medical malpractice_ETCH - Hospital Orientation Presentation - PowerPoint Presentation by liwenting

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            This module contains:
   Instructions for                 Pain Management
    completion of module             Child Abuse
   Welcome to ETCH                  Death & Dying
   Service Excellence               Emergency Codes
   Family-Centered Care             Pneumatic Tube System
   Child Life                       Dress Code
   No Information Patient           Parking and Other Info
   Patient Safety Goals             Forms to Complete
   Restraints
   Isolation/Infection Control
    Instructions for Completing the
             ETCH Module
   Carefully read through the entire module.
   When you have completed the module, download the
    Completion Form and the Information Security
    Compliance Statement Form.
   Sign these two forms and turn in to your instructor.
   IMPORTANT! These forms, along with your
    Centralized Student Orientation transcript and
    immunization record, MUST be in the ETCH
    Education office PRIOR to your clinical rotation!
       Our Philosophy

Because Children are Special…
               Our Mission…
   Delivery of Care to patients between the ages of
    birth to 21 years, in the East Tennessee and
    surrounding region
   Education of patients, families, the community,
    students in medical disciplines, ETCH employees
    and healthcare providers in the CRPC area
   Research through participation in the BENCH
    networking program
   Community Involvement
ETCH History
            Opened in 1937
             and located on
             Laurel Ave.
            Originally called
             Knox County
ETCH History
           Moved to 21st and
            Clinch in 1970
           2018 Clinch Ave
            P.O. Box 15010
           Much expansion
            since then
 ETCH 2005
and beyond…
     East Tennessee Children‘s Hospital
       offers many services such as…
   Child Life
   Pastoral Care
   Social Work
   Specialty Outpatient Clinics
   Home Health Services
   Rehabilitation Services
   Clinical Nurse Specialists in the areas of Surgery, Critical
    Care, Hematology/Oncology, and Pulmonary Care
   Nutrition Services
   Healthy Kids Program
   Ronald McDonald House
   Service Excellence…

Our Responsibility. Our Commitment.

          Children’s Hospital
 People don’t care

how much we know

until they know how

  much we care.
Service Excellence Vision

     To be the kind of
    organization where
   children and families
  want to come for care,
physicians want to practice,
 employees want to work.
Service Excellence…
Our Responsibility. Our Commitment.

Statement of Purpose

We strive to give extraordinary care and service to our
patients, their families, members of the Children’s
Hospital family, and the communities we serve.
Our Philosophy of Service Excellence
*We take pride in our professions and feel personal ownership and
responsibility for achieving Children‘s Hospital mission.
*We seek opportunities to be friendly and to help patients, families, and
*We are always courteous and respectful.
*We show care and compassion by acknowledging people‘s feelings.
*We demonstrate respect for privacy and confidentiality in all we do.
*We never tire of explaining what to expect, what we are doing, and
*We try to understand how our work affects others and look for ways to
help each other.
*We respect diversity among our patients, families, co-workers and
      SHARE: Service Excellence in Action

   S SENSE people’s needs before they ask.

   H HELP each other our through teamwork.

   A ACT with empathy and compassion.
   R RESPECT the dignity and privacy of others.

   E EXPLAIN what is happening.
Customer Satisfaction: A fool’s gold?
What is fool‘s gold? Something that looks more
valuable than it really is. Let‘s compare the difference
between customer ―satisfaction‖ and ―loyalty.‖

The customer satisfaction formula:

Doing it right the first time+effective complaint handling

The customer loyalty formula:

Doing more than is expected+Doing more than the
situation warrants
Does customer satisfaction = customer loyalty?

On a five-point scale, people who mark a 4 (satisfied),
compared to those who mark a 5 (very satisfied) are
5 times more likely to defect to the competition.

Satisfaction is based much on convenience, while loyal
customers will often drive longer to seek out your services
because of the way they are treated and the service they
receive. Loyal customers will tell others about how good you
are---they have a story to tell.

What separates the excellent from the best?
Nothing---They do the same things especially more
consistently and under pressure over time.
The secret of excellence is consistency and the
enemy of excellence is too much variation.

Organizations with a reputation for world-class
service simply know how to attract and keep
individuals who will deliver the same courteous,
compassionate care, day in and day out, regardless
of the circumstances.
    ATTITUDE: The one thing I have control over
 An attitude is my frame of mind when I approach a
  situation. I choose my attitude in every situation.
 Stimulus--------*Interpretation----------Response
 *All emotional growth in life occurs in the interpretation
Learn to ask: What would cause me to act like that?
Asking this simple question when we are faced with
  difficult people can help us maintain tolerance and even
  compassion for our patients, families, and co-workers.
    Non-Verbal Communication
   93% of what we communicate in attitude
    is non-verbal.
    – 7% In words
    – 38% By tone of voice
    – 55% By body language

    – And it’s done in the first few seconds. Even
      in job interviews by a professional, the
      decision is essentially made in 20 seconds!
     Never get tired of explaining!

