HIPP and Order Set Update June

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					                        HIPP P&P and Order Set Update-                         June 13,2008

Level 2 Changes
  Title                                  Brief Highlights                                        Clic

Dialysis       Shortens and clarifies the title.                                                Click
Catheter,      Adds a new table illustrating the difference between drawing general blood       P&P
Temporar        samples versus blood cultures.
y: Blood       Adds language regarding needleless system.                                       Dialy
Drawing        Removes the need to draw up an extra 0.2ml heparin (5000 units/ml) when          Tem
                flushing the catheter.                                                           Draw
               Updates definition of dialysis catheter.

Insulin                                                                                          Click
Pens                                                                                             job a


                            Practice Reminders !!
               Insulin pen dosages must have an independent double check done by a
                second nurse to ensure the 5 rights.
               Pay special attention to the type of insulin pen (ensuring the "right
                med" portion of the 5 rights) being used as there are several types of
                insulin pens available for use - long acting insulin, short acting insulin and
                mixed type of insulin pens.
Schedulin                                                                                            Click
g of                                                                                                 P&P
ts for                                                                                               Sche
Imaging                  Please read this entire document as it is new and is crucial to             Outp
             establish a safe and expedient process for scheduling outpatients having                Ima
             elective Imaging studies done at St. Joseph Hospital (SJH).

Critical            Adds a policy statement as this relates to one of the National Patient Safety   Click
Results              Goals.                                                                          P&P
Reporting           Updates the chart of situations that are considered a critical result
: Blood             Indicates that one of three persons is to be called for those situations that   Criti
Bank                 are considered a critical result- physician, RN or pathologist. ( Refer to      Repo
                     chart)                                                                          Bank
                    Specifies that the call for a critical result must be made within 5 minutes
                     of when the blood banker becomes aware of the potential critical result.

After you've read the updates above, please click next
             to receive education credit.

To contact newsletter staff, click on selected name below.

Policy Administrator: Marj Sytsma

HIPP Newsletter Editor: Sarah Jane Hilliard

                Whatcom Region
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Policies support accountability in meeting our ethical, professional, and legal
obligations as caregivers and good stewards.

TITLE:   Dialysis Catheter, Temporary: BLOOD DRAWING
DEPARTMENT: Patient Care                           EFFECTIVE DATE: May 08, 2008
APPROVED BY/DATE: May 08, 2008 by
Diana Meyer, Policy Liaison for VP of Patient REVISED. Replaces:
DOCUMENT NUMBER: WR.PTC.155                        LAST REVIEWED:
KEY WORDS: Permacath, tunneled, non-
                                                   NEXT REVIEW: May 08, 2011

SCOPE: RN's who have been trained to use tunneled or non-tunneled temporary dialysis
catheters lines.

To draw blood for lab work from dialysis catheter when no peripheral veins or other
central lines are present.


    1. POPULATION SPECIFIC: Adults only.
    2. A physician’s order must be obtained prior to using a dialysis catheter for blood
    3. Always aspirate the Heparin in the catheter lumen prior to use.
    4. Catheters are clamped when not in use.
    5. Be sure all air bubbles are expelled. Air goes directly to the heart if injected into
       vascular system.
    6. Adherence to instructions to prevent line contamination and air embolus.


    1. Assemble all equipment.

                                       Drawing Blood Samples
                                         and Blood Cultures
Clean Gloves
Blood Specimen Tubes
Blood Culture Bottles (if drawing Blood Culture)
1 – 10ml Syringe w/ Saline
1 – 3ml Syringes for Heparin
1 – 10ml Syringe for discard
1-10ml Syringe for Blood Sample
Blunt Plastic Cannula
Heparin 5,000 units per ml
Normal Saline Vial
Alcohol Wipes

    2. Draw up Heparin 5,000 units/ml in 3 ml syringe to equal stated lumen volume.

              a.     Individual lumen volumes are printed on each lumen.

              b. Note volume on lumen, it will be printed on clear tubing of catheter end,
                 near heparin cap or on the white pinch clamp on the catheter tubing end

              c.     The blue "venous" lumen will be larger.

                          i. Example: 1.4 ml lumen; draw up 1.4 ml Heparin.

