Kp-Protocols

Front 1

Stroke National Hospital Inpatient Quality Measures

STK-1: VTE (Venous Thromboembolism ) prophylaxis (SCD or Chemical e.g Heparin or Lovenox)
STK-2: Discharge on Antithrombotic therapy
STK-3: Anticoagulation therapy for A.fib/A.flutter
STK-4: Thrombolytic therapy (within 3 hr of last known well)
STK-5: Antithrombotic therapy by end of hospital Day 2
STK-6: Discharge on Statin Medication
STK-10 Assessed for Rehab (OT, PT, ST)

Back 1

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Front 2

Code Stroke -- Efficiency Measures

-- Door-to-MD exam: 10 mins
-- CT completed and read (from time of order) 45 min
--- ECG completed

Back 2

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Front 3

Any Braden scale under 18 need a care plan and HAPU's need proper documentation

--each wound needs its own insert and can not group all wounds into one category.

Back 3

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Hint 3

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Front 4

Fall Prevention printed materials will be given to families if pt's Schmid score is > 3 (Fall Prevention)

Back 4

- Fall precaution:
Pt. in isolation room with door closed, the blinds need to be drawn (open) to keep the pt in nurse's direct sight.

Front 5

All IV pumps from isolation rooms will be wiped by EVS and covered with blue bags until SPD cleans them.

-- Do NOT USE any pump with blue bags.

Back 5

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Hint 5

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Front 6

Airbone isolation:

--- TB, Measles, Samllpox, Varicella, SARS, Avian Flu

Back 6

interventions for airbone isolation:

-- Strict hand hygiene
-- gloves
-- N95 mask or PAPR
(Powered Air Purified Respirator)
--Active Negative pressure alarm
-- Notify Engineer to initiate or DC daily smoke via Easynet Request
-- Pt. leaving room must wear a SURGICAL mask.

Hint 6

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Front 7

Droplet Isolation:

-- Invasive Haemophilus influenza type b,
-- Neisseria meningitis, pneumonia
-- Diphtheria
-- Pertussis
-- mumps
-- Pneumonic plague
-- influenza,
-- Parvovirus B 19
-- Rubella

Back 7

Drop. isolation interventions:

-- strict hand hygiene
-- gloves
-- surgical mask

-- isolation may be DC after 24 hours of effective antibiotic treatment and confirmed with culture sensitivity for meningitis cases only.

Hint 7

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Front 8

Contact isolation:

-- MRSA,
-- VRE and other multi-drug resistant organisms (e.g. ESBL), RSV
-- Varicella
-- Viral hemorrhagic infection
-- wounds with drainage not contained in a dressing.

Back 8

-- hand hygiene
-- Gloves
-- Gown

--Any Mult-drug resistant orgainisms in the SPUTUM MUST add a DROPLET sign (blue) to the door.

Hint 8

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Front 9

Contact plus:

-- C. Diff (suspected or confirmed)

-- Infectious diarrheal condition (e.g. Norovirus)

Back 9

-- Wash hand with soap and water at least 15 second.

-- Gloves and gown.
-- Clean all surfaces and equipments with BLEACH wipes.

(notify EVS to use bleach wipes. )

Hint 9

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Front 10

Protective Isolation
-- for pt after chemo or with compromised immunity

Back 10

-- No fresh cut flowers.

-- Visitors with any infections or respiratory illness should not enter

Hint 10

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Front 11

Hello Yellow Project:

-- The Quick Audit Tool for isolation room must be removed from the yellow folder and placed in the first draw of the isolation cart.

Back 11

Hello Yellow Project:

missing Meds in Staff resources folder needs to be documented in the missing meds list and hand over to ADAs.

Hint 11

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Front 12

C. Diff :

-- once no loose stool for 48 hours, pt may be OFF isolation. and order for DC isolation can be put in.
Do NOT retest the patient. (No loose BM > 48 hours is adequate)

-- 2-page print out instruction from the clinical library can be given t. family.

-- any patient with 3 loose stools in 24 hour period or a Dx of C. diff should be put on contact + iso.

Back 12

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Front 13

Code Red -- Fire
Code Blue -- Adult life threatening Emergency
Code Orange--Disaster
Code White -- Pediatric/child life threatening emergency
Code Secure -- Infant Security
Code C -- OB emergency
Code Gray-- Combative Person
Code Silver-- Person with Weapon

Back 13

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Front 14

Check Time Card:

-- mainframe
-- enter NUID and password
-- COMMAND : F2/F3
--> enter HK00
--> enter 4 (Timecard maintenance menu)
--> enter 3 (Timecard Display)

Back 14

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Front 15

Set up Email Account:

-- Inotes
-- type in your username
-- password: NUID+your last name (all lowercase, no space)

Back 15

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Front 16

Call Rapid Response Team:

-- Vocera:
Press Call Button
Say"Urgent Broadcase to Rapid Response Team to room ____"

If Vocera out:
--- Dial 7111,
--- Tell operator to call request a RRT to floor/room___

Back 16

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Front 17

Core Measures of KP:

-- CAP (Community Acquired Pneumonia)
-- CHF (Congestive heart Failure)
-- AMI (Acute Myocardial Infarction)
-- Stroke
-- SCIP (Surgical Care Improvement Project)

Back 17

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Front 18

Community Acquired Pneumonia (CAP) process:

-- blood c/s draw beore giving antibiotics

-- Initial antibiotics within 6 hrs.
-- initial antibiotics selection for CAP in Immunocompetent pt.
-- Pneumonococcal Vaccination
-- Influenza vaccine ( Oct -- March)
-- Adult smoking cessation counseling contact number

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Front 19

Advance Directives

-- Oral / written
-- All pt over 18 yrs are asked on admission whether they have an advance directive. will be documented on admission face sheet and on the "Conditions of admission" form.

Back 19

-- when pt doesn't have Advance directive (AD), every effort is made to obtain a copy and place it in the chart.

Hint 19

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Front 20

pt may change their mind about Advance directive at ANY time.

Back 20

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Front 21

Shift assessment:
--initial assessment should be completely within 8 hours ( 2 hours in critical Care unit)

-- H&P and other screening assessment should be completed within 24 hours of admission.

Back 21

-- H&P may not be older than 30 days, requires update if pt is having surgery.

Hint 21

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Front 22

Care Plan :

-- Evaluate and revised at lease EVERY SHIFT.

Back 22

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Front 23

Tools used for employees' competency:

1. skill checklist
2. direct observation
3. written tests
4. self-learning modules.

-- Annual Training and Review.
(Pt's right, safetly, isolation, Hazardous materials, TB, latex ..)

-- CPR reviewed Bi-annually.
-- RN license reviewed Bi-annually.

Back 23

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Front 24

weights

-- Pt will be weight on:
admission,
transfer in
in AM (especially CHF patients)

Back 24

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Front 25

Compliance:

-- employee adhere to laws, regulations, licensing requirements, and standards.

Back 25

KP anonymous Compliance Hotline for Compliance:

1-888-774-9100

Compliance Officer for Orange County: Roxanne Shaw
Office phone: [phone]

Front 26

Language --

-- Use interpreter service
(document interpreter's name, employee ID, lanuage)

-- Use Language Line Company
-- Use American Sign Language (ASL)

Back 26

-- Family and friends should not be used to provide interpretation services (except on request by pt. )

-- NEVER use child < 18 yrs to interpret.

Hint 26

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