 75% of all medical malpractice lawsuits could
  have been prevented by explaining things better.
 One of the most common complaints patients and
  their families have is that things were not better
 The highest ranked quality desired in choosing a
  doctor is the doctor’s willingness to listen and
  explain in words I can understand.

The longer I live, the more I realize the impact of attitude on life.
Attitude, to me, is more important than facts. It is more important than
the past, than education, than money, than circumstances, than failures,
than successes, than what other people think or say or do. It is more
important than appearance, giftedness, or skill. It will make or break a
company… a church… a home. The remarkable thing is we have a
choice every day regarding the attitude we will embrace for that day. We
cannot change our past… we cannot change the fact that people will act
in a certain way. We cannot change the inevitable. The only thing we
can do is play on the one string we have, and that is our attitude. I am
convinced that life is 10% what happens to me and 90% how I react to it.
And so it is with you… we are in charge of our attitudes.

                                            Charles Swindoll
Child/Family Centered Care

      Children‘s Hospital
        Knoxville, TN
      Definition of Child/Family
           Centered Care
  Child/Family Centered Care is an approach to the
planning, delivery, and evaluation of health care that
   is grounded in mutually beneficial partnerships
 among health care providers, patients, and families.
            It redefines the relationships
between and among consumers and health providers.
*Child/Family Centered practitioners recognize the
vital role that families play in ensuring the health and
well-being of infants, children, adolescents, and
family members of all ages. They acknowledge that
emotional, social, and developmental support are
integral components of health care. They promote
the health and well-being of individuals and families
and restore dignity and control to them.
*Child/Family centered care is an approach to
health care that shapes policies, programs,
facility design, and staff day-to day
interactions. It leads to better health
outcomes, and wiser allocation of resources,
and greater patient and family satisfaction.
Child/Family Centered Care is the
Right Way to Treat People…
*Human Resources
*Architecture and Design
*Family participation in care
*Communicating with families
*Family to family support and networking
*Linking families with community resources
*Educating Child/Family Centered professional
collaboration in policy and program development
In Child/Family Centered Care:
*People are treated with dignity and respect
*Health care providers communicate and share
complete and unbiased information with patients and
families that are affirming and useful
*Individuals and families build on their strengths by
participating in experiences that enhance control and
*Collaboration among patients, families, and
providers occurs in policy and program development
and professional education, as well as in the delivery
of care
In a Hospital that Practices
Child/Family Centered Care,
Administrative, Clinical, and Support
*Recognize the family is the constant in the child‘s life
*Facilitate collaboration between families and professionals
*Honor the racial, ethnic, cultural, and socio-economic
diversity of family
*Recognize family strengths and respect various methods of
*Share complete and unbiased information with parents
*Encourage and facilitate family to family networking
*Understand and incorporate developmental needs
*Design accessible health care delivery systems
           Core Concepts
 Strengths
 Collaboration
 Partnership
 Information Sharing
 +Support
 Flexibility
 Empowerment
               C/FCC in Action

   Inclusion of parents on Steering Committee
   Increased MD involvement
   Parent Advisor Programs
   Resident Education
   Website Changes
   Chronic Care Parent Notebook
   NICU Journal
   Questions for My Doctor
   Family presence during procedures and codes
   Kangaroo Care in the NICU
      C/FCC in Action, continued
   Orientation / Inservices / Courses—Inclusion of
    Family Centered Care Concepts
   Disaster Planning
   Review of Parent Materials
   Family Resource Center
   Welcome Guide for Families
   Inclusion of Parent Advisors on Hospital
    Benefits of Child/Family Centered
 Improves medical and developmental
 Leads to health care that is more responsive
  to patient and family-identified needs and
 Reduces health care costs
 Enhances patient/family/staff satisfaction
Age-Specific Interventions