    3. Draw up 10 ml normal saline into syringe.

              a.   The saline is used to irrigate the catheter after blood drawing and prior to
                   heparinization or connecting to IV fluids.

    4. Explain the procedure to the patient.

                                       Drawing Blood Samples
                                         and Blood Cultures
    1.    Put on clean gloves.
    2.    Clamp catheter.
    3.    Clean catheter's port or cap with alcohol. Let dry for one minute. Clean Blood Culture Bottle
          septum with alcohol.
    4.    Attach empty 10ml syringe to catheter.
    5.    Release the clamp and withdraw 5ml to remove any Heparin in the catheter.
    6.    Clamp again, remove and discard the syringe.
    7.    Attach 2nd 10ml syringe for blood sample. Release clamp, withdraw sample, and clamp catheter.
    8. NOTE: If there is difficulty drawing blood from line, check catheter to see if clamped area on tube is
          still pinched, have patient change position, take a deep breath, or lift both arms.
                   a.   If you are still unable to withdraw blood, notify the physician.
    9.    Remove syringe and transfer blood via needleless system into specimen tubes. See Lab's
          website on obtaining Blood Cultures.
    10.    Discard syringe.
    11. Attach 10ml saline filled syringe. Release clamp and inject saline.
    12. Re-clamp the catheter before the syringe is completely empty, maintaining positive pressure on
          the plunger, remove syringe.
   13. Attach syringe with pre-measured Heparin 5,000 units / ml according to lumen size (explained in
   14. Unclamp and inject Heparin. Clamp while maintaining positive pressure on the plunger.
   15. Document in appropriate record.

For more information see The Best Practice Learning Line: Collecting Blood Culture


   1. Dialysis Catheters are used for exchanging blood to and from the hemodialysis
      machine from the patient. It has a red lumen and a blue lumen. They are
      named venous and arterial but both lumens are the vein. The red lumen withdraws
      blood from the patient and carries it to the dialysis machine. The blue lumen
      returns blood to the patient from the dialysis machine.

           a.   There are two types of dialysis catheters, Tunneled and Non-Tunneled:

                        i.  Tunneled catheter is surgically placed for long term use with a
                         cuff and has two lumens. The tunnel is thought to add a barrier to
                       ii. Non Tunneled catheters are temporary and non-cuffed; either
                         double or triple lumen. They are usually placed at the bedside.
                       iii. Both of these catheters must always be clamped when not in

           b. The catheter is placed in one of the large veins, usually the superior vena
              cava (SVC).
                    i. It is placed in the internal jugular vein in the neck (often on the
                      left side), and the catheter is then advanced downwards toward the
                    ii. Alternatively an SVC catheter can be inserted via subclavian
                      veins right behind the clavicle, often on the right.
                   iii. If the access of SVC is difficult, the femoral veins can be used.
                      This is an inferior option, however, because the groin site is more
                      prone to infection and also because patient cannot sit upright.


   1. Mount Baker Kidney Center Policy and Procedure on blood draws.
   2. Infusion Nursing, Standards of Practice. Developed by Infusion Nurses Society.
      Revised 2006.
   3. Best Practice Learning Line: Collecting Blood Culture Specimens
   4. NW Regional Lab's website on obtaining Blood Cultures

 See Above

HELP: For more infomation contact the Medical Care Unit (MCU) Team Leader, or a Mt.
Baker Kidney Center dialysis nurse

                          End of Policy Document

To suggest a change to this policy, contact your Regional Policy Administrator.   For a
question concerning policy format, the policy database or a general question
concerning PeaceHealth policies, contact the System Policy Coordinator.

                Whatcom Region

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Policies support accountability in meeting our ethical, professional, and legal
obligations as caregivers and good stewards.

TITLE:   Scheduling of Outpatients for Imaging
DEPARTMENT: Imaging                          EFFECTIVE DATE: April 01, 2008
APPROVED BY/DATE: April 01, 2008 by Jack
                                         REVISED. Replaces:
Estrada, Imaging Director
KEY WORDS: x-rays, elective, Mt. Baker
                                             NEXT REVIEW: April 01, 2011
Imaging, MBI, sedation

SCOPE: Imaging Services, Admitting, Scheduling, PCU, Pediatrics, ordering

PURPOSE: To establish guidelines for scheduling outpatients having elective Imaging
studies done at St. Joseph Hospital (SJH).

