee whose duties include lifting, transferring and repositioning of patients be properly trained in the
use of patient handling equipment and then requires the use of this equipment in patient lifts, transfers, and repositions.
38
EQUIPMENT MANAGEMENT (Safe Medical Device Reporting)
A Medical Device is an item that is used for the diagnosis, treatment, or prevention of a disease, injury or other condition
and is NOT a drug or biologic.
All medical device-related patient/employee incidents are reported as soon as possible by any individual, who witnesses,
discovers or otherwise becomes aware of the occurrence. This individual does not need to make the judgment if the incident
is reportable to FDA or manufacturer.
Safe Medical Device Act (SMDA) Steps for Reporting:
Attend to the medical needs of the patient.
Maintain the medical device in the condition it was in at the time of the incident, including the control settings.
Remove and sequester the device and any associated accessories (tubing, patient circuit etc.) from service.
If available, save all materials including any disposable items and packaging that contains manufacturer name, lot numbers
and serial numbers etc.
Notify Biomedical Department (Ext. 5108) immediately to perform an equipment inspection on the malfunctioning
equipment. During hours when Bio-Med is not staffed, notify the Nursing Supervisor.
If a patient has been seriously injured, notify the Risk Management Department at Ext. 5682 soon as possible.
Complete a Variance Report form and forward it to Risk Management as soon as possible.
Remember, anyone can report a device incident.
Hours of Operation:
The normal working hours for Clinical Engineering are Monday through Friday, 7:00am till 4:00pm.
39
EQUIPMENT MANAGEMENT (Con’t)
Reporting Malfunctioning Medical Equipment and equipment labels:
Any patient care medical device found not operating as normally intended must be removed from the area of service
immediately. The item is to be affixed with a note documenting the reported problem, your name and extension. All
medical equipment repairs must be communicated to the Biomedical Engineering Department at extension 5108
immediately, this includes normal and after hours calls. To expedite service please record the CEID number for the device
before calling X5108. All medical devices owned by the hospital should have a CEID number affixed to it. The following is
an example of a CEID tag:
For devices that are included in a regularly scheduled performance assurance (PA) program an additional inspection tag will
also be affixed to the device. The date on the inspection tag should not be greater then 12-months. The following is an
example of the TriMedx safety inspection tag:
For medical devices not included in the PA program, in addition to the CEID tag they will have a grey “approved for use”
tag. The grey tags may or may not have a date and rep indicated. The date on these tags can be greater then 12 months.
The following is an example of a grey approved for use tag with the date and rep. field:
40
UTILITIES MANAGEMENT
Utility Systems
Utility systems provide support to life, infection control, environment, equipment and communication support
systems which include:
 Electrical Distribution
 Gas Utilities
 Water/Steam
 Communication Systems
 Vertical Transport (Elevators)
 Clinical Vacuum and Medical Oxygen Systems
PSJH has colored outlets for various functions:
Ivory Outlets-provide normal power.
Ivory Outlets/Green Dots-approved for use on medical equipment in clinical areas. Green dot electrical cords
should be plugged into red outlets.
Red Outlets-backed up by the emergency generators.
In an emergency, red outlets should be used for critical patient care equipment only. Make sure that you can
Locate the red outlets in your department.
Any utility related concerns must be directed to Engineering at Ext. 5251 (24 hours a day).
41
HAZARDOUS MATERIALS
Hazardous materials are substances that are potentially dangerous to your health and safety. They
range from flammable liquids to disease causing organisms.
Location of Material Safety Data Sheets (MSDS)
The hospital inventory of Material Safety Data Sheets (MSDS) is located online from the
PSJH Intranet page (MSDS Online). In the event of any hazardous material incident,
PSJH staff must contact the Security Department (EXT. 5220) for further directions.
Every work area at Provena Saint Joseph Hospital is responsible for maintaining MSDS on any toxic
substances used in that particular work area. MSDS should be located in an area that is accessible to
the employees. There is also a master copy of all MSDS in the Emergency Department. It is
important that you know what hazardous materials exist in your department and where Material
Safety Data Sheets are located in your work area, in case of an emergency.
Spill Handling Guidelines
In the event of a hazardous chemical spill:
 Be careful not to touch it or walk through it.
 Immediately place signs to prevent other people from entering the area.
42
HANDLING SPILLS
Minor Spills
When the volume of the spill (blood, chemo or OPIM) is small, clean up is to be initiated by trained staff
wearing protective equipment in the department where the spill occurs. The appropriate spill kit must be used.
Never dispose of hazardous materials in the trash or chutes.
Contact Security at (Ext. 5220) for assistance immediately. For assistance in the clean up, and
complete a written report of the clean-up operations.
Major Spills
Major spills, because of the proportions and type of spill, may need the intervention of an off-site professionally
trained team to clean up the spill. Contact Security at (Ext. 5220) for assistance immediately. A trained
employee will be sent who will decide if clean up can be managed by Environmental Services or our medical
waste hauler.
Large Chemical Spill
For a large chemical spill such as a flammable liquid, Contact Security at (Ext. 5220) for assistance
immediately for containment of the spill security will contact the medical waste hauler for cleanup.
Mercury Spill
For a mercury spill, Contact Security at (Ext. 5220) for assistance immediately. Who will make
arrangements for the cleanup and disposal of waste mercury? DO NOT dispose of “waste mercury” in regular
trash or down drains.
43
I attended the 2008-2009 Provena Saint Joseph Hospital Safety Fair via Net Learning.
Name:_____________________________
Dept.______________________________
Date:______________________________
Completion Score:_______________________
Ambulance Technician Study
You Are Here> Home :: Content :: Cardiac :: ECG Rhythms
<< Cardiac<< ECG Basics
ECG Rhythms
ECG Rules >>
ECG RHYTHMS
This section will cover some of the most common ECG patterns that you'll come across on an
ambulance.
Normal Sinus Rhythm
Looking at the ECG you'll see that:

Rhythm - Regular

Rate - (60-100 bpm)

QRS Duration - Normal

P Wave - Visible before each QRS complex

P-R Interval - Normal (<5 small Squares. Anything above and this would be 1st degree
block)

Indicates that the electrical signal is generated by the sinus node and travelling in a normal
fashion in the heart.


Sinus Bradycardia
A heart rate less than 60 beats per minute (BPM). This in a healthy athletic person may be
'normal', but other causes may be due to increased vagal tone from drug abuse,
hypoglycaemia and brain injury with increase intracranial pressure (ICP) as examples
Looking at the ECG you'll see that:

Rhythm - Regular

Rate - less than 60 beats per minute

QRS Duration - Normal

P Wave - Visible before each QRS complex

P-R Interval - Normal

Usually benign and often caused by patients on beta blockers


Sinus Tachycardia
An excessive heart rate above 100 beats per minute (BPM) which originates from the SA
node. Causes include stress, fright, illness and exercise. Not usually a surprise if it is
triggered in response to regulatory changes e.g. shock. But if their is no apparent trigger
then medications may be required to suppress the rhythm
Looking at the ECG you'll see that:

Rhythm - Regular

Rate - More than 100 beats per minute

QRS Duration - Normal

P Wave - Visible before each QRS complex

P-R Interval - Normal

The impulse generating the heart beats are normal, but they are occurring at a faster pace
than normal. Seen during exercise

Supraventricular Tachycardia (SVT) Abnormal
A narrow complex tachycardia or atrial tachycardia which originates in the 'atria' but is not
under direct control from the SA node. SVT can occur in all age groups
Looking at the ECG you'll see that:

Rhythm - Regular

Rate - 140-220 beats per minute

QRS Duration - Usually normal

P Wave - Often buried in preceding T wave

P-R Interval - Depends on site of supraventricular pacemaker

Impulses stimulating the heart are not being generated by the sinus node, but instead are
coming from a collection of tissue around and involving the atrioventricular (AV) node


Atrial Fibrillation
Many sites within the atria are generating their own electrical impulses, leading to irregular
conduction of impulses to the ventricles that generate the heartbeat. This irregular rhythm
can be felt when palpating a pulse
Looking at the ECG you'll see that:

Rhythm - Irregularly irregular

Rate - usually 100-160 beats per minute but slower if on medication

QRS Duration - Usually normal

P Wave - Not distinguishable as the atria are firing off all over

P-R Interval - Not measurable

The atria fire electrical impulses in an irregular fashion causing irregular heart rhythm


Atrial Flutter
Looking at the ECG you'll see that:

Rhythm - Regular

Rate - Around 110 beats per minute

QRS Duration - Usually normal

P Wave - Replaced with multiple F (flutter) waves, usually at a ratio of 2:1 (2F - 1QRS) but
sometimes 3:1

P Wave rate - 300 beats per minute

P-R Interval - Not measurable

As with SVT the abnormal tissue generating the rapid heart rate is also in the atria,
however, the atrioventricular node is not involved in this case.