Age-Specific Interventions are the
  skills you use to give care that
meets each patient‘s unique needs.
    Every patient is an individual
       with his or her own...
 likes and dislikes
 feelings
 limitations and abilities
 experiences
Everyone grows and develops in a
  similar way or stages that are
        related to their age
         at their own pace.
         Strategies to Enhance Coping:
   Newborns: Pacifier, Blanket, Soothing sounds, Touch,
   Toddlers: Pacifier, Blanket, Favorite toy, Holding a hand,
    Party Blowers, Blowing bubbles, Pop-up books, Toys,
    Mobiles, Pre-Post Procedural play, Play Dough
   Preschoolers: Party Blowers, Blowing bubbles, Counting,
    Pop-up Books, Holding a hand, Manipulative toys,
    Computer games, Listening to music, Singing songs, Pre-
    Post Procedural Play, Play Dough
   School Age: Deep breathing exercises, Music, Hand-held
    games, Computer games, Imagery/fantasy, Pretending to
    be in a favorite place or doing a favorite thing, Pre-Post
    Procedural play, Squeezing Nerf balls
   Adolescents: Deep breathing exercises, Music (head sets
    are popular), Computer games, Imagery/fantasy, Imagine a
    favorite activity, Squeezing a Nerf ball, Hand-held games
       Child Life Specialists-
         What do they do?
 Child Life Specialists are individuals who
  have a degree in a type of early childhood
  education or development.
 They may sit for a national certification
  exam after obtaining a certain number of
  clinical hours on the job.
 They have many roles, and this may vary
  institution to institution.
       The Role of the Child Life
         Specialists At ETCH
   Provide therapeutic play for stressed, anxious
   Provide play opportunities and other experiences
    which foster continued growth and development
    and prevent adverse reactions.
   Provide developmentally appropriate education
    and preparation to patients for upcoming
    procedures. Help patients express their feelings
    and cope with stress in ways that enhance their
    sense of mastery and self-esteem.
       The Role of the Child Life
         Specialists At ETCH
   Teach patients appropriate coping techniques –
    relaxation, deep breathing, etc…
   Provide distraction for patients during procedures
    in the clinical setting and other procedural areas in
    the hospital.
   Initiate medical play with patients to encourage
    the expression of fears and misconceptions.
   Incorporate place to encourage positive
    interactions with taking medicine and other
    behaviors to be in compliance with their treatment
       The Role of the Child Life
         Specialists At ETCH
   Provide planning/scheduling to help with patient
    behavior modification.
   Serve as a resource to all departments relating to
    development and psychosocial issues and provide
    ways by which these needs can be met.
   Provide a means by which the hospital staff can
    make meaningful observations of patients in
    normal play and educational situations to better
    assess the patient‘s progress and needs.
      The Role of the Child Life
        Specialists At ETCH
 Orient new Child Life students and
  volunteers to the appropriate departments.
 Organize volunteers to provide the
  following services:
    – Requested toys and supplies
    – Visits to the playroom and teen room
    – Play at the bedside
              Child Life Staff…
   During your rotation,
    notice the Child Life
    staff and how they
    interact with your
   Child Life Specialists
    provide an invaluable
    service to our patients
    and families here at
No Information Procedure

East Tennessee Children‘s Hospital
       What is the purpose of ―No
   This procedure provides guidelines for addressing a ―No
    Information‖ status on a patient and outlines steps to
    initiate, authorize, notify personnel, and flag pertinent
   The procedure defines a ―No Information‖ patient as one
    who is not acknowledged as being in the institution.
   The procedure provides a basis for all staff that may have
    contact with the patient. Everything is done on a need to
    know basis.
 Who can initiate (ask for) ―No
    Information‖ status?
Legal guardian   Department of
   (HIPPA,        Children‘s     Nursing Staff
admitting sec.     Services
  will ask)
   Security                         Law
   Officers      Social Work     Enforcement
  Relations      Attending MD
     Who has the authority to
     authorize (give the OK)?
 Nursing
 Nurse Managers
 Nursing Directors
 Social Work
 Security
    Flagging the medical record…
 Meditech - admitting flags the patient as
  confidential by preceding the patient‘s name
  with a ―c‖ (e.g. cSmith, John). This
  patient‘s medical record is tracked by
  Information Systems. All staff DO have
  computer access to confidential patients, but
  volunteers do not.
 Medical Record – chart is flagged with the
  name ―Cody Seagreen‖
    Flagging the medical record…
   Patient assignment board – room number will list
    the name ―Cody Seagreen‖
   Label – tag with ―Cody Seagreen‖
   Patient door sign – ―Cody‖
   Surgery Schedule – actual patient name will be
   Patient census – actual name will print if run by
    authorized personnel
   Over-the-bed card – actual patient name listed
    (keep door closed, call child by REAL name)
       Responding to requests for
   Respond to ALL requests
    for information with the
    following: “We have no
    information on a patient
    by that name.”
   Community relations will
    respond to all media
    requests for information.
Patient Safety Goals for ETCH

