Nursing jci recipe book 2017 (complete version, 28th june) by ttsh nursing

Content Update from Version 1 •

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Amended IPSG 2: – Separated SBAR from Critical content. – Added in “call-out” in verbal order. – Refined content in FAQ. Amended IPSG 6 outpatient: – Refined content in Fall screening and identification and key measures. – Added post fall management for inpatient and outpatient. – Refined outpatient management in FAQ. Added 6th Edition Key Changes Added IPSG 4 Added FMS Added HRP Added PFE Added ASC Added ACC Added COP Added AOP

6th Edition Key Changes MMU: CD Disposal Low Volume CD Disposal Location

Squirt into base of Sharp bins with witness

High Volume CD Disposal Location

Squirt into base of Sharp bins lined with absorbent gel pads with witness

ASC: Procedural Sedation • Define as the technique of administering sedatives or dissociative agents with or without analgesics to induce an altered state of consciousness that allows the patient to tolerate painful or unpleasant procedures while preserving cardio-respiratory function. This is regardless of the medication, dose, or route of administration • Including IV, IM and oral sedation • Refer to recipe book on Workflow on administration and monitoring of sedation IPSG4: Time-Out and Sign-Out • All procedures as stated by the institution as invasive procedures will require Time-Out and Sign-Out. • Sign-Out is to be performed at the end of the procedure before the patient or the procedurist leaves. • Component of Sign-Out includes: – Name of procedure performed – Completion of sponge, instrument and needle count (as applicable) – Specify instructions to follow up from the doctor. – Labelling of specimen (Read aloud patient name, nature of specimen and investigation) – Any equipment issues to highlight MOI: Copy and Paste, Abbreviation • Copy and Paste should be avoided • If used, to ensure that information used are reflected accurately and attributed. • Random audits will be performed and plagiarism will result in disciplinary actions. • Each abbreviation only has ONE meaning. • Refer to revised abbreviation list in Intranet • To search for abbreviation in the list, press Ctrl + F and change option to WorkBook. IPSG 1: Serving of patient diet • Verify patient’s name • Check diet order by matching diet chit with headboard • Hospital enhancement system in progress (September) IPSG 2: IDRT (Critical Content) and SBAR (Critical Situation) • During Intra-hospital transfers, in between meals and shifts, the handover tool would be the IDRT (Identification, Diagnosis, Risk/Referral and Treatment). It would be the critical content during handover. • During critical situation such as resuscitation or patient deterioration, use SBAR (Situation, Background, Assessment and Recommendation).

6th Edition Key Changes IPSG 6.1: Outpatient fall • Screening of fall is performed at every outpatient setting • Situational risks are identified in each clinic, where appropriate. • Interventions are implemented and documented in C-doc. AOP: Care for the terminally ill (special population) • Additional assessment will be performed for the terminally ill patient (Special population) once EOL status is commenced. • Assess for patient’s hygiene and feeding needs and document it in the Nursing Kardex. COP: Multi-disciplinary Goals • Nursing: Patient Care Record (PCR) or Daily Multi-disciplinary Goals for ICU. • To be aware of all the goals set for the patient by other family groups, to refer to JCI Recipe Book for Nurses. PCI: Food from family, Blood, chemical and Chemo spill kit • Encourage patient and family not to leave food in the hospital • All patient food is to be labelled with Name, NRIC, Opened Date and Time. • Encourage patient to consume cooked food within 4 hours • Half consumed, opened or uncovered food or feeds to be discarded after 1 hour • Any opened or half consumed food in the fridge to be discarded after 24 hours. • Familiar with blood and chemical spillage management FMS: Run-Hide-Tell • In dangerous situation (Terrorist, suspicious strangers), to run, hide in a safe environment and tell by calling 999 or SMS 71999 in event when you are unable to speak. SQE: Every staff to be involved in quality activities • Every staff to be involved in quality activities, such as hand hygiene or quality projects in the department. • Involvement in quality activities are documented in annual appraisal. PFR: Likelihood of students and trainees participating in care processes • This information is provided to patients in Patient’s Charter. • Patient’s permission is sought when students and trainees are involved. PFE to refer to PFE form • Nursing PFE is documented on the PFE form • All other family groups may document their PFE in the respective notes, however they can refer to Section A of Inpatient PFE form – Language and education – Learning capacity – Learning barriers – Learning intervention • Other family groups may document on the PFE form as well.