POLICY: There is a joint venture agreement with Mt. Baker Imaging (MBI) to provide
all elective outpatient-imaging services at MBI and not SJH. There are a few, select
exceptions to this policy. For those outpatient exams that may be done at SJH, the
following policy outlines the process to be followed in scheduling the exams.


   1.    Population specific: Ensure that the outpatient exam being scheduled for SJH
         meets the exclusionary criteria for not performing the exam at MBI.

            a.    All elective outpatient-imaging exams need to be scheduled at MBI.
                 SJH does not provide elective outpatient-imaging services, except for
                 cardiovascular imaging, and imaging services provided through the
                 Emergency Department and/or the Procedural Care Unit (PCU).

            b. Nuclear Medicine outpatient exams may be scheduled at SJH.

            c.    Outpatient exams that require sedation for the procedure (e.g. MRI
                 claustrophobic patients) may be scheduled at SJH provided they are
                 admitted through the PCU.

            d.    Interventional Radiology (IR) patients will be scheduled at SJH. These
                 may be scheduled in the IR suite, CT scan, MRI, or Ultrasound areas for
                 invasive procedures.
        e.    Patients from assisted living residences or patients that require the use of
             a patient lift device (e.g. lifting from a wheelchair to an imaging
             table/gantry) may be scheduled at SJH.

        f.    Pediatric patients requiring sedation are having other procedures done at
             SJH, and/or those that have special needs that require the procedure be
             performed in the hospital may be scheduled at SJH. Elective pediatric
             outpatients will be scheduled at MBI. If there are any questions
             surrounding this patient population, please receive approval from Imaging

2.    Patients that are scheduled for exams that require (or potentially may require)
     sedation for the procedure will be admitted to the PCU for pre and post procedure

        a.    Physicians admitting patients through the PCU will need to provide admit
             and discharge orders, exam orders, and, when appropriate as mandated by
             the Medical Staff Rules, a history and physical. They should fax the
             “Admission to Ambulatory Care” form to relay verbal orders to the PCU.

        b.    Patients that are directed by their physician to self-medicate prior to a
             procedure will be admitted through the PCU as indicated above.
                                           i. At the start of the procedure, if the patient
                     discloses the fact that they have self-medicated and were not
                     admitted to the PCU, the exam will be postponed and their
                     physician will be contacted for PCU admit/discharge orders.
                                          ii. Once the orders have been received, the
                     exam will be performed at the next available time and the patient
                     will be discharged through the PCU.

        c.    Pediatric patients receiving sedation for their procedure will follow the
             pediatric sedation order set guidelines.
                                           i. Pediatric patients receiving sedation or that
                     have special needs requiring the procedure to be done in the
                     hospital setting will be admitted to and discharged from PCU.

3. Mt. Baker Imaging hours of operation are 7:30am-5:30pm.

        a.    All requests for after hours imaging should be directed toward MBI
             scheduling department. They have arrangements for these types of
             requests. If a physicians office deems it necessary to have an outpatient
             exam done, IE: CT, MRI, Ultrasound, at SJH, they will need to either
             admit their patient through the PCU or the ED if it is an emergency.
                                             i. If Mt Baker imaging is unable to
                    accommodate the scheduling request or if the need for the exam is
                    more urgent than can be scheduled, a technologist from MBI will
                    speak directly to a technologist from SJH. The approving MBI
                    technologist’s name will be included in the comments when
                                            ii.  The ordering physician should be
                    instructed to send the patient to the ED or PCU as appropriate for
                    the patient’s condition. Patients should have a complete exam
                    order with all pertinent information for the procedure (e.g. type of
                    exam, patient symptoms or signs, etc.) and physicians should
                    provide a means to accurately and efficiently reach them with any
                    call reports after hours (pager, cell phone, etc.).
                                          iii. Patients should be informed that they
                    might have to wait for their exam to be done, depending on other,
                    more acutely ill or critical patients that need to be done ahead of
                    their procedure; they will be accommodated as soon as reasonably

        b.    On call personnel should not be called in for any routine, elective
             outpatient CT, MRI, Ultrasound or X-Ray exams.
                                          i. Until an arrangement has been made to
                     accommodate walk in clinic radiography exams on the weekend at
                     MBI, SJH Imaging will continue to accommodate these routine x-
                     ray patients.
                                         ii. All other modalities will need to be
                     admitted through the PCU or ED if they are urgent or emergent.