JCAHO establishes patient safety goals each
 year. The existing goals are evaluated and
 may be continued or replaced with new
 goals on an annual basis. New goals are
 announced each year in July and become
 effective the following January.
             Patient Safety Goals
   Improve accuracy of patient identification.
   Improve effectiveness of communication among
   Improve safety of using medication.
   Eliminate wrong-site, wrong-patient, wrong-procedure
   Improve safety of infusion pump use.
   Improve effectiveness of clinical alarm systems.
   Reduce risk of health care-associated infections.
   Accurately and completely reconcile medications across
    the continuum of care.
   Reduce the risk of patient harm resulting from falls.
        Approved Abbreviations
   Approved abbreviations may be used on any
    permanent charting document. Approved
    abbreviations are those deemed acceptable by the
    Medical Records Committee when charting on a
    patient document in lieu of the written word or
    phrase. Only approved abbreviations are to be
   Reference: Medical Abbreviations and Eponyms,
    2nd Edition, Sheila Sloane, 1997.
ETCH ―Do Not Use‖ Abbreviations List
   All Chemotherapy drugs: Use the complete spelling for drug
   MS, MSO4, or MgSO4-(Magnesium sulfate or Morphine sulfate) –
    Use the complete spelling for drug names.
   TAC-(triamcinilone)-Use the complete spelling for drug names.
   Ug-(microgram)-Use “mcg”
   U or u; IU-(Unit or International unit)-Write out “unit” or
    “ international units”
   QD or QOD-(every day or every other day)-Write out “every day”
    or “every other day”
   X3d-(Days OR doses)- Write out “for three days” or “for three
   Zero after decimal point (1.0)-(1 mg)-Do not use terminal zeros for
    doses expressed in whole numbers
   No zero before decimal point (.5mg)-(0.5mg)-Always use zero
    before a decimal when the dose is less than a whole unit.
   Miscellaneous corrections-Do not write over words for corrections.
    Line or “X” out errors.
Restraint Use at ETCH
            Physical Restraint
 Any manual method or physical or mechanical
  device that restricts freedom of movement or
  normal access to one‘s body, material or
  equipment attached or adjacent to patient‘s body
  that he or she cannot easily remove which include:
 * Soft wrist
 * Soft ankle
 * Soft vest
*** Leather restraints are not used at ETCH!
   Patients rights, including the right to be free
    from unnecessary seclusion and restraint
    and to receive the least restrictive treatment
    possible, must be protected and upheld for
    patients secluded and restrained, in postural
    and safety support devices, and requiring
    routine treatment immobilization.
 Restraining devices are used only when
alternative measures to provide safety are
ineffective. These may include, but are not
limited to:
* Increased supervision
* Pain control (if applicable)
* Emotional reassurance
* Reorientation
* Diversion
    What Students Need to Know!
   Read the policy on
   If you are assigned to
    a patient requiring
    restraint, notify your
    instructor, allowing
    her or the patient‘s
    nurse to guide you in
    your care of that
Isolation/Infection Control

East Tennessee Children‘s Hospital
Standard Precautions
          -All patients will be
          considered to be on
          Standard Precautions
          -Applies to blood, all body
          fluids except sweat, non-
          intact skin, & mucous
          -Gloves are to be worn
          when coming in contact
          with any of the above
          -Gowns are to be worn
          when splashing is likely
          -Mask or face shields when
          splashing is likely
References Available on ALL
            OSHA Manual
            Isolation Guidelines Manual
            Infection Control Nurse x8191
            Employee Health Nurse x8644
            Policies/Procedures – ETCHnet –
                    infection control
                       Contact Isolation
-#1 way things                             -Hand washing is
passed                                     the #1 way to
-Contact with the                          prevent spread…
secretions (feces,                         -Gloves when
emesis, nasal                              entering room
secretions)                                for touching ANY
-Secretions live                           surface/patient/bed/
on dry surfaces,                           linens/equipment
some for 72 hours                          -Gowns if uniform/
-Infected secretions                       clothes will touch
make contact with                          patient/bed/linens/
mucous membranes                           equipment
                          PUDDLE – lying
(mouth)                   around
                   Droplet Isolation
-The infectious material
is big, thick, heavy                                -Mask if working
 respiratory droplets                               within 3 feet of
-Coughed, sneezed out,                              patient
then drop to the ground                             -Maintain Standard
-When drop, die                                     Precautions
-Usually droplet
isolation does not
last very long
                     Combination Droplet plus Contact
                    refer to algorithms for diagnoses of
                         Meningitis and Pneumonia
                 Airborne Isolation
-Infectious materials            Airborne
are airborne particles           -Observe Standard
-Airborne plus                   Precautions
Contact                          -Mask unless you are
-AFB precautions –               immune
very strict isolation,
Hepa mask required
(children with TB
are not always on
          Linens and Isolation…
   -Remember – all
    linens are handled as
    – Blue bags – blood
      and/or body fluids
    – Green bags – clean
      linens you determine
      can‘t be used
    – Red bags – ONLY if
      with blood
       Trash/Disposable items and
            Isolation (B.I.C.)
   Anything with blood (B) goes into red bag trash.
   The disease and mode of transmission of the organism in question
    determines the way secretions/excretions are disposed of. Any
    materials containing the infectious (I) agent go in red bag trash
    (diapers of a Rotovirus patient, tissues used with an RSV patient).
   Tissues, diapers etc. not containing the infectious agent are put into
    regular trash.
   If the disposable item is a suction container with body fluids, add the
    solidifier and put into Red bag trash.
   If the disposable item is either a syringe (without needle) or IV tubing
    and there is visible blood present, these must go into Red bag trash.
   Foley bags containing urine always go into red bag trash.
   Chemotherapy (C) materials go into red bag trash.
            In Summary…
 Stop and apply the signs…
 Use personal protective equipment…
 Use appropriate trash bags for contaminated
 Educate parents…
 PRACTICE isolation principles!
Pain Assessment and
The staff at Children‘s Hospital believes that pain is a
  negative experience best measured by the individual in
  pain. Compassionate care includes the assessment of pain
  on admission and regularly during the visit, accompanied
  by effective interventions. Pain is manageable through
  pharmacological and non-pharmacological interventions
  using a multidisciplinary approach with the patient and/or
  care giver as an integral part of the team. Effective pain
  management focuses on minimizing the pain and the
  adverse psychological and physiological effects of
  unrelieved pain.
       Pain Management includes:
Assessment includes:                 Supportive care includes:
   Assessment on admission             Pharmacologic relief-give as
   Pain history                         ordered per physician
   Pain description and intensity      Provide non-pharmacologic
    using appropriate pain scales        pain relief measures: including
   Before, during and after pain        behavioral techniques such as
    producing events                     breathing techniques,
                                         relaxation, rocking, etc.;
   Each new report of pain              cognitive interventions such as
   Before and after each pain           positive thoughts, distractions,
    management intervention:             medical play; and sensory
    pharmacological and non-             interventions such as hot/cold,
    pharmacological                      stroking; repositioning.
 Record location, description, intensity and
  pain scale used.
 Record pharmacological/non-
  pharmacological interventions. Note any
  side effects of medication. Note sedation
  level when opioids in use.
 Record response to pain interventions.
 Record assessment data as needed. Record
  in accordance with unit specific standards.
                 Pediatric Myths
    Children don‘t experience pain like adults or they won‘t
    remember it. One myth is that young children, particularly
    infants, have immature central nervous systems and this
    immaturity decreases pain intensity.