2017/ Complete Version / Updated 28th JUNE

Content

Page

IPSG 1: Identify Patient Correctly

IPSG 2: Improve Effective Communication

IPSG 3: Improve the Safety of High-Alert Medications

IPSG 4: Ensure Safe Surgery

IPSG 5: Reduce the Risk of Health Care-Associated Infections

IPSG 6: Reduce the Risk of Patient Harm Resulting from Falls

PCI: Prevention and Control of Infections

SQE: Staff Qualifications and Education

QPS: Quality Improvement and Patient Safety

MPE: Medical Profession Education

MMU: Medication Management and Use

PFR: Patient and Family Rights

MOI: Management of Information

FMS: Facility Management and Safety

HRP: Human Subjects Research Programs

PFE: Patient and Family Education

ASC: Anesthesia and Surgical Care

ACC: Access to Care and Continuity of Care

COP: Care of Patients

102

AOP: Assessments of Patients

114

A Head to Toe Approach to Remember International Patient Safety Goals!

IPSG 1. Identify Patients Correctly - Important Points Correct Patient identification Process

If the first 2 identifiers are not available, staff can also use the following as identifiers to identify the patient: - Patient’s date of birth - Patient’s address - Patient’s hospital registration no.

2 Patient Identifiers should be used: • Allocating patient identification band • Giving medications or blood products • Taking blood and other specimens • Providing treatments or procedures (including x-rays and scopes) • Before sending or fetching patient • Handing over a patient to another dept Never use patient’s room/bed number or locations as the identifiers!

When serving diet: • Verify patient’s name • Check diet order by matching diet chit with headboard. Hospital system enhancement for second identifier is in progress.

Where should we attach 2 Patient Identifiers other than wrist? In situations where an ID band cannot be applied to the wrist or lower limb, staff should attach the ID label to patient’s deltoid area (upper arm) and cover/affix it with a waterproof transparent dressing. Where there is difficulty in the application of ID band/label, the issue should be brought to the attention of the supervisor and/or doctors for decision and relevant documentation should be made. 2

IPSG 1. Identify Patients Correctly - FAQs Questions Tell me how do you identify the correct patients? Or

Answers Ask patient for 2 patient identifiers and check against relevant documents. • Patient’s name • NRIC No./ Passport No. / Work Permit No.

Tell me how do you know if the patient receives the correct treatment?

Alternative identifiers if above not available: • Date of birth • Home address • Hospital registration number

Tell me how do you ensure the correct treatment is delivered to uncommunicative or unconscious patient?

Check wrist band against relevant documents.

How would you ensure the correct treatment is delivered to patient with unknown status?

For patient with unknown status, to use:

In outpatient – check with carer and verified against relevant documents • Patient’s name • NRIC No./ Passport No. / Work Permit No.

• Medical Record No. (MRN) • Hospital Registration No.

IPSG 1. Identify Patients Correctly - FAQs Questions

Answers

Tell me what would you do if there is really no choice to attach patientâ&#x20AC;&#x2122;s wrist tag on any skin surface (i.e. severe skin excoriations)?

We will clip the identifier tags on the patientâ&#x20AC;&#x2122;s clothes (shown in image below):

IPSG 2. Improve Effective Communication - Important Points Effective HANDOVER of care of patient is required during: 1. Intra-hospital Handover, e.g. shift change, breaks, transfer to another unit/level of care. 2. Inter-hospital Handover, e.g. transferring a patient to another acute care hospital, community hospital or nursing home.

Standardized critical content to communicate during handovers are:

Read-back to communicate critical results verbally or via phone The test and the critical result with patient’s name & NRIC number must be - written down - read-back by the receiver - confirmed correct by the caller Critical results need to be communicated & acknowledged by the responsible clinician within: Laboratory & Radiology: - Inpatient/Ambulatory – 1 Hour - Outpatient – 2 Hour

IDRT - Identification - Diagnosis & condition - Risks /referrals - Treatment

SBAR Standardized tool used during handovers of patient care in emergency/urgent clinical situation : Situation Background Assessment Recommendations

Verbal/Telephone Medication Orders NOT ALLOWED Except in clinical settings using the paper IMR and during an emergency situation where delay in administration of medication will result in unfavorable outcome. The staff receiving the verbal order is required to practice “call-out”. 5

IPSG 2. Improve Effective Communication - FAQs Questions Tell me what would you do if the doctor is not around to order medications during an emergency?