        c.    When the SJH scheduling staff is not available and the PCU receives a
             call to schedule an after hours patient, the PCU staff will call the SJH
             Imaging department modality and let them know that a patient is coming
             through the PCU for an Imaging study.

4.    When there are requests to schedule an outpatient outside of the established
     parameters, the following chain of command will be utilized:

        a.    The schedulers will direct all questions regarding elective outpatient
             imaging studies in the following order:

                                         i.   Modality technologist
                                        ii.   Modality lead technologist
                                       iii.   Imaging Manager
                                       iv.    Imaging Director.

        b. These individuals are available via telephone and/or pager.

Elective outpatient: the procedure is not an emergency or urgent matter that requires
completion immediately; it may be done at a scheduled time.


         Pediatric Sedation for Procedure


         Access to Imaging Services by Non-Medical Staff
         HIPP Guidelines: Imaging Ordering
         HIPP Policy: Sedation for Procedure
         Medical Staff Rules for History & Physical

HELP: For questions about this policy please contact the Imaging Manager or director.
Written by Jack Durbin, Imaging Manager.

                             End of Policy Document

To suggest a change to this policy, contact your Regional Policy Administrator.    For a
question concerning policy format, the policy database or a general question
concerning PeaceHealth policies, contact the System Policy Coordinator.

                   Whatcom Region

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Policies support accountability in meeting our ethical, professional, and legal
obligations as caregivers and good stewards.

TITLE:    Critical Results Reporting: Blood Bank
DEPARTMENT: Laboratory                       EFFECTIVE DATE: May 22, 2008
APPROVED BY/DATE: May 22, 2008 by Dr
                                              REVISED. Replaces:
Mark Owings, NWRL Medical Director
DOCUMENT NUMBER: WR.BB.105                    LAST REVIEWED:
KEY WORDS:                                    NEXT REVIEW: May 22, 2011

SCOPE:    Blood Bank Technologists

PURPOSE:     To promptly communicate with the appropriate personnel when critical
results are noted by the blood bank regarding transfusion of a patient.

POLICY:    Northwest Regional Laboratory Blood Bank technologists shall report critical
results in relation to blood transfusions in a timely manner.


   1.    Population Specific: None
   2.    The following situations are considered critical results and either the pathologist,
         patient’s physician or registered nurse (RN) must be called within 5 minutes of
         when the blood banker becomes aware of the potential critical result (even if
         unable to enter the results into the blood bank computer system pending
         confirmation from PSBC).
SITUATION                                       PHYSICIAN          RN      PATHOLOGIST
Warm autoantibody with the need to              X                                   X
transfuse least-incompatible blood
Possible TRALI                                                                      X
Acute hemolytic transfusion reaction                                                X
Possible delayed transfusion reaction                                               X
No components available in Seattle (e.g.,             X
no CMV-negative pheresis units)
No components available in Bellingham                               X
(e.g., irradiated)
New antibody in recently transfused                                 X               X
patient (rule out delayed hemolytic
transfusion reaction)
Any delay in transfusion not listed                                 X
Substitution of Rh-positive blood to a                X                             X
female of child-bearing age
Positive antibody screen and emergent                               X               X
need for blood
Positive DAT on cord blood                                          X
Possibility of transfusion-transmitted                                              X

   1. Document all Calls in the above circumstances on the Order Notification Sheet
      and include:

    Caregiver's name
    Location
    Date and time of call
    That a read back (rbok) of   the critical result was performed.


       JCAHO: NPSG #2A

HELP: For questions or assistance with this document, please contact the blood bank

                           End of Policy Document

To suggest a change to this policy, contact your Regional Policy Administrator.       For a
question concerning policy format, the policy database or a general question
concerning PeaceHealth policies, contact the System Policy Coordinator.

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