   The fact is that the anatomic requirements for pain
    processing are intact by mid to late gestation. Research
    further indicates that preterm infants may have a greater
    sensitivity to pain that term infants and older children
    because their ability to modulate the pain is not developed.
                 Pediatric Myths

    Children are at an increased risk for respiratory
    depression from opioids.

   Research indicates that infants older than 1 month
    are at no greater risk for respiratory depression
    from opioids than older infants. Careful
    monitoring can minimize adverse effects.
              Numeric Pain Scale

 0       1     2    3    4     5    6     7    8    9     10

 No                        Moderate                     Worst
Pain                         Pain                       Possible

   *The patient is asked to rate pain from 0 to 10, with 0
 equaling no pain and 10 equaling the worst possible pain.
     This scale should be used for children age 7 or above.

   Explain to the patient that each face is a person who may feel happy
  because they have no pain or sad because they have some pain. The
 scale ranges from “0 No Hurt” to “10 Hurts Worst”, (as much as you can
imagine), although you don‟t have to be crying to feel this bad. Ask them
       to choose the face that best describes how they are feeling.
       *This scale is recommended for persons ages 3 and older.
 Optimal management of the
   patient experiencing pain
enhances healing and promotes
  physical and psychological
Recognizing Signs & Symptoms
       of Child Abuse
    Recognizing Signs & Symptoms of Child

 There are four forms of Child Abuse:
       Physical Abuse
       Physical Neglect
       Sexual Abuse
       Emotional Abuse/Neglect
 This module will help you to recognize signals of child
 abuse and the characteristics of abusive parents.
Four Forms of Child Abuse
Physical Abuse

   Definition: The non-accidental injury of a child.
   Guidelines to follow in determining non-accidental injury

         • Any injury that requires medical treatment outside the
           range of normal corrective measures.
         • Any punishment that involves hitting with a closed fist or
           instrument, kicking, inflicting burns, or throwing the child
           obviously represent child abuse.
Four Forms of Child Abuse
Physical Neglect

   Definition:     Failure to provide the necessities of life for
   a child.

       Examples would include:

          •      Lack of Medical care
          •      Inadequate nourishment and/or housing
          •      Lack of supervision
Four Forms of Child Abuse
Sexual Abuse

 Definition: The exploitation of a child for the sexual
 gratification of an adult or any significantly older person.

        It is called incest if it occurs between family
Four Forms of Child Abuse
Emotional Abuse / Neglect

  Definition: Excessive, aggressive or unreasonable
   parental behavior that places demands on a child to
   perform beyond his/her capabilities.

        » Sometimes emotional abuse is not what a parent
          does, but what the parent doesn‟t do.
        » Children who receive no love, care, support or
          guidance will carry those scars into adulthood.

     Child abuse is not usually a single physical attack or
      a single act of deprivation.
     It occurs across economic and social lines and is
      usually a pattern of behavior.
     It takes place over a period of time and its effects are
     The longer the child abuse continues the more
      serious the injury to the child.

   All 50 states have MANDATORY reporting laws for
  child abuse.
  In Tennessee, the state agency that deals with child
  abuse or neglect is the Department of Child Services
   Anyone who suspects child abuse or neglect MUST
  report it.
   At Children‟s Hospital we would report any suspicions
  to the Social Work Department.

  The behavior and attitudes of the parents, their own life
    histories, even the condition of their home, can offer
    valuable clues to the presence of child abuse and

These parents…

  •   Were often abused as children
  •   Were expected to meet high demands by their parents
  •   Were unable to depend on their parents for love/nurturing
  •   Cannot provide emotionally for themselves as adults
  •   Expect their children to fill their emotional void

These parents…
 •   Have poor impulse control
 •   Expect rejection
 •   Have low self-esteem
 •   Are emotionally immature
 •   Are isolated, have no support system
 • Marry a spouse who is not emotionally supportive and who
   passively supports the abuse


 • May seem unconcerned about the child
 • May see the child as bad, evil, a monster or witch
 • Usually offer illogical, unconvincing/contradictory
   explanations or have no explanations of child‟s injury
 • Usually attempt to conceal the child‟s injury or protect the
   person responsible
 • Routinely employ harsh, unreasonable discipline
   inappropriate for child‟s age or transgressions
 Recognition and prompt action on
the part of healthcare providers are
          important in the
    prevention of further abuse!
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       Death and Dying
Caring for children nearing the end of

            ETCH 2005
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    Principles for End of Life Care
•Respecting patient and family goals, wishes and
•Caring for the entire family
•Using resources and skills from different team
•Listening to and attending to the concerns of the
•Building systems and mechanisms of support
         Children are Different

 Children understand the concept of death
  differently according to their age and
  developmental stages
 Children most often focus on living, not on dying
 Children do not have the same burdens as
  parents, such as financial concerns, but children
  are often ‗protecting‘ their parents or other family
  members at the same time that their families are
  trying to ‗protect‘ them
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Barriers to end of life care
•Children don‟t die:
  •The death of a child is so unthinkable,
  painful, that many individuals cannot
  accept the possibility that it may occur
  •It is „unnatural‟ for a child to precede it‟s
  parents, even grandparents, in death
  •It can‟t happen to my child
 Over 50,000 children between the ages of 0-
  19 die in the United States each year
 26,000 children die in the first year of life
    –   Asphyxia
    –   Congenital Birth Defects
    –   Prematurity
    –   Respiratory distress
    –   SIDS
          Where do children die?
 When hospitalized, most deaths occur in
  intensive care units, either in the NICU or the
 Many of those deaths may be unexpected and
  despite all efforts and intents by the healthcare
  staff to preserve life
 On the other hand, many of the deaths have
  been anticipated by the hospital staff and
  efforts have been made to ‗prepare‘ the family
        Why don‘t children die at home?
   Sudden tragic or traumatic           Families rely on long term
    death                                 relationship with hospital care
   Difficult to predict when             team
    children will die                    Lack of pediatric palliative
   Difficult to make decisions for       care expertise in the
    minors                                community
   Difficulty in transporting and       Insurance issues such as lack
    caring for children on                of payment for home services
    ventilators                           or refusal to allow life-
   Parental fears of controlling         extending measures alongside
    symptoms effectively                  comfort measures
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       How can we provide the best
             possible care?
   Multi-disciplinary= MD‘s, nurses, chaplains, social
    work, child life, nutritionists, respiratory therapists
   Culturally sensitive=religious differences, family
    dynamics and interactions, ceremonies
   Family centered=care extends beyond patients to all
    other significant family members; family wishes are
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        Healthcare members as
 Studies reveal that most times parents
  perceive that their child ‘suffers some or
  a great deal’ with symptoms and side
  effects their child experiences prior to
  death—even when providers described
  the child as ‘comfortable’
 Our greatest goal is to assist the child and
  the family in the achievement of what they
  perceive as a „good‟, peaceful death
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              Family Support

 Many different team members may be called
  upon to support family members, extended
  family and friends
 Families develop a special attachment for
  those who share this very special journey with
 Any team member may become the one person
  a specific family member wants to talk with,
  vent to, cry on
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             Patient Care Conferences