Answers We do not accept verbal / telephone orders. Except in clinical settings using the paper IMR (ICL, Endo Centre and NHG 1 Health), and during an emergency situation where delay in administration of medication will result in unfavorable outcome and read back is not feasible, the RN receiving the verbal order is required to “call out” for the team’s awareness and under the supervision of the Dr. The call out shall include calling out the drug name. dosage and route upon administration of the medication.

Tell me what is the process of receiving critical results?

Critical test results with patient’s name and NRIC number will be • Written down • Read back to caller • Confirmed correct by caller • Notify clinician & Document

Tell me how do you communicate patient care?

Standardized critical contents are communicated during handovers of patient care, which is: • 2 patient identifiers • Diagnosis and Condition • Risks • Treatment

Lists of TTSH HAM & Look-alike Soundalike drugs can be found in Intranet

We don’t stock concentrated electrolytes!*

*Except in these locations: • ICUs & high-dependency wards (3A, 3B, 6A, 6B & 6C) • POTASSIUM CHLORIDE 7.45% INJ is available in Ward 9A Haemodialysis Unit, & is only allowed to be added to dialysis fluids. • Magnesium Sulfate 49.3% INJ is also available in OT/PACU, procedural suites, ED & E-kits for resuscitation purposes.

Look-Alike Sound-Alike Meds • Avoid placing LASA next to each other • Tall man letterings, bold & underline, and words on black background to distinguish LASA names • Pink bin labels to alert physical product look-alike

HAM Storage All HAM are to be labeled with “High-Alert” sticker on • Container where drugs are stored • Dispensed drugs from pharmacy and when using patient’s own medication from home

Look-alike Sound-alike (LASA) & High Alert Medications (HAM) labels

IPSG 3. Improve the Safety of HighAlert Medications (HAMs) - FAQs Questions

Answers

Do you have high-alert medications in your hospital? What are they?

Yes.

Show me your list of high-alert medications? Or Where can you find the list of high-alert medications?

Intranet  Pharmacy Notice Board  High Alert Medications.

Tell me, do you take any measures to improve the safety of high alert medications?

All High-Alert Medications (HAM) are labelled with a “High Alert” sticker on • Container where drugs are stored • Dispensed drugs from pharmacy • Using patient’s own medication from home

Some of these medication includes heparin, warfarin, insulins, and cytotoxic drugs and concentrated KCl.

Other safety measures includes, • Use of Safety limits (Guardian Feature) on infusion pumps • Warfarin Initiation protocol Phamacy Notice Board  High alert Medication Warfarin Initiation Guidelines • Administration policy as per QP-NUR-GEN-005 Tell me, do you keep concentrated electrolytes here?

No, we do not stock concentrated electrolytes (except for ICU, HD, OT, PACU, ward 9A-AHU) Note: magnesium sulfate inj is available in the E-kit (E-trolley), for resuscitation purposes.

IPSG 4. Ensure Safe Surgery - Important Points Site Marking • Permanent/Skin marker • Target site, not at site of entry • Use ONLY • Involve patients • The procedure-site marking will be done by the person who will be performing the procedure and the patient is also actively involved in the site-marking process.

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Time Out is performed right before the start of the surgery/invasive procedure in the presence of procedurist and the patient. It involves the entire team and remain silent during the Time Out. No one from the team shall leave the room/designated cubical.

Sign Out is performed at the end of the procedure location/room before patient or the procedurist leaves. Components of Sign Out: • Name of procedure performed • Completion of sponge, instrument and needle count (as applicable) • Specify instructions to follow up from the doctor. • Labelling of specimen (Read aloud patient name, nature of specimen and investigation) • Any equipment issues to highlight JCI-IPSG-HAP-004 Video on Time-out & Sign-out is available on NOOG and Kampung Workplace.

Components of Time Out: • Correct patient • Correct procedure, treatment or surgery • Correct side and site • Correct Imaging report/medical records • Review anticoagulant • Correct functional equipment or requisites 10

IPSG 4. Ensure Safe Surgery - FAQs Questions

Answers

Tell me what you do to ensure safe surgery or procedure provided to your patient?