1st Degree AV Block
1st Degree AV block is caused by a conduction delay through the AV node but all electrical
signals reach the ventricles. This rarely causes any problems by itself and often trained
athletes can be seen to have it. The normal P-R interval is between 0.12s to 0.20s in
length, or 3-5 small squares on the ECG.
Looking at the ECG you'll see that:

Rhythm - Regular

Rate - Normal

QRS Duration - Normal

P Wave - Ratio 1:1

P Wave rate - Normal

P-R Interval - Prolonged (>5 small squares)


2nd Degree Block Type 1 (Wenckebach)
Another condition whereby a conduction block of some, but not all atrial beats getting
through to the ventricles. There is progressive lengthening of the PR interval and then
failure of conduction of an atrial beat, this is seen by a dropped QRS complex.
Looking at the ECG you'll see that:

Rhythm - Regularly irregular

Rate - Normal or Slow

QRS Duration - Normal

P Wave - Ratio 1:1 for 2,3 or 4 cycles then 1:0.

P Wave rate - Normal but faster than QRS rate

P-R Interval - Progressive lengthening of P-R interval until a QRS complex is dropped


2nd Degree Block Type 2
When electrical excitation sometimes fails to pass through the A-V node or bundle of His,
this intermittent occurrence is said to be called second degree heart block. Electrical
conduction usually has a constant P-R interval, in the case of type 2 block atrial
contractions are not regularly followed by ventricular contraction
Looking at the ECG you'll see that:

Rhythm - Regular

Rate - Normal or Slow

QRS Duration - Prolonged

P Wave - Ratio 2:1, 3:1

P Wave rate - Normal but faster than QRS rate

P-R Interval - Normal or prolonged but constant


3rd Degree Block
3rd degree block or complete heart block occurs when atrial contractions are 'normal' but
no electrical conduction is conveyed to the ventricles. The ventricles then generate their
own signal through an 'escape mechanism' from a focus somewhere within the ventricle.
The ventricular escape beats are usually 'slow'
Looking at the ECG you'll see that:

Rhythm - Regular

Rate - Slow

QRS Duration - Prolonged

P Wave - Unrelated

P Wave rate - Normal but faster than QRS rate

P-R Interval - Variation

Complete AV block. No atrial impulses pass through the atrioventricular node and the
ventricles generate their own rhythm

Bundle Branch Block
Abnormal conduction through the bundle branches will cause a depolarization delay through
the ventricular muscle, this delay shows as a widening of the QRS complex. Right Bundle
Branch Block (RBBB) indicates problems in the right side of the heart. Whereas Left Bundle
Branch Block (LBBB) is an indication of heart disease. If LBBB is present then further
interpretation of the ECG cannot be carried out.
Looking at the ECG you'll see that:

Rhythm - Regular

Rate - Normal

QRS Duration - Prolonged

P Wave - Ratio 1:1

P Wave rate - Normal and same as QRS rate

P-R Interval - Normal


Premature Ventricular Complexes
Due to a part of the heart depolarizing earlier than it should
Looking at the ECG you'll see that:

Rhythm - Regular

Rate - Normal

QRS Duration - Normal

P Wave - Ratio 1:1

P Wave rate - Normal and same as QRS rate

P-R Interval - Normal

Also you'll see 2 odd waveforms, these are the ventricles depolarising prematurely in
response to a signal within the ventricles.(Above - unifocal PVC's as they look alike if they
differed in appearance they would be called multifocal PVC's, as below)
Junctional Rhythms
Looking at the ECG you'll see that:

Rhythm - Regular

Rate - 40-60 Beats per minute

QRS Duration - Normal

P Wave - Ratio 1:1 if visible. Inverted in lead II

P Wave rate - Same as QRS rate

P-R Interval - Variable

Below - Accelerated Junctional Rhythm
Ventricular Tachycardia (VT) Abnormal
Looking at the ECG you'll see that:

Rhythm - Regular

Rate - 180-190 Beats per minute

QRS Duration - Prolonged

P Wave - Not seen

Results from abnormal tissues in the ventricles generating a rapid and irregular heart
rhythm. Poor cardiac output is usually associated with this rhythm thus causing the pt to go
into cardiac arrest. Shock this rhythm if the patient is unconscious and without a pulse


Ventricular Fibrillation (VF) Abnormal
Disorganised electrical signals cause the ventricles to quiver instead of contract in a
rhythmic fashion. A patient will be unconscious as blood is not pumped to the brain.
Immediate treatment by defibrillation is indicated. This condition may occur during or after
a myocardial infarct.
Looking at the ECG you'll see that:

Rhythm - Irregular

Rate - 300+, disorganised

QRS Duration - Not recognisable

P Wave - Not seen

This patient needs to be defibrillated!! QUICKLY


Asystole - Abnormal
Looking at the ECG you'll see that:

Rhythm - Flat

Rate - 0 Beats per minute

QRS Duration - None

P Wave - None

Carry out CPR!!


Myocardial Infarct (MI)
Looking at the ECG you'll see that:

Rhythm - Regular

Rate - 80 Beats per minute

QRS Duration - Normal

P Wave - Normal

S-T Element does not go isoelectric which indicates infarction
Info
ECG Component Time(sec) Small Squares
P Wave
0.10
up to 2.5
PR Interval
0.12 - 0.20
2.5-5.0
QRS
0.10
1.5-2.5
Thanks to Nixon Mcinnes for their support in producing this site
SJW 2006
An Introduction Guide to
Basic EKG Interpretation
“Say what? “
A guide to be used in preparation for EKG Class before you attend
Provena Health
Mercy Medical Center
1
Cardiac Anatomy and Physiology
The circulatory system is required to perfuse the tissues of the body to maintain cell life.
It delivers oxygen and nutrients and removes waste products for elimination by the
kidneys, liver and lungs. Effective circulation depends on normal electrical activation
and mechanical function of the heart, normal cardiac structure and appropriate
regulation. The important components of the circulatory system are the heart, great
arteries (aorta and pulmonary artery), arterioles, capillaries, venules, great veins and
lymphatics. The system is divided into two circuits in series, one supplying systemic
requirements and the other serving the pulmonary tissues.
The pulmonary artery is the only artery in the body to deliver deoxygenated blood.
The pulmonary veins are the only veins in the body to deliver oxygenated blood.
Poorly oxygenated blood collects in two major veins: the superior vena cava and the
inferior vena cava. The superior and inferior vena cava empty into the right atrium.
The coronary sinus which brings blood back from the heart itself also empties into the
right atrium. The right atrium is the larger of the two atria although it recieves the same
amount of blood. The blood is then pumped through the tricuspid atrioventricular
valve into the right ventricle. From the right ventricle, blood is pumped through the
pulmonary semi-lunar valve into the pulmonary trunk. This blood leaves the heart by
the pulmonary arteries and travels through the lungs (where it is oxygenated) and
into the pulmonary veins.
The oxygenated blood then enters the left atrium. The blood then travels through the
bicuspid valve, also called mitral valve, into the left ventricle. The left ventricle is
thicker and more muscular than the right ventricle because it pumps blood at a higher
pressure. From the left ventricle, blood is pumped through the semi-lunar valve into the
2
aorta. Once the blood goes through systemic circulation, peripheral tissues will
extract oxygen from the blood, which will again be collected inside the vena cava and
the process will continue. Peripheral tissues do not fully deoxygenate the blood, thus
venous blood does have oxygen, only in a lower concentration as arterial blood.
Cardiac Cycle
The cardiac cycle can be divided into distinct periods determined by electrical and
mechanical events.
Systole represents the time of contraction and ejection of blood
from the ventricles.
Diastole represents ventricular filling and a brief period just prior to
filling at which time the ventricles are relaxing.
Atrial Contraction is the first phase of the cardiac cycle. It is initiated by the p wave of
the electrocardiogram (ECG), which represents electrical depolarization of the atria.
Atrial depolarization then causes contraction of the atrial musculature. As the atria
contract, the pressure within the atrial chambers increases so that a pressure gradient
is generated across the open atrioventricular (AV) valves causing a rapid flow of blood
into the ventricles.
Atrial contraction normally accounts for about 10% of left ventricular filling when a
person is at rest because most of the ventricular filling occurs before the atria contract
and therefore is passive. However, if heart rate is very high (e.g., during exercise), the
atrial contraction may account for up to 40% of ventricular filling. This is sometimes
referred to as the "atrial kick."
Ventricular contraction is phase of the cardiac cycle is initiated by the QRS complex
of the ECG which represents ventricular depolarization. When the intraventricular
3
pressures exceed the pressures within the aorta and pulmonary artery, the aortic and
pulmonic valves open and blood is ejected out of the ventricles.
Approximately 150-200 msec after the QRS, ventricular repolarization occurs (T-wave).
This causes ventricular active tension to decrease and the rate of ejection (ventricular
emptying) to fall.
How the ECG works
When cell membranes in the heart depolarize, voltages change and currents flow.
Because a human can be regarded as a bag of salt water, in other words, a volume
conductor, changes in potential are transmitted throughout the body, and can be
measured. When the heart depolarizes, it's convenient (and fairly accurate) to represent
the electrical activity as a dipole --- a vector between two point charges. Remember that
a vector has both a size (magnitude), and a direction. By looking at how the potential
varies around the volume conductor, one can get an idea of the direction of the vector.
This applies to all intra-cardiac events, so we can talk about a vector (or axis) for P
waves, the QRS complex, T waves, and so on.
Cardiac Conduction System
In order for normal depolarization and repolarization to occur, the electrical impulse
within the cardiac cell must follow a specific pathway within the heart. This pathway is
known as the conduction system.
The SA (sinoatrial) node is located in the upper part of the right atrium and is normally
the primary, dominant pacemaker of the heart. When the SA node is stimulated the
impulse travels to the AV node (atrioventricular) node, which is located between the
atria and ventricles. The impulse then moves on to the Bundle of His and innervates
the right and left bundle branches, which are located within the intraventricular septum.
Finally, the Purkinje fibers located within the ventricular muscles are stimulated,
4
causing ventricular repolarization. The EKG tracing reflects these depolarization and
repolarization events.
Although the SA node is the primary and dominant pacemaker of the heart, another
pacemaker may take control of the heart rate under certain circumstances. In general,
the pacemaker with the fastest inherent rate is dominant. In adults and children, this
should be the SA node, which fires a rate of 60 – 100 beats per minute (in adults).
The AV node fires at a rate of 40 – 60 beats per minute and the ventricular fibers
fire at a rate of 20 – 40.
Changes in the serum concentration of ions, particularly potassium, can cause
changes in SA nodal firing rate. Hyperkalemia induces bradycardia or can even stop
SA nodal firing. Hypokalemia causes tachycardia and ventricular ectopies.
Whenever an action potential is generated, Na+ enters the cell and K+ leaves the cell.
Characteristics of the Cardiac Cell

Automaticity refers to the ability of the cardiac muscles to depolarize
spontaneously, i.e without external electrical stimulization from the
nervous system.
5

Contractility is the intrinsic ability of a cardiac muscle fibre to shorten
in response to the electrical stimulus, causing a contraction.
If myocardial performance changes while preload, afterload and
heart rate are all constant, then the change in performance must be
due to the change in contractility.

Condcutivity is the ability of the cardiac muscles (cells) to receive an
electrical impulse and conduct it to other cardiac cells.

Excitibility (also referred to as irritability) is the capability of the
resting polarized cardiac cell to depolarize in response to an
electrical stimulus.

Rhythmicity is the ability of the heart to conduct electrical impulses in
a regular, timely fashion.
Cardiac Output (CO)
The primary function of the heart is to impart energy to blood in order to generate
and sustain an arterial blood pressure necessary to provide adequate perfusion of
organs. The heart achieves this by contracting its muscular walls around a closed
chamber to generate sufficient pressure to propel blood from the cardiac chamber
(e.g., left ventricle), through the aortic valve and into the aorta.
Each time the heart beats; a volume of blood is ejected. This stroke volume (SV),
times the number of beats per minute (heart rate, HR), equals the cardiac output
(CO).
CO = SV · HR
Stroke volume is expressed in ml/beat and heart rate in beats/minute. Therefore,
cardiac output is in ml/minute. Sometimes, cardiac output is expressed in
liters/minute.
Heart Rate (HR)
Heart rate is normally determined by the pacemaker activity of the SA node located
in the posterior wall of the right atrium. The SA node exhibits automaticity that is
determined by spontaneous changes in Ca++, Na+, and K+ conduction. Heart rate is
decreased below the intrinsic rate primarily by activation of the vagus nerve
innervating the SA node. Normally, at rest, there is significant vagal tone on the SA
node so that the resting heart rate is between 60 and 80 beats/min.
This vagal influence can be demonstrated by administration of atropine, which leads
to a 20-40-beats/min increase in heart rate depending upon the initial level of vagal
tone. The heart is innervated by vagal and sympathetic fibers. The right vagus nerve
primarily innervates the SA node, whereas the left vagus innervates the AV node;
6
however, there can be significant overlap in the anatomical distribution. Atrial muscle
is also innervated by vagal efferents, whereas the ventricular myocardium is only
sparsely innervated by vagal efferents. Sympathetic efferent nerves are present
throughout the atria (especially in the SA node) and ventricles, including the
conduction system of the heart.
Stroke Volume (SV)
There are three primary mechanisms that regulate SV.
1) Preload can be defined as the initial stretching of the cardiac myocytes (cells)
prior to contraction.
2) Afterload is the pressure the ventricle generates during systolic ejection is very
close to aortic pressure
3) Changes in contractility alter the rate of force and pressure development by the
ventricle, and therefore change the rate of ejection
Autonomic Nervous System
The autonomic nervous system consists of sensory neurons and motor neurons that run
between the central nervous system (especially the hypothalamus and medulla
oblongata) and various internal organs such as the:




Heart
Lungs
Viscera
Glands (both exocrine and endocrine)
It is responsible for monitoring conditions in the internal environment and bringing about
appropriate changes in them. The contraction of both smooth muscle and cardiac
muscle is controlled by motor neurons of the autonomic system.
The normal pacemaker site for the heart is located within the SA node. Cells within
this pacemaker region have an intrinsic firing rate that is modulated primarily by
changes in autonomic nerve activity. If there is a high level of vagal tone on the SA
node, then this will cause sinus bradycardia (a sinus rate <60 beats/min).
Conversely, an abnormally high level of sympathetic tone on the SA node will cause
sinus tachycardia (a sinus rate >100 beats/min).
7
Sympathetic Nervous System
Stimulation of the sympathetic branch of the autonomic nervous system prepares the
body for emergencies: for "fight or flight".
The release of noradrenaline:








Stimulates heartbeat
Raises blood pressure
Dilates the pupils
Dilates the trachea and bronchi
Stimulates the conversion of liver glycogen into glucose
Shunts blood away from the skin and viscera to the skeletal muscles,
brain, and heart
Inhibits peristalsis in the gastrointestinal (GI) tract
Inhibits contraction of the bladder and rectum
Vagus Nerve
The vagus nerve (cranial nerve X) is the tenth of twelve paired cranial nerves, and is
the only nerve that starts in the brainstem (within the medulla oblongata) and extends,
through the jugular foramen, down below the head, to the abdomen. The vagus nerve is
arguably the single most important nerve in the body.
8
ParasympatheticNervous System
Parasympathetic innervation of the heart is mediated by the vagus nerve. The right
vagus innervates the Sinoatrial node. Parasympathetic hyperstimulation predisposes
those affected to bradyarrhythmias. The left vagus when hyperstimulated predisposes
the heart to Atrioventricular (AV) blocks.
Parasympathetic stimulation causes:





Slowing down of the heartbeat
Lowering of blood pressure
Constriction of the pupils
Increased blood flow to the skin and viscera
Peristalsis of the GI tract
Sympathetic and Parasympathetic effects on the cardiac conduction system
Paper
ECG paper is traditionally divided into 1mm squares. Vertically, ten blocks usually
correspond to 1 mV, and on the horizontal axis, the paper speed is usually 25mm/s, so
one block is 0.04s (or 40ms). Note that we also have "big blocks" which are 5mm on
their side.
9
Always check the calibration voltage on the right of the ECG, and paper speed. The
following image shows the normal 1mV calibration spike:
Damping
Note that if the calibration signal is not "squared off" then the ECG tracing is either over
or under-damped, and should not be trusted.
1. P wave = depolarization of the atria.
QRS = depolarization of the ventricle.
T wave = repolarization of the ventricle.
Description of the waves on the ECG.
2. Cardiac muscle cells depolarize with a positive wave of depolarization, and then
repolarize to a negative charge intracellularly.
3. Skin "leads" or electrodes have a positive and negative end.
4. A positive waveform (QRS mainly above the baseline) results from the wave of
depolarization moving towards the positive end of the lead. A negative waveform
(QRS mainly below the baseline) is when a wave of depolarization is moving
away from the positive electrode (towards the negative end of the lead).
5. ECG paper has 1millimeter small squares - so height and depth of wave is
measured in millimeters.
10 mm = 1.0 mVolt
6. Horizontal axis is time.
. 04 seconds for 1 mm (1 small box).
. 20 seconds for 1 large box = 5 small boxes = 5 x .04 seconds.
10
Positive QRS in Lead I.
Negative QRS in Lead aVR.
R wave = 7-8 mm high in Lead I.
QRS wave = .06 seconds long in Lead I.
Rate
Rate is cycles or beats per minute.
Normal rate for the SA node 60 – 100.
<60
bradycardia
>100
tachycardia
SA node is the usual pacemaker, other potential pacemakers (if SA node fails) are atrial
pacemakers with inherent rates of 60-80, AV node (rate 40-60), or ventricular pacer
(rate 20-40). In certain pathologic conditions ectopic (out of place) pacemakers can go
much faster at rates 150-250 cycles/minute. There are three methods of calculating
rate:
Most Common Method:
(Most rates can be calculated this way). Find an R wave on a heavy line (large box)
count off "300, 150, 100, 75, 60, 50" for each large box you land on until you reach the
next R wave. Estimate the rate if the second R wave doesn't fall on a heavy black line.
Rate calculation
Memorize the number sequence:
300, 150, 100, 75, 60, 50
1.
11
2. Mathematical method:
Use this method if there is a regular bradycardia, i.e. - rate < 50. If the distance
between the two R waves is too long to use the common method, use the
approach: 300/[# large boxes between two R waves].
Count number of large boxes between first and second R waves=7.5. 300/7.5
large boxes = rate 40.
3. Six-second method:
Count off 30 large boxes = 6 seconds (remember 1 large box = 0.2 seconds, so
30 large boxes = 6 seconds). Then, count the number of R-R intervals in six
seconds and multiply by 10. This is the number of beats per minute. This is most
useful if you have an irregular rhythm (like atrial fibrillation) when you want to
know an average rate.
Count 30 large boxes, starting from the first R wave. There are 8 R-R intervals
within 30 boxes. Multiply 8 x 10 = Rate 80.
ECG Lead Placement
Lead Selection

Lead II is the same as standard lead two as seen in a 12 lead EKG.
12
o
o

It is the most common monitoring lead.
It is not the optimal monitoring lead
V1 lead is the best lead to view ventricular activity and differentiate
between right and left bundle branch blocks.
o The only way to view V1 is with a five lead system.
o Therefore, MCL1 was designed to overcome the inconvenience
of a five lead system and provide all the advantages of V1
viewing
Tips for Preparation






Wash site with soap and water
Dry briskly, try not to abrade the skin
Clip hair if necessary
When possible attach leads to electrodes prior to attachment to patient
Make sure electrode backing is moist
Change electrodes daily
Troubleshooting Tips






Change the electrodes everyday.
Make sure all electrical patient care equipment is grounded.
Be sure all the lead cables are intact. Some manufacturers require
changing the cables periodically.
Be sure the patient's skin is clean and dry.
Make sure the leads are connected tightly to the electrodes.
Patient movement frequently causes interference. For example, the
action of brushing teeth may cause interference that mimics V-tach
13
ECG (EKG) Waveforms
P wave, the first positive deflection is called the P wave, which represents the
contraction of the atria. The P wave represents the wave of depolarization that spreads
from the SA node throughout the atria, and is usually 0.08 to 0.1 seconds (80-100 ms)
in duration
PR interval is a short, flat pause called the PR interval, which is the space between the
P wave and the R wave. The PR interval represents the time between when the
electrical signal causes the atria to contract and when that signal causes the ventricles
to contract. The period of time from the onset of the P wave to the beginning of the QRS
complex is termed the P-R interval, which normally ranges from 0.12 to 0.20 seconds
in duration. This interval represents the time between the onset of atrial depolarization
and the onset of ventricular depolarization.
QRS interval, there may be a small dip called the Q wave (it may not be present)
followed by a tall spike called the R wave and another small dip called the S wave.
Together, the Q, R, and S waves (called the QRS complex) represent the activation of
the left and right ventricles. The pattern of the QRS complex depends on the location of
the electrode recording it. The QRS complex represents ventricular depolarization. The
duration of the QRS complex is normally 0.06 to 0.10 or < 0.12 seconds. This relatively
short duration indicates that ventricular depolarization normally occurs very rapidly. If
the QRS complex is prolonged (> 0.1 sec), conduction is impaired within the ventricles.
T wave represents the resetting, or repolarization, of the electrical cells in the ventricles.
By contrast, the resetting of the cells in the atria actually occurs while the ventricles are
contracting, which masks the signal so it does not appear on the waveform. When the
ventricles have reset, the entire cycle repeats and is represented by a new EKG
waveform. The T wave represents ventricular repolarization and is longer in duration
than depolarization (i.e., conduction of the repolarization wave is slower than the wave
of depolarization). Sometimes a small positive U wave may be seen following the T
wave. This wave represents the last remnants of ventricular repolarization. Inverted or
prominent U waves indicate underlying pathology or conditions affecting repolarization.
QT interval represents the time for both ventricular depolarization and repolarization to
occur, and therefore roughly estimates the duration of an average ventricular action
potential. The QT interval can range from 0.2 to 0.4 seconds depending upon heart
14
rate. At high heart rates, ventricular action potentials shorten in duration, which
decreases the Q-T interval. Because prolonged Q-T intervals can be diagnostic for
susceptibility to certain types of tachyarrhythmias, it is important to determine if a given
Q-T interval is excessively long.
EKG Rhythms Interpretation 5 Basic Steps
1.
2.
3.
4.
5.
Rhythm check: regular / irregular, patterns
Rate: exact / approximate; atrial / ventricular
P waves: regular / upright, Look similar? In front / behind the QRS? More than 1?
PR interval: within normal measurement? Constant? Patterns?
QRS complex: within normal measurement? Look similar?
15
Sinus Rhythms
Sinus rhythm occurs when the sinoatrial node, the normal cardiac pacemaker,
depolarizes spontaneously, and the consequent wave of depolarization follows the
natural pathways through the heart. The parasympathetic system normally slows the
spontaneous discharge rate of the sinoatrial node from 100bpm to about 70bpm.
Sinus rhythms (SR) are a class of rhythms that originate at the SA node. It is the
standard against which all dysrhythmias are measured.
The criteria for a Normal Sinus Rhythm is:





P wave before each QRS
PR interval 0.12 to 0.20 seconds
QRS < 0.12 seconds
QT interval < 0.40 seconds
Heart rate between 60 to 100 beats a
minute
If the rhythm does not meet of the above criteria, then it cannot be interpreted as a
normal sinus rhythm
Patients in Sinus Bradycardia (SB) can be asymptomatic. If slow heart rates are
accompanied by a decrease in cardiac output, symptoms like syncope, hypotension,
chest pain, or shortness of breath may be present. Treatment is not indicated unless
patient is symptomatic. If symptomatic, consider atropine and pacing. Drips may be
considered for pressure and rate. Treatment should be aimed at treating the underlying
cause.
The criteria for Sinus Bradycardia is:





P wave before each QRS
PR interval 0.12 to 0.20 seconds
QRS < 0.12 seconds
QT interval < 0.40 seconds
Heart rate less than 60 beats a minute
Sinus Tachycardia (ST) is usually cause by non-cardiac factors. Fear, anxiety, fever,
anemia, hypovolemia, pain, pulmonary embolism may be factors in ST. Cardiac causes
can include heart failure, acute MI, myocarditis, and pericarditis. Medications such as
atropine. Isuprel, dopamine, Dobutamine, epinephrine can also cause an increase in
heart rate.
16
The criteria for Sinus Tachycardia is:





P wave before each QRS
PR interval 0.12 to 0.20 seconds
QRS < 0.12 seconds
QT interval < 0.40 seconds
Heart rate greater than 100 beats a
minute to about 150 beats a minute
Dysrhythmias (Arrhythmias)
About 14 million people in the USA have arrhythmias (5% of the population). The most
common disorders are atrial fibrillation and flutter. The incidence is highly related to age
and the presence of underlying heart disease; the incidence approaches 30% following
open-heart surgery.
Patients may describe an arrhythmia as a palpitation or fluttering sensation in the
chest. For some types of arrhythmias, a skipped beat might be sensed because the
subsequent beat produces a more forceful contraction and a thumping sensation in the
chest. A "racing" heart is another description.
A frequent cause of arrhythmia is coronary artery disease because this condition results
in myocardial ischemia or infarction. When cardiac cells lack oxygen, they become
depolarized, which lead to altered impulse formation and/or altered impulse conduction.
The former concerns changes in rhythm that are caused by changes in the automaticity
of pacemaker cells or by abnormal generation of action potentials at sites other than the
SA node (termed ectopic foci).
Altered impulse conduction is usually associated with complete or partial block of
electrical conduction within the heart. Altered impulse conduction commonly results in
reentry, which can lead to tachyarrhythmias. Changes in cardiac structures that
accompany heart failure (e.g., dilated or hypertrophied cardiac chambers), can also
precipitate arrhythmias. Finally, many different types of drugs (including antiarrhythmic
drugs) as well as electrolyte disturbances (primarily K+ and Ca++) can precipitate
arrhythmias.
Arrhythmias can be either benign or more serious in nature depending on the
hemodynamic consequence of the arrhythmia and the possibility of evolving into a lethal
arrhythmia. Occasional premature ventricular complexes (PVCs), while annoying to a
patient, are generally considered benign because they have little hemodynamic effect.
Consequently, PVCs if not too frequent, are generally not treated. In contrast,
ventricular tachycardia is a serious condition that can lead to heart failure, or worse, to
ventricular fibrillation and death.
17
Premature Atrial Contractions
If the premature impulse falls in the relative refractory period or later, an atrial
contraction may occur. This is called a Premature Atrial Contraction (PAC). The rate
is determined by the underlying rhythm. Isolated PACs can occur in healthy adults and
can be caused by anxiety, stress, excessive caffeine, nicotine, alcohol and drug use.
Frequent is measured at 6 or more. Symptoms such as palpitations and fluttering may
be present. Presence of PACs may forewarn of more serious atrial dysrhythmias such
as atrial fibrillation and atrial flutter.
Examine the PAC for common characteristics of atrial complexes:



Upright normal P wave
Looks different from Sinus P wave
Narrow QRS complex < 0.12 seconds
If the SA node or the internodal pathways fail, suffer stress or damage, the atria can
frequently initiate impulses from other portions of the atrial tissue. PACs are one
possible outcome. Other dysrhythmias that may occur are atrial fibrillation and atrial
flutter.
Atrial Fibrillation
Atrial fibrillation (A fib or AF) describes a condition in which the atrial tissue randomly
generates action potentials from man different regions. Physically, the atrial muscle
appears to quiver. There are no noticeable P waves, and the overall rhythm is
irregularly irregular







The atrial rate is impossible to count and may be as fast as 400 plus
Ventricular rate is variable
 Uncontrolled: over 100 beats a minute
 Controlled: 60 – 100 beats a minute
 Over controlled: less than 60 beats a minute
 Rapid (RVR): is > 150 beats a minute
No P waves
Irregular rhythm
Chaotic baseline
Narrow QRSs
Heart rates greater than
Atrial Flutter
Atrial flutter (A flutter) is recognized by the distinct “saw tooth” pattern of the P waves.
The atria are “fluttering” at a rapid rate. These atrial impulses produce a series of waves
that occur at a rate of at least 250 per minute. To keep the heart rate in control, the AV
18
node blocks many of the atrial impulses but allows some to reach the ventricles. Can be
seen in patients with valvular heart disease, hypoxemia, lung disease, pulmonary
embolus, heart failure, cardiomyopathy, and post cardiac surgery. The QRS complexes
can appear at different intervals and frequencies. Naming conventions for depend on
these relations:


Saw tooth pattern waves
PR not measurable
Atrial flutter 2:1 block
 2 flutter waves followed by 1 QRS
Atrial flutter with variable block
 Common
 Can range between as few as 1 flutter wave to 6 flutter waves between each
QRS complex
The clinical significances of both atrial fibrillation and atrial flutter are that a fast heart
rate can decrease cardiac output. The atria generally don’t have time to fill completely,
the preload to the ventricles is reduced and atrial kick and cardiac output suffers. The
erratic and turbulent blood flow can form small blood clots. If a blood clot is release, it
can cause a stroke. The primary aim of treatment is to control the heart rate then
restore sinus rhythm.
For various reasons, conduction through the AV node may be come impeded or
impaired. This may be benign or develop into a fatal dysrhythmia.
Junctional Dysrhythmias
Junctional dysrhythmias originate in the AV junction. When the SA node is unable to
perform as the primary pacemaker of the heart, the AV node will assume control of the
heart rate. The impulse is generally conducted differently than from the SA node and
retrograde conduction is seen.
19
Premature Junctional Contractions
The AV node like other cardiac tissue has automaticity. The AV node is stimulated
before it fires by itself. Occasionally, an extra impulse may develop in the junction,
spreading to the atria and down to the ventricles. Just like in the case of PACs, the
Premature Junctional Contractions (PJCs) occur periodically.
 The rate is determined by the underlying
rhythm and number of premature beats
 The P wave of the PJC may be seen
inverted before the QRS, inverted after the
QRS or not at all
 Etiology and treatment same as PAC
A PJC may be seen in patients with respiratory difficulty. The poor gas exchange
irritates myocardial tissue and causes abnormal activity. Clinically, PJCs are not usually
treated.
Junctional (Junctional Escape)
If no stimulus reaches the AV node, the cells assume that the SA node never fired. The
AV junction will reach it automatic threshold and generate an action potential. Unlike,
PJCs, the escape complexes will appear late in the rhythm (why they are call escape
beats) and although you may not treat PJCs, escape rhythms may need treatment. P
waves, if seen, will be retrograde conducted and be inverted before or after the QRS
and may not be seen at all. The QRS complex should remain narrow because the
impulses are generated above the ventricles.

Rate is between 40 to 60
beats a minute
 Rhythm is regular
 P waves are inverted when
seen
 QRS should be normal
Cardiac output may be impaired or lost along with loss of the atrial kick. Patients may be
asymptomatic. Symptoms might include lightheadedness and syncope and may be
treated like symptomatic bradycardia.
Accelerated Junctional and Junctional Tachycardia
Accelerated Junctional
 Rate 60 – 100 beats a minute
Junctional Tachycardia
 Rate 100 – 250 beats a minute
Etiologies usually include ischemia, digoxin toxicity, hypoxia and electrolyte imbalance.
Treatment is usually observation and discontinuing the offending medications.
20
Supraventricular Tachycardia
The term Supraventricular Tachycardia (SVT) refers to any tachycardia in which the
pacemaker is located above the ventricles. With fast heart rates the P waves may not
be seen. SVT is used to classify rapid, regular rates greater than 150 beats a minute
in which P waves are not identifiable.
Treatment of SVT is the same as for all rapids rates, control of the rate and return to
normal sinus rhythm.
Valsalva maneuvers like bearing down, coughing, and throwing up can cause the heart
rate to decrease. Carotid massage should only be done by a licensed independent
practitioner trained in the skill.
Adenosine is the medication of choice for rapid heart rates. It has a fast half-life and can
either break the rapid heart rate, converting it to sinus or it can slow the conduction to
allow visualization of the underlying rhythm. Adenosine (Adenocard) is given rapidly
with a rapid intravenous bolus of normal saline. The initial dose is 6 mg followed by a
doubling of the dose to 12 mg, which may be repeated once more if not effective.
Rhythms included in SVT include but not limited to:
 Atrial Tachycardia
 Junctional Tachycardia
 Atrial Fibrillation with a rapid ventricular response
 Atrial Flutter
 Rapid unidentifiable sinus tachycardia
21
Heart Blocks
AV blocks result from an impaired impulse transmission between the atria and
ventricles. Atrial impulse formation is normal, however, they are delayed, intermittently
blocked, or completely blocked by the AV node. The major distinguishing characteristics
are either PR interval abnormalities and/or more Ps than QRSs.
1st Degree heart Block
1st Degree AV Blocks (AVB) are generally benign. They are characterized by a
constant PR interval greater than 0.20 seconds. The rhythm is otherwise normal. Rates
may range from bradycardias to tachycardias with a full variation in between. Normally,
there are no symptoms associated with 1st Degree AVB.
Excessive medications, AV node trauma, Ischemia or disease, hyperkalemia, rheumatic
fever, viral myocarditis or congenital heart disease may precipitate this rhythm. It may
be temporary or permanent and in some cases, may progressive to a more severe
block. Treatment depends on cause.
2nd Degree Heart Block
2nd Degree AV Blocks are subdivided into 2 types: Mobitz I and Mobtiz II
2nd Degree AV Block (AVB) Type I, Wenchebach, or Mobitz Type I, is distinguished
by a repeating cycle of increasing PR intervals. As the interval gets longer, a P wave is
either not conducted (there is no QRS) or the P wave is simply dropped. The cycle then
repeats again. Impulse generation is delayed at the AV node. The delay progressively
lengthens the PR intervals until the impulse cannot be conducted. Mobitz Type I is more
common than Mobitz Type II and are generally not dangerous. The patient may
complain of palpitations or skipped beats. Digoxin toxicity, post-operative surgery,
inferior MI and congenital heart disease may accompany this rhythm. Treat
symptomatic low heart rate.
22
2nd Degree AV Block (AVB) Type II or Mobitz Type II, can be recognized by a
consistent PR interval and frequently non-conductive P waves. QRS complexes may
appear widened depending on the location of the block. Wide QRS complexes indicate
that the ventricles are depolarizing from an action potential in the ventricular tissue,
rather than from at the AV node or above. Generally, Mobitz Type II is not a good sign
and may tend to worsen leading to 3rd Degree Heart Blocks. Impulse conduction is
intermittently blocked at the AV node or Bundle of His. Impulse transmission time can
be normal or prolonged, but always constant. Impulse can be blocked in a fixed or
varying rate.
Most frequently seen after an acute anterior wall MI, severe CAD, cardiomyopathy, agerelated deterioration of the conduction system. Slow ventricular rate can impair cardiac
output and lead to hypotension, angina, CHF or syncope. Frequently progresses to
more severe block. Atropine has little to no effect and pacing is the only
treatment. Attempt Transcutaneous and then Transvenous pacing.
3rd Degree AV Block (AVB), Complete Heart Block (CHB), is the most dangerous
heart block. There is absolutely no conduction through the AV node. Due to the
automaticity of each region of the heart, the atria beat at their intrinsic rate of about 60
to 80 beats a minute and the ventricles, which are completely isolated from the atrial
beat at their slower rate of 20 to 40 beats a minute. The QRS complexes will often be
wide, but depending on the origin of the ventricular action potential, they may remain
narrow. The P – P interval and R – R intervals will each be regular and consistent. The
P – P will be faster than the R – R and there will be no relation between the two.
3rd Degree AVB can be caused by AV node disease, ischemia, calcium or betablockers, acute inferior and anterior wall MI, chronic degeneration of conduction with
age. Both second and third degree heart blocks require pacemaker intervention!
23
Ventricular Dysrhythmias
Normal impulse conduction can either be interrupted by an ectopic impulse or absent
due to failure of a higher pacemaker to control and initiate the heart rate. Ventricular
dysrhythmias can be a very serious problem. Impulses from the ventricle follow an
abnormal pathway and may lead to alteration in cardiac output, which could be lethal.
Premature Ventricular Contractions (PVC)
In adults, coronary heart disease is the leading cause of PVCs. Premature Ventricular
Contractions (PVC) result from an irritable focus in the ventricles and initiate an early
beat. The rate is determined by the underlying rhythm and number of premature beats.
The PVC will occur as an early beat and is usually followed by a compensatory pause. If
no compensatory pause is present, the PVC is said to be interpolated (between the two
poles) the QRS of the PVC is wide and bizarre. PVCs can be caused by a variety of
conditions including respiratory problems and stress. PVC s can also be seen after an
MI, with low potassium and magnesium, low PO2/hypoxia, digoxin toxicity, and
improper PA catheter placement. Drugs like theophylline, Isuprel and dopamine can
precipitate PVCs.
Patients can experience symptoms like hypotension, syncope, and further
dysrhythmias. Medications used in the treatment of PVCs include, amidodarone,
Lidocaine, and other antiarrhythmics.
PVCs are classified on the basis of their origin.
Unifocal PVCs originate from the same focus
They all have the same shape or morphology
Multifocal PVCs arise from multiple foci.
Each PVC has a unique morphology.
PVCs are also classified by their frequency
If each normal contraction is followed by a single
PVC, we call this Bigeminy
If two normal contractions are followed by a single PVC, this is called trigeminy
If three normal contractions are followed by a single PVC, this is called quadrigeminy,
etc.
24
Couplets
Two PVCs in a row are called a couplet
Three or more PVCs in a row is called a short run of V-tach
R on T Phenomena
R on T phenomena is described as an action potential, depolarization of ventricular
muscle during the recovery phase of the ventricle. R on T can lead to a fatal
dysrhythmia called ventricular tachycardia (v tach). R on T can occur with very fast
rates, but also with prolonged QT intervals, ectopic beats like PACs, PJCs, and PVCs. It
can be precipitated by electrolyte imbalance.
Ventricular Tachycardia (VT, V tach)
Ventricular tachycardia (VT) is a serious, life
threatening, rapid dysrhythmia in which the
ventricles depolarize very quickly. V tach is
actually said to happen whenever three or more
PVCs in a row occur.
Rate for v-tach may vary between 100 to 250
beats a minute, may be intermittent or sustained and might have been preceded by
signs of cardiac irritability: R on T, Bigeminy and couplets.
If you have a pulse for every complex, the pulse will be weak and cardiac output low.
If you have a pulse for some beats, this is ominous.
If you have no pulse, you need to intervene and resuscitate the patient!
Ventricular tachycardia may lead to ventricular fibrillation. Treatment includes
admiodarone, Lidocaine, synchronized cardioversion and / or defibrillation.
Ventricular Fibrillation (VF, V fib)
Ventricular fibrillation (VF, vfib) is the most common fatal dysrhythmia in adult
patients. Vfib represents a chaotic depolarization or random ventricular cells. The
ventricles are said to be quivering and have been described as resembling a bowl of
jello! There is no cardiac output and death will result without intervention and
termination.
Vfib can be fine or coarse, as tissue dies, the voltage decreases, coarse might be better
than fine, all things considered.
25
Idioventricular Rhythm
Idioventricular rhythm (agonal rhythm) is the heart’s last possible mechanism to
maintain a heart rate. In the absence of a higher pacemaker, the ventricles initiate an
impulse at their inherent rate (escape rate) of 2o to 40 beats a minute. The heart rate is
usually ranges between 20 to 40, regular, no P waves, wide and bizarre QRS.
Asystole
Asystole is the absence of all electrical activity in the heart. It is seen on the EKG
monitor as a straight line. It is a lethal rhythm with poor prognosis. Asystole must be
“conformed: in 2 leads and by turning the gain up. If the rhythm demonstrates fine
fibrillatory characteristics, treat like vfib. Ensure that the patient’s leads have not fallen
off or become otherwise, detached from the patient. Consider atropine, epinephrine and
attempt a pacemaker. Consider stopping rescue efforts.
26
nursesaregreat.com - Brush up on Your Drug Calculation Skills
Page 1 of 9
Brush up on Your Drug
Calculation Skills
by
Louise Diehl, RN, MSN, ND, CCRN, ACNS-BC, NP-C
Nurse Practitioner - Owner
Doctor of Naturopathy
Lehigh Valley Wellness Center
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Lehigh Valley
Wellness Center
Many nurses are weak with drug calculations of all sorts. This article will help
to review the major concepts related to drug calculations, help walk you
through a few exercises, and provide a few exercises you can perform on your
own to check your skills. There are many reference books available to review
basic math skills, if you find that you have difficulty with even the basic
conversion exercises.
Common Conversions:
1 Liter = 1000 Milliliters
1 Gram = 1000 Milligrams
1 Milligram = 1000 Micrograms
1 Kilogram = 2.2 pounds
Methods of Calculation
Any of the following three methods can be used to perform drug calculations.
Please review all three methods and select the one that works for you. It is
important to practice the method that you prefer to become proficient in
calculating drug dosages.
Remember: Before doing the calculation, convert units of measurement to one
system.
I. Basic Formula: Frequently used to calculate drug dosages.
D (Desired dose)
H (Dose on hand)
V (Vehicle-tablet or liquid)
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D
x V = Amount to Give
H
D = dose ordered or desired dose
H = dose on container label or dose on hand
V = form and amount in which drug comes (tablet, capsule, liquid)
Example: Order-Dilantin 50 mg p.o. TID
Drug available-Dilantin 125 mg/5ml
D=50 mg
H=125 mg
V=5 ml
250
50
x5=
= 2 ml
125
125
II. Ratio & Proportion: Oldest method used in calculating dosage.
Known
H
:
Desired
V
::
D
:
X
Means
Extremes
Left side are known quantities
Right side is desired dose and amount to give
Multiply the means and the extremes
HX = DV
X=
DV
H
Example: Order-Keflex 1 gm p.o. BID
Drug available-Keflex 250 mg per capsule
D=1 gm (note: need to convert to milligrams)
1 gm = 1000 mg
H=250 mg
V=1 capsule
250
:
1
::
1000
:
X
250X = 1000
X=
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1000
250
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X = 4 capsules
III. Fractional Equation
H D
=
V X
Cross multiply and solve for X.
H D
=
V X
HX = DV
X=
DV
H
Example: Order - Digoxin 0.25 mg p.o. QD
Drug Available - 0.125 mg per tablet
D=0.25 mg
H=0.125 mg
V=1 tablet
0.125 0.25
=
1
X
0.125X = 0.25
X=
0.25
0.125
X = 2 tablets
IV. Intravenous Flow Rate Calculation (two methods)
Two Step
Step 1 - Amount of fluid divided by hours to administer = ml/hr
Step 2 -
ml/hr x gtts/ml(IV set)
= gtts/min
60 min
One Step
amount of fluid x drops/milliliter (IV set)
hours to administer x minutes/hour (60)
Example: 1000 ml over 8 hrs
IV set = 15 gtts/ml
Two Step
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Step 1 -
1000
= 125
8
Step 2 -
125 x 15
= 31.25 (31 gtts/min)
60
One Step
1000 x 15 15,000
=
= 31.25 (31gtts/min)
8 hrs x 60
480
V. How to Calculate Continuous Infusions
A. mg/min (For example - Lidocaine, Pronestyl)
Solution cc x 60 min/hr x mg/min
= cc/hr
Drug mg
Drug mg x cc/hr
= mg/hr
Solution cc x 60 min/hr
Rule of Thumb
Lidocaine, Pronestyl
2 gms/250 cc D5W
1 mg = 7 cc/hr
2 mg = 15 cc/hr
3 mg = 22 cc/hr
4 mg = 30 cc/hr
B. mcg/min (For example - Nitroglycerin)
Solution cc x 60 min/hr x mcg/min
= cc/hr
Drug mcg
Drug mcg x cc/hr
= mcg/hr
Solution cc x 60 min/hr
Rule of Thumb
NTG 100 mg/250 cc
1 cc/hr = 6.6 mcg/min
NTG 50 mg/250 cc
1 cc/hr = 3.3 mcg/min
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C. mcg/kg/min (For example - Dopamine, Dobutamine, Nipride, etc.)
1. To calculate cc/hr (gtts/min)
Solution cc
x 60 min/hr x kg x mcg/kg/min = cc/hr
Drug mcg
Example: Dopamine 400 mg/250 cc D5W to start at 5 mcg/kg/min.
Patient’s weight is 190 lbs.
250 cc
x 60 min x 86.4 x 5 mcg/kg/min = 16.2 cc/hr
400,000 mcg
2. To calculate mcg/kg/min
Drug mcg/ x cc/hr
= mcg/kg/min
Solution cc x 60 min/hr x kg
Example: Nipride 100 mg/250 cc D5W was ordered to decrease your
patient’s blood pressure.
The patient’s weight is 143 lbs, and the IV pump is set at 25
cc/hr. How many mcg/kg/min of Nipride is the patient
receiving?
100,000 mcg x 25 cc/hr 2,500,000
=
= 2.5 mcg/kg/min
250 cc x 60 min x 65 kg
975,000
A. How to calculate mcg/kg/min if you know the rate of the infusion
Dosage (in mcg/cc/min) x rate on pump
= mcg/kg/min
Patient’s weight in kg
For example:
400mg of Dopamine in 250 cc D5W = 1600 mcg/cc
60 min/hr
= 26.6 mcg/cc/min
26.6 is the dosage concentration for Dopamine in mcg/cc/min based on
having 400 mg in 250 cc of IV fluid. You need this to calculate this
dosage concentration first for all drug calculations. Once you do this
step, you can do anything!
NOW DO THE REST!
If you have a 75 kg patient for example...
26.6 mcg/cc/min x 10 cc on pump
= 3.54 mcg/kg/min
Patients’s weight in kg (75 kg)
= 3.5 mcg/kg/min (rounded down)
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B. How to calculate drips in cc per hour when you know the mcg/kg/min
that is ordered or desired
mcg/kg/min x patient’s weight in kg
= rate on pump
dosage concentration in mcg/cc/min
For example:
400 mg Dopamine in 250 cc D5W = 26.6 mcg/cc/min
3.5 mcg/kg/min x 75 kg
= 9.86 cc
26.6 mcg/cc/min
= 10 cc rounded up
ALWAYS WORK THE EQUATION BACKWARDS AGAIN TO
DOUBLE CHECK YOUR MATH!
For example:
10 cc x 26.6 mcg/cc/min
= 3.5 mcg/kg/min
75 Kg
Dosage (in mcg/cc/min) x rate on pump
= mcg/kg/min
Patient’s weight in kg
For example:
400mg of Dopamine in 250 cc D5W = 1600 mcg/cc 60 min/hr = 26.6
mcg/cc/min
26.6 is the dosage concentration for Dopamine in mcg/cc/min based on
having 400 mg in 250 cc of IV fluid. You need this to calculate this
dosage concentration first for all drug calculations. Once you do this
step, you can do anything!
NOW DO THE REST!!
If you have a 75 kg patient for example
26.6 mcg/cc/min x 10 cc on pump
= 3.54 mcg/kg/min
Patients’s weight in kg (75 kg)
Now do some practice exercises to check what you learned
A. Practice Problems:
1.
2.
3.
4.
5.
6.
7.
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2.5 liters to milliliters
7.5 grams to milligrams
10 milligrams to micrograms
500 milligrams to grams
7500 micrograms to milligrams
2800 milliliters to liters
165 pounds to kilograms
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8. 80 kilograms to pounds
B. Practice Problems: Use the method you have chosen to calculate the
amount to give.
1. Order-Dexamethasone 1 mg
Drug available-Dexamethasone 0.5 mg per tablet
2. Order-Tagamet 0.6 gm
Drug available-Tagamet 300 mg per tablet
3. Order-Phenobarbital 60 mg
Drug available-Phenobarbital 15 mg per tablet
4. Order-Ampicillin 0.5 gm
Drug available-Ampicillin 250 mg per 5 ml
5. Order-Dicloxacillin 125 mg
Drug Available-Dicloxacillin 62.5 mg per 5 ml
6. Order-Medrol 75 mg IM
Drug Available-Medrol 125 mg per 2 ml
7. Order-Lidocaine 1 mg per kg
Patient’s weight is 152 pounds
8. Order- 520 mg of a medication in a 24 hour period. The drug is
ordered every 6 hours.
How many milligrams will be given for each dose?
C. Practice Problems:
1. Order-1000 ml over 6 hrs
IV set 15 gtts/ml
2. Order-500 ml over 4 hrs
IV set 10 gtts/ml
3. Order-100 ml over 20 min.
IV set 15 gtts/ml
D. Practice Problems:
1. Dopamine 400 mg in 250 cc D5W to infuse at 5 mcg/kg/min. The
patient’s weight is 200 pounds. How many cc/hour would this be
on an infusion pump?
2. A Dopamine drip (400mg in 250 cc of IV fluid) is infusing on your
80 kg patient at 20 cc/hour. How many mcg/kg/min are infusing
for this patient?
3. A Nitroglycerin drip is ordered for your patient to control his
chest pain. The concentration is 100 mg in 250 cc D5W. The
order is to begin the infusion at 20 mcg/min. What is the rate you
would begin the infusion on the infusion pump?
4. A Nitroglycerin drip (100mg in 250 cc D5W) is infusing on your
patient at 28 cc/hour on the infusion pump. How many mcg/min
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is your patient receiving?
5. A procainamide drip is ordered (2gms in 250 cc D5W) to infuse at
4 mg/min. The patient weighs 165 pounds. Calculate the drip rate
in cc/hour for which the infusion pump will be set at.
6. A Lidocaine drip is infusion on your 90 kg patient at 22 cc/hour.
The Lidocaine concentration is 2 grams in 250 cc of D5W. How
many mg/min is your patient receiving?
Summary
Many nurses have difficulty with drug calculations. Mostly because they don’t
enjoy or understand math. Practicing drug calculations will help nurses
develop stronger and more confident math skills. Many drugs require some
type of calculation prior to administration. The drug calculations range in
complexity from requiring a simple conversion calculation to a more complex
calculation for drugs administered by mcg/kg/min. Regardless of the drug to be
administered, careful and accurate calculations are important to help prevent
medication errors. Many nurses become overwhelmed when performing the
drug calculations, when they require multiple steps or involve life-threatening
drugs. The main principle is to remain focused on what you are doing and try
to not let outside distractions cause you to make a error in calculations. It is
always a good idea to have another nurse double check your calculations.
Sometimes nurses have difficulty calculating dosages on drugs that are
potentially life threatening. This is often because they become focused on the
actual drug and the possible consequences of an error in calculation. The best
way to prevent this is to remember that the drug calculations are performed the
same way regardless of what the drug is. For example, whether the infusion is a
big bag of vitamins or a life threatening vasoactive cardiac drug, the calculation
is done exactly the same way.
Many facilities use monitors to calculate the infusion rates, by plugging the
numbers in the computer or monitor with a keypad and getting the exact
infusion titration chart specifically for that patient. If you use this method for
beginning your infusions and titrating the infusion rates, be very careful that
you have entered the correct data to obtain the chart. Many errors take place
because erroneous data is first entered and not identified. The nurses then
titrate the drugs or administer the drugs based on an incorrect chart. A method
to help prevent errors with this type of system is to have another nurse double
check the data and the chart, or to do a hand calculation for comparison. The
use of computers for drug calculations also causes nurses to get “rusty” in their
abilities to perform drug calculations. It is suggested that the nurse perform the
hand calculations from time to time, to maintain her/his math skills.
Answers to Practice Problems
A. Practice Problems
1. 2500 mL
2. 7500 mg
3. 10,000 mcg
4. 0.5 gm
5. 7.5 mg
6. 2.8 L
7. 75 kg
8. 176 lbs
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B. Practice Problems
1. 2 tablets
2. 2 tablets
3. 4 tablets
4. 10 mL
5. 10 mL
6. 1.2 mL
7. 69 kg = 69 mg
8. 130 mg for 4 doses
C. Practice Problems
1. 41.6 (42)
2. 20.8 (21)
3. 75
D. Practice Problems
1. 17 cc/hr
2. 6.65 mcg/kg/min
3. 3 cc
4. 186.5 mcg/min
5. 30 cc/hr
6. 3 mg/min
Reference: Dosage Calculations Made Incredibly Easy! by Springhouse Corporation,
1998
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ALL RIGHTS RESERVED
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