   The physical, medical, emotional needs of the patient with a life-
    limiting diagnosis are not only overwhelming to the family, but
    oftentimes also to the healthcare providers
   Patient care conferences are an excellent means of improving
    communication, brainstorming for new ideas, providing continuity
    of care and being supportive of one another
   Any team member can request a patient care conference and one
    may be helpful even if every single team member is not able to
   Common reasons for a patient care conference are: anticipated
    discharge, pain control, difficulties with coping, etc.
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         Ethical Considerations
   Sometimes we may not agree with the care a
    patient is receiving from his/her family, physician,
    hospital nurse, home health agency, etc.
   Please refer to policy/procedure regarding ―Ethical
    Patient Care Issues‖ E03 in the nursing documents
    found on etchnet.
   Should you feel you are in a situation that puts you
    in direct conflict of your own ethics, please
    discuss it with your instructor and he (or she) will
    assist you in resolving that issue
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   Sometimes it is very difficult to find the balance of
    caring for and supporting a family yet not
    overstepping professional boundaries
   It is always inappropriate when our patient‘s families
    know as much about our problems, situations, or
    loved ones as a close friend would know; We are
    taking care of their family—they are not taking care
    of us
   Likewise, we only need to know enough pertinent
    information about a family to allow us to take
    excellent care of that patient
   It is NEVER about US
     Where is the
   Is it possible to care for someone without caring about
   Is it possible to provide comfort to a child who is
    dying and not be affected by that?
   Is it possible to become so involved with the family
    that it detracts from our ability to provide optimum
    care for the patient?
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          Taking Care of Us
 How do we refill our tank?
 What are things we can do for ourselves that
  heal our spirit?
 How do we manage stress?
 How do we know when to step back? How
  can we know when enough is enough?
 Do we support—rather than enable– each
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 Exercise—no, really
 Eat healthy—contrary to popular belief,
  chocolate does not have heal all powers
 Laugh—find something, someone who will
  always tickle your funny bone
 Cry—when you need to--in private, among
  friends, at funerals; however, patient‘s
  families should not be the ones to comfort you
 Spend time with the people you love doing
  things that are fun for you
Emergency Codes
      Emergency Phone Number
   Dial ―333‖ to report an
   Report Location and
    type of emergency
   Be specific!
   Emergency Code Plan
    Notebook in each
    work area
             Code Red
                   Code Black
   Bomb Threat
   Report to your original
    work area & wait for
   Stay calm and alert!
   Report anything
                   Code White
   Tornado Warning
    (sighting of a tornado)
   Remain calm…speed is
   Move patients & visitors
    to center of building
    away from windows
   Close blinds, drapes &
                                Code Able
   External Disaster
   Code Able I : Any mass casualty
    incident that threatens the integrity and
    function of the institution and requires
    mobilization of all hospital resources

   Code Able II:           Any mass
    casualty incident involving nuclear,
    biological and /or chemical injuries,
    and that threatens the integrity and
    function of the institution and requires
    mobilization of all hospital resources

   Initiate Disaster Plan
                  Code Green
   Security breeches that
    threaten immediate
    danger to patients,
    staff or hospital
   Security will respond
   Other designated staff
    may respond
                    Code Pink
   3 levels
    -Code Pink 0 (<1 yr)
    -Code Pink 1 (1 – 5yrs)
    -Infant or Child
    Code Pink 5 (>5 yrs)
   Nursing –secure area
    & support family
   Security – secure all
              Code Boy/Girl
   Elopement / Runaway
   Secure area
   Be alert!
                      Code 99
   Medical Emergency
   BLS certified staff
    will begin CPR
   Non BLS certified
    staff will call code and
    seek nursing
   Code Team will
    respond and will be in
    charge of the situation

           I THINK I JUST
           SENT THAT
           STOOL TO
       - Key Points
                    DO NOT SEND ANY
       Pneumatic Tube System
           – Key Points
   Packaging and handling of items to be
    – Secure breakable items in the carrier with either
      a liner or bubble wrap
    – Place all items, with the exceptions of plastic
      bags of IV fluid and medical records, into a zip
      lock bag prior to placing in the carrier\Reuse
      bags that have been used to transport
      pharmaceuticals, sterile supplies or paper
        Pneumatic Tube System
            – Key Points
   Packaging and handling of items to be
    transported – Continued…..
    – Snap the carrier properly at both ends or middle
      latch prior to sending through the tube
    – Wash hands after handling a carrier - the
      pneumatic tube system is not clean
         Pneumatic Tube System
             – Key Points
   Laboratory Specimens - Continued…
    – Place specimen(s) in BIOHAZARD zip lock bag with
      the following precautions:
        » Only specimens from the same patient in one bag
        » Wrap glass items (blood culture bottles, glass tubes)
          with bubble wrap before placing in Biohazard zip
          lock bag
        » Place all labels or paperwork in the side pouch of
          the biohazard bag
        » Secure zip lock closure
        Pneumatic Tube System
            – Key Points
   Laboratory Specimens – Continued…
    – Place BIOHAZARD bag within the bubble
      wrap bag, Add extra bubble wrap as necessary
      and fold bag to immobilize contents
    – Note: This step is critical for Blood Culture
      bottles and glass tubes to prevent breakage!
        Pneumatic Tube System
            – Key Points
   Blood product bags can be “returned” via
    the tube system with the following
    – Remove all sharps
    – Close all tubing ends
    – Place in BIOHAZARD bag with paperwork in
      the outside pouch
         Pneumatic Tube System
             – Key Points
   Laboratory Specimens
    – Check to ensure that all container lids or tube
      stoppers have been tightened securely
    – Note: For Urine or liquid stool specimens - do
      not completely fill containers!
   Laboratory
    –   Surgical specimens
    –   CSF specimens (Spinal fluid) from LP
    –   Formalin and/or alcohol preserved specimens
    –   Tissues for pathology
    –   Trach traps, Gastric washings
    –   Blood products for transfusion
    THE TUBE SYSTEM – Continued….

   Pharmacy
    – Chemotherapy
    – Narcotics
    – Employee prescriptions; over the counter
   Central Supply
    – Employee purchases
    THE TUBE SYSTEM – Continued….

   Other Items
    – Contaminated patient used products (ie,
      instruments, sharps) used laryngoscope blades
      may be sent if placed into Biohazard Bag,
      sealed placed in bubble wrap and then placed in
    – Patient valuables
    – Any container that might leak
    Pneumatic Tube System Spill
   Stop sending carriers from the station where the
    contamination was first noticed
   Notify Engineering and state:
    – Receiving station’s number
    – Sending station’s number (if known)
    – Type of spill (specimen type and suspected amount
    – Time the contaminated carrier arrived (or was first
    – Number of contaminated carriers that have arrived
    – If no answer, page at 417-0328
     Pneumatic Tube System Spill
      Procedure – Continued …
   Remove contents of carrier using protective
    clothing (utilizing Standard Precautions, ie.,
    gloves; gown and goggles as needed)
   Discard the specimen and secondary containment
    bag into red bag trash
   Call the sending station and notify of spill (request
    another specimen if applicable)
   Place the carrier in a biohazard bag, contact
    Central Service and deliver the carrier to Central
Pneumatic Tube System Spill
 Procedure – Continued …
   Complete an Employee Injury Report form
    explaining the type of exposure and personnel
    exposed. Call Employee Health or Infection
    Control (or the Nursing Coordinator if on nights,
    weekends, or holidays)
    – DO NOT leave a voice-mail message - Contact with
      Employee Health or the Coordinator must be made
      within 2 hours
    – When a spill occurs, the entire system will be shut
      down for clean up by Engineering
Dress Code for Students
       at ETCH
     At Children‘s Hospital, projecting a
 professional image is important in our work.
Students should be in school uniforms when in the hospital. Identification
   should be visible at all times! Uniforms should be neat, clean and not
   interfere with your work.
Students must maintain a clean body, free of odors, Fingernails must be
   clean, neatly trimmed and no more than ¼ inch in length. Due to
   infection control concerns, the use of artificial nails and/or extenders is
   prohibited for students in clinical areas. The use of perfumes,
   colognes, aftershave and other scented items must be avoided.
Hair must be neat and well groomed. No hairstyle that detracts from the
   ability to carry out your responsibilities will be allowed. Mustaches
   and beards must be well groomed and neatly trimmed.
Feet must be covered with hose or socks at all times. Shoes must be
   clean. Sandals, open-backed shoes and canvas shoes are not permitted
   for clinical areas.
                Dress Code, cont.
   Students who are in the building to pre-plan or for other
    school-related tasks must be dressed appropriately and be
    properly identified.
   The following are NOT allowed: Jeans, leather skirts or
    pants, sweat pants, shorts or tight-fitting pants, mini-skirts,
    halter or spaghetti strap tops, sleeveless tops, tight-fitting
    or sheer tops, air-brush or screen printed T-shirts.
   Jewelry should be appropriate. Earrings and jewelry
    should not be excessive. Female students should wear no
    more than two earrings per ear, male students should
    refrain from wearing earrings while in the clinical area.
   Students SHOULD wear lab coats and school ID when on
 During your clinical rotation, you may park in the ETCH Parking Garage
(#7 on the map). You will be provided with a purple Student Parking Pass
                       that is good for one day only.
             These may be obtained from your instructor or

     from the ETCH Education Dept. on 2nd Floor of Koppel Plaza.
            Come Prepared!
 Come in dress code! Wear your Student
 Due to very limited storage space, bring as
  little with you as possible! Do not bring
  large backpacks, coats, etc.!
 Leave your valuables at home!
 No cell phones in patient care areas!
Children’s Hospital wishes the very
    best to each of you in your
            new career!

Success is not the key to happiness. Happiness is the
   key to success. If you love what you are doing,
                 you will be successful.
                                     ~Albert Schweitzer~
               FINAL STEP:
Click the link below to view and then PRINT these 2 pages:
    Children‘s Hospital Component Compliance Form
       Information Security Compliance Statement
    Sign both and give the originals to your instructor

                Click here for forms

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