For safe surgery ensure that : 1. Pre-procedure verification is carried out against the checklist to ensure correct patient, correct procedure, correct site, correct document and test performed. 2. Site marking is done by the surgeon as appropriate. 3. Time out is held immediately before the start of the procedure. 4. Sign out is held at the end of the procedure

Could you share with me on Time Out?

Time out is held immediately before the start of the procedure with all team members present. The team verify on the following: 1. Correct patient (IPSG 1). 2. Correct procedure, treatment/surgery. 3. Correct side and site. 4. Correct imaging report/medical records 5. Correct function equipment/requisites.

Tell me, when do you require site marking for the patient?

Site marking is performed for all invasive procedures as per the hospital protocol and policies. It is done with an arrow (ď&#x192;Ź) marked adjacent to target site. We will involve the patient during the process and site marking is done by the procedurist who perform the procedure.

Tell me more about Sign-Out

Sign-Out is conducted in the area where the procedure was performed before the patient leaves. The following components of the sign-out are verbally confirmed by a member of the team, on the following: 1. Name of the surgical/invasive procedure that was recorded/written 2. Completion of instrument, sponge, and needle counts (as applicable) 3. Labeling of specimens (when specimens are present during the sign-out process, labels are read aloud, including patient name) 4. Any equipment problems to be addressed (as applicable)

IPSG 4. Ensure Safe Surgery - FAQs Questions

Answers

Show me the documentation on Time Out and Sign Out performed for your patient.

For patient not on procedure sedation, document time/sign out in C-doc. For outpatient cases, access C-doc outpatient. For patient require procedure sedation : use hard copy procedural sedation form. For patient with hard copy doc (carepath) use procedure sedation and delete unnecessary fields.

Hand hygiene audit data

Hand Hygiene All healthcare workers must adhere to the 5 moments of hand hygiene by: • Using alcohol-based hand rub • Washing hands with an antiseptic agent It is one of TTSH’s priority indicator. The 5 moments for hand hygiene

• Talk about Infection Prevention Champions (IPCs), shared governance and QAs. • Ward Dashboard indicators • Root causes of hand hygiene non-compliance were identified and appropriate interventions were implemented. • Reminders are placed at relevant locations to promote the practice of hand hygiene. • Hand hygiene audits are conducted at the institutional level and the local level. • Results from the institutional level audits are published on the intranet for access to information on the progress towards our target of 100%.

Where to find level audit data on Intranet?

TTSH Intranet  JCI Gold Seal JCI Documents PCI WINICINF003 Hand Hygiene 13

IPSG 5. Reduce The Risk of Healthcare Associated Infection - FAQs Questions Show me, how do you perform hand hygiene. (Auditor might stand and observe quietly)

Answers Handwash • Wet hands • Use 1 full pump (5mls) of antiseptic solution • Rub thoroughly using 7 steps (refer poster) • Rinse and dry hands. Recommended minimal duration for antispetic handwash is 30 seconds or as per manufacturer recommendation. Handrub Apply 1 – 2 pumps (3mls) of hand rub to palm of one hand and rub hands together, covering all surfaces of hands and fingers until hands are dry or hand rub following the 7 steps of hand washing.

Tell me, how do you know that these steps are sufficient to reduce the risk of infection?

Our institution follows the World Health Organisation (WHO) guidelines on hand hygiene in healthcare.

Tell me, in which situation would you perform a handwash?

Do handwash when: • Hands are visibly contaminated with blood or body fluids. • Patient is tested positive with Bacillus anthracis or Clostridium difficile. • Patient with mites infection Do handrub when hand are not visibly soiled with blood & body fluids.

WI-NIC-INF-003

IPSG 5. Reduce The Risk of Healthcare Associated Infection - FAQs Questions Tell me the initiatives you have done in your department to improve the rates of hand hygiene?

Answers • Hand Hygiene pledge • Visual signage for hand rubs • Peer reminder and checks • Monthly audits • Infection Prevention Champions (IPC) • Annual Hand Hygiene Day in May. • Frequent audit by mystery auditor Share department initiatives if any.

Show me the Hand Hygiene audit data from your department.

Show unit dashboard and be prepared to share: • The poorest hand hygiene moment in the department • The healthcare provider whom are the weakest link. • The interventions done to improve it

IPSG 6. Reduce the risk of patient harm resulting from Falls - Important Points FALL RISK Inpatient

Outpatient (except designated high fall risk clinics)

Fall risk assessment and reassessment criteria Initial assessment done within 24 hours Reassessment: • Change in fall risk factors (Unsteadiness, Continence, Cognitive impairment) • Post-surgery • New complain of giddiness • Upon transfer • Post fall Patient at risk for falls are identified by: • Pink wrist tag • Pink column at headboard Post Fall Management • Assess injury, vital signs and mental status • Inform doctor to review patient • Initiating post fall management form Key measures to reduce falls All patients receive standard fall precautions e.g. position call bell within reach, assist patient accordingly to the functional assistance required etc. When high fall risk is identified, patient receives targeted interventions based on their risk factors. Interventions are planned and documented. (Refer to Whefra form-care planning section to show the specific measures that are planned and implemented for the patient)

Fall screening and identification All patient are screened for fall risk: Evidence of Mobility impairment which includes: • Patient looking unsteady when they walk, or on a wheelchair, or complain of giddiness. • Visual Impairment • History of fall within past 6 months. Situational risk are identified in each clinic, where appropriate. Interventions are implemented and documented. Key measures to reduce falls • Once identified as fall risk, a pink sticker will be applied on patient clothing or clinic ambassador assist patient. • Patient and/or carer receives falls education. Brochure will be given to all patient. • Offer direct help/assistance • Advise carer to always accompany the patient and not to leave patient alone • Observe patient for signs of weakness or giddiness after procedures and assist as appropriate • Interventions are documented. Post Fall Management: (Inpatient & Outpatient) - Assess injury, vital signs and mental status - Inform doctor to review patient - Initiating post fall management form 16

IPSG 6. Reduce the risk of patient harm resulting from Falls - FAQs Questions

Answers

Tell me, how do you ensure a safe environment for your patient?

We will perform hand hygiene and also reduce the risk of patient falls. • All patients who are admitted or transferred into the ward are assessed using the WHeFRA tool within the 24 hours of admission or transfer in. • High risk (>8), Low risk (<8). • Doctors orders on “fall precaution” supersedes WHeFRA score. • When high fall risk is identified, targeted measures are planned and implemented.

Show me the interventions performed to prevent falls for your patient.

Refer to the “Fall Risk Assessment (mWHeFRA) & Care Plan” form

Tell me, when do you know that your patient are at higher risk of falls?

Patients are reviewed every shift for change in condition/fall risk factors. (A review is done every shift, triggered during PCR documentation. A review is a brief process to quickly make a judgement if patient’s condition has changed since last WHeFRA assessment*). Patients are at higher risk of falls when: • A change in fall risk factors/condition (Unsteadiness, Continence, Cognitive impairment) • Post-surgery • New complain of giddiness • Upon transfer • Post fall SD-NUR-GEN-019 Prevention and Management of Patient Falls

IPSG 6. Reduce the risk of patient harm resulting from Falls - FAQs Questions Tell me how do you reduce the risk of patient harm for patients on fall risk?

Answers We identify patients who are at risk of injury using the “ABCS” framework*. High fall risk patients with risk of injury will be flagged using the card “Fall: Injury Risk”. Measures include: • Adjusting the bed to the lowest level to reduce the impact of fall. • Cohorting the patient in the ‘High Fall Risk Cubicle’ (HFRC) for close observation if the patient is observed to be impulsive, confused, agitated and attempts to mobilize unsafely without calling for help. *ABCS Framework: • Age or frailty - Age ≥ 80 years and frail due to medical conditions. • Bones - Osteoporosis, met static bone cancer, previous fragility fracture • Prolonged Coagulation - Those with bleeding tendencies and anticoagulation usage. • Recent Surgery - Post operative patients especially those with amputation, abdominal or thoracic

SD-NUR-GEN-019 Prevention and Management of Patient Falls

IPSG 6. Reduce the risk of patient harm resulting from Falls - FAQs Questions Tell me what would you do if you witness a patient fall.

Answers 1. 2. 3. 4. 5. 6. 7.

Tell me, how do you prevent the risk of patient harm from falls in the outpatient setting?

Assess injury, vital sign & mental status. Initiate “Post Fall Assessment Form” to guide the assessment. Inform doctor to review patient following fall. Monitor patient as per doctor‘s orders. Document the incident and report to Ward NM/NC. Raise incident report. Initiating other investigations and management options listed in the ‘Post Fall Management Guidelines’ as appropriate. If patient is discharged <24hours after incident, provide advice & education on abnormal signs to monitor for when patient is at home.

We perform fall screening for all patient who arrived at outpatient: • Mobility impairment which includes: Patient looking unsteady when they walk, with or without walking aids or if patient is on a wheelchair. • Visual Impairment such as use of any walking cane or use of eye pad on any one eye • History of fall within past 6 months.

SD-NUR-GEN-019 Prevention and Management of Patient Falls

IPSG 6. Reduce the risk of patient harm resulting from Falls - FAQs Questions

Answers

Tell me, what happens next after identifying the fall risk patients in the outpatient setting?

Fall precautions measure were implemented: • Once identified as fall risk, a pink sticker will be applied on patient clothing or clinic ambassador assist patient. • Patient and/or carer receives falls education and a brochure will be given to all patient. • Offer direct help/assistance • Advise carer to always accompany the patient and not to leave patient alone • Observe patient for signs of weakness or giddiness after procedures and assist as appropriate.

Show me where do you document fall intervention? (Outpatient)

Refer to clinical documentation.

SD-NUR-GEN-019 Prevention and Management of Patient Falls

PCI Prevention and Control of Infections - Important Points Everyone is part of the PCI team! Standard Precautions Purpose: To reduce the risk and transmission of microorganisms from both recognized or unrecognized sources of infection in the hospital.

Types of Isolation & PPE Used in the care of specific patients known or suspected to be infected/colonised with pathogens spread by the following transmission routes: • Airborne • Droplets • Contact

Isolation Rooms Call FCC if pressure gadget is not working. Use a tissue paper to test if the negative pressure is functioning.

Donning of PPE: Isolation room without ante-room, to wear PPE outside isolation room

Special requirements for vulnerable patients: Immunocompromised patients, Perform hand hygiene & adhere to Standard Precaution. Switch off exhaust fan. 21

PCI Prevention and Control of Infections - Important Points Linen Management

Disinfection & Sterilization (WI-NIC-INF-005)

Non-Contaminated Linen Into canvas bag Contaminated Linen (blood/body fluids/scabies) Red biodegradeable bag  Disposable plastic bag Canvas bag Waste Disposal General: Black/white/transparent bags Bio-hazard: Yellow bags Cytotoxic: Purple bags Radioactive: Red bags Glass bottles: Glass bottle bins Sharps & Needles Disposal Sharps, broken glass ampoules and vials: Sharp container Expired Products • Practice Earliest-Expiry-First-Out (EEFO) for products with expiry dates • Adhere to First-In-First-Out (FIFO) for products with no expiry dates

Check for expiry dates • Drugs: Send to pharmacy for disposal • Consumables: Discard as general waste Single Use Item • No reuse of single-use item • Single use items are not to be reprosses or re-sterilised even when they were opened and not used on patient.

Critical items Items entering sterile tissues or vascular system • Must be sterile and comply with expiry dates Semi-critical items Items in contact with mucous membranes, nonintact skin (e.g. Suction bottles, laryngoscope blades) • Require high level disinfection Non-critical items Items in contact with intact skin (e.g. bedpan and BP cuff) • Require low level disinfection Food Label for Enteral Feeds/Food NAME NRIC Opened/ Stored On:

DATE

TIME

• Ensure patient’s food is labelled and dated • Advise patient to consume cooked food within 4 hours • Discard opened, half consumed or uncovered pack/ can of formula feeds or beverages stored at room temperature after 1 hour • Any opened or half-consumed food/drinks store in the fridge will be discarded after 24 hours. Note manufacturer’s recommendation for milk 22

PCI Prevention and Control of Infections - FAQs Questions

Answers

Tell me, what do you know about infection control?

Upon joining the institution, we have orientation programmes that includes: • 5 moments for hand hygiene • Standard & transmission based precautions • Other specific infection control polices

Tell me, how do you prevent the spread of diseases in your institution?

• 5 moments for hand hygiene • 1st tier: Practice of Standard Precautions for all patients • 2nd tier: Transmission based precautions • Appropriate use of PPE • Staff Vaccination • Patient & family education • Annual health screening

Tell me, what do you do when you are required to assist a procedure for an infectious patient?

We will practice the Standard Precaution. • 5 moment for hand hygiene • Gloves: Contact with blood and body fluid secretions, excretions, and contaminated items, