This booklet has been prepared to educate and familiarize non-employees with the mandatory requirements for Atlantic Health System.
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The Department Manager
Atlantic Health System VISION:
Atlantic Health System will be recognized as one of the nation’s best health care systems.
Deliver high-quality, safe, affordable patient care within a healing culture
Educate, in an exemplary manner, present and future health care professionals
Innovate through leadership
Improve the health status of the communities we serve
Patient Rights are posted in every patient room, waiting areas and other departments where care is provided. Patient rights include, but are not limited to the following: Privacy, Confidentiality, Right to Information, Informed Consent, Pain Management, Participation in Care Decisions, Advance Directives, Restraints and Seclusion, Abuse and Neglect, Patient Complaints.
Cultural awareness refers to the understanding that our patients, employees, physicians, and visitors may have different cultural, spiritual, or religious beliefs than our own. Direct patient care providers are expected to identify and support the cultural or spiritual needs of every patient, respecting the customs and traditions of other people.
Atlantic Health provides risk management services 24 hours/7 days a week. Check the Risk Manager Web oncall director for the covering individual on evenings, nights, weekends and holidays. An electronic Quantros Report (occurrence report) is completed for any unusual occurrence involving patients, visitors, damage to equipment or property.
Occupational Safety and Health Administration (OSHA) Training Bloodborne Pathogens and TB The Occupational Safety and Health Administration (OSHA) “Bloodborne Pathogens Standard” was issued in 1991 and was designed to protect healthcare personnel (HCP) at risk for occupational exposure to the hepatitis B (HBV) and C (HCV) and the Human Immune Deficiency (HIV) viruses.
The Atlantic Health Exposure Control Plan is available to all hospital personnel on the hospital Infection Control intranet site or in hard copy in the libraries of the hospitals, Infection Prevention Offices, and Occupational Medicine Service (OMS).
HBV is a disease of the liver with an incubation time of 6 weeks to 6 months. Symptoms may be so mild that a person does not know that they have been infected, moderate in intensity, or so severe that hospitalization is required. HBV may become a chronic illness leading to cirrhosis, liver cancer and at times death. The good new is that it can be prevented with a vaccine that has been available since the early 1980’s.
HCV is also a disease of the liver and also has an incubation time of 2 weeks to 6 months. Symptoms of HCV are similar to those of HBV but often milder. It has risks and complications similar to HBV. Unfortunately there is no vaccine available for HCV.
HIV is the virus that causes the Acquired Immune Deficiency Syndrome (AIDS). It attaches the body’s immune system and has an incubation period of weeks to months. There is also no vaccine available for HIV.
Potentially Infected Body Fluids and Routes of Transmission Bloodborne pathogens (BBP) are found in the following body fluids of an infected individual; blood; cerebrospinal, amniotic, synovial, pleural, and peritoneal fluid; semen and vaginal secretions; and any body fluid visibly contaminated with blood. Exposure to a BBP occurs through:
Sharps injury from needles, scalpel, or anything than can pierce, puncture, or cut your skin.
Exposure to non-intact skin (open cuts, sores or nicks in skin).
Following work practices: These are procedures that you must follow to reduce your and your co-workers risk of exposure. For example: Promptly dispose of needles and sharps in appropriate containers, do not recap needles or eat or drink in patient care areas. Always wash your hands before and after patient contact and when they are visibly soiled.
Wearing appropriate personal protective equipment (PPE) will reduce exposure risks. Wear the following PPE when you may have contact with body fluids:
Gloves to protect your skin.
Fluid resistant gowns to protect skin and clothing.
Masks to protect your nose and mouth from splashes and sprays of body fluids.
Protective eyewear to protect your eyes from splashes and sprays of body fluids.
Put on and remove PPE correctly in order to prevent infections. The Care Environment To keep your environment free of hazards:
Clean all equipment and work surfaces as soon as possible after contact with body fluids.
Clean up contaminated broken glass using a dust pan and brush, not your hands.
Handle linens as little as possible. Confine and contain trash in plastic bags by keeping them closed.
Dispose of body fluids that may be contaminated with potentially infectious materials into a liquid regulated medical waste (RMW) located in soiled utility rooms. Non liquid items soiled with bodily fluids go into red bag containers. A biohazard symbol indicates a potentially infectious material.
Procedures to Follow with Exposure to a Potentially Infectious Body Fluid
Wash the affected area immediately with soap and water. If exposure is to your eyes, nose, or mouth; flush with large amounts of water or saline.
Immediately report the exposure to whoever is in charge of the department. Contact the “Off Shift Supervisor” as there may be a need to complete an incident report.
Proceed to the Emergency Department (ED) for an evaluation. Take the name of the source patient with you to the ED, if possible.
A report of the incident may be required. For guidance on procedures to follow you may contact the hotline numbers at each facility:
Chilton Medical Center: 973-831-5116
Morristown Medical Center: 973-971-5819
Newton Medical Center: 973-579-8577
Overlook Medical Center: 908-522-5304
If you have questions regarding bloodborne pathogens contact one of the following resources for assistance:
Infection Control Department, CMC phone: 973-831-5150
Infection Control Department, MMC on call cell phone: 973-294-0512
Infection Control Department NMC on-call cell phone: 973-222-4933
Infection Control Department OMC on-call cell phone: 973-294-0645
Occupational Medicine Service pager: 877-595-7143
Tuberculosis: Control Measure for TB Patients Follow airborne precautions when a patient is or may be infected with TB disease.
Placing the patient in a negative air pressure isolation room (NPIR). Contact unit resources for proper procedures.
Particulate respirators (N95) must be worn when entering patient rooms. Anyone caring for TB patients must be fit-tested annually in order to use these respirators.
When caring for patients with or who may have TB disease –
Minimize the transportation of patients; when they must leave their isolation room, when possible, have them wear a surgical mask.
Keep patients on airborne precautions until three (3) negative sputum tests are confirmed.
Discontinue airborne precautions only when an infectious disease specialist, pulmonologist, or the Infection Prevention Department approves it.
All Caregivers are required to have an annual tuberculin skin test (TST) except those with proof of the following:
Adequate treatment for TB disease or preventive therapy for TB infection
A medical contraindication
Infection Prevention What is Infection Prevention?
Infection Prevention addresses factors related to the spread of infections with the healthcare setting. This practice improves patient safety by reducing risk of infection. It requires the commitment of every healthcare worker to achieve this goal.
Hand Hygiene (washing or using alcohol rubs) is the number one way to prevent the spread of infections.
Information Resource: Infection Prevention website contains all pertinent policies, procedures, guidelines, forms and links for information.
Hand Hygiene: The practice of hand hygiene measures is required before and after handling patients. Using medical equipment on patients, before giving medications, contact with patient skin, contact with body fluids or excretions, wound dressing, removing gloves, or in the patient’s environment are all examples of when hand hygiene is a requirement to ensure patient safety, and to protect against cross-contamination.
The process of hand washing requires – wetting the hands first with water, applying soap and rubbing hands together for at least 15 seconds, covering all surfaces of the hands and fingers, rinsing with water and drying thoroughly. Use a paper towel to turn off the faucet upon completion.
Alcohol-based rubs can be used when your hands are not visibly soiled or contaminated with fluids. Do not use alcohol-based rubs with caring for patients with C. difficile. When applying this product ensure that all surfaces of hands and fingers, including under fingernails have been covered. Continue rubbing until product dries – at least 15 seconds.
Fingernails and Lotions: Natural nails kept to one-fourth inch long. No artificial nails are permitted for healthcare workers who: provide direct patient care, supervise direct patient care, or have contact with patient care supplies, equipment or food. Only hospital-approved, non-glycerin based lotion is permitted and available for use at Atlantic Health.
Healthcare Acquired Infections (HAI) are infections a patient acquires while receiving treatment for a condition. It is one of the top 10 leading causes of death in the United States. These infections: Urinary Tract, Bloodstream, Ventilator Associated Pneumonia, Surgical Site, and Multidrug Resistant Organisms can be acquired through patient medical equipment, tubes used to administer IV fluids, machines that help a patient breathe, body parts where surgery took place, and from medications, the environment, and your hands. National Patient Safety Goal #7 refers to improving patient safety by reducing the risk of healthcare acquired infections. Complying with hand hygiene, following hospital protocols, as well as personal protective equipment (i.e. gloves) complies with this safety goal and reduces this risk.
Isolation Precautions: Regardless of a patient diagnosis, there are standard as well as different types of precautions designed to protect you from getting specific types of diseases. Make sure you follow all instructions on posted signs and wear appropriate personal protective equipment (gowns, gloves, or masks). Please remember that many of the patients in our hospitals are recovering from severe illnesses and/or have poor immune systems. Infections with organisms like influenza can lead to very serious illness and even death. To ensure safe patient care, do not come to hospital if you have an upper respiratory tract infection with a fever, or diarrhea or vomiting.
When handling patient equipment, follow responsible care and cleaning between patients. Supplies or equipment labeled as single use must be disposed of after use on a patient. Contact Sterile Processing or Infection Prevention for any cleaning questions.
Seasonal flu usually occurs in the Fall through early Spring. It most severely affects the very young, the elderly and those with chronic illnesses. Symptoms include: fever, headache, fatigue, dry cough, sore throat, runny or congested nose, muscle aches, and can include diarrhea, vomiting and nausea.
On average 5% to 20% of the U.S. population contracts the flu. More than 114,000 are hospitalized and approximately 36,000 people die from this virus. The annual shot is the most effective method to prevent infection with this virus.
The CDC recommends the following precautions for healthcare workers: practice hand hygiene before and after patient contact; follow standard precautions; wear a surgical mask when working within 3 feet of the patient; and get the flu vaccine.
A “pandemic” is an epidemic that occurs in many parts of the world at the same time. For an influenza pandemic to occur, a new strain of the virus must emerge and spread easily from person to person. The 2009 H1N1 was classified as a pandemic with increased risk for serious flu-related complications. The precautions recommended by the CDC have been standard, respiratory, airborne, as well as wearing respiratory protection such as the N95 respirator which requires fit-testing.
In the event of a pandemic, visitors may be restricted. In a serious pandemic, it may be necessary to close most facility entrances and to post security at the open entrances. Staff and visitors may need to be screened for flu-like symptoms.
Occupational Medicine Services asks that all staff, volunteers, visitors, and physician are aware of the symptoms. They ask that individuals experiencing symptoms go home, and if needed, follow up with your physician.
Hazardous Materials and Waste Hazardous materials and waste in use at Atlantic Health include: several EPA listed chemotherapy drugs, xylene; mercury, solvents, various chemicals, reagents, and spill clean-up materials.
Regulated Medical Waste (RMW) classes of materials or products at Atlantic Health include needles, syringes, and sharps, human blood, blood products and pathological waste, isolation waste, cultures and stocks of infectious agents and associated biological.
Sharps including needles, pipettes, test tubes, vacutainers, cultures/stocks and glass sides are to disposed of in the approved rigid containers. Non-sharps including bloody gauze pads, empty feeding bags and tubing, and empty suction canisters are disposed of in “Red Bag Receptacles.”
Liquid RMW are disposed of in “red and biohazardous liquid receptacles.” All articles and containers with free-flowing RMW must be placed into liquid receptacles to comply with the US Department of Transportation.
Unless IV Bags or tubing has been contaminated with blood or regulated body fluids, they are not considered RMW and can be disposed of in regular waste.
All batteries, lamps, mercury containing devices and consumer electronics must be collected and handled separately.
Emergency Management The Atlantic Health System Emergency Operations Plan is available on the Atlantic Health intranet under Forms and Policies then Safety Manual and Emergency Management. Each department has a role in emergency management and department specific plans/policies are defined.
The Atlantic Health System Emergency Operations Plan addresses the four phases of Emergency Management: Mitigation, Preparedness, Response and Recovery. Refer to manuals for further guidance. A Hazard Vulnerability Analysis is done as a risk assessment. Emergency Management exercises are conducted a minimum of twice a year for Internal and External Disasters, ensuring preparedness, response and protocols to follow. Further reference includes the EM Quick Reference Guide posted throughout the facilities, as well as Communications Matrices available in the Biological, Chemical and Radiological Response Plans.
The Incident Command Center (ICS) is a standardized all-hazard incident management system that enables hospitals and others to organize resources, staff, and facilities in order to remain operational during an emergency and promote the restoration of day-to-day operations. Communications are maintained through a variety of methods including email, internet/intranet, dedicated call-in lines, department snowball lists, faxes, emergency telephones, handheld radios and information sharing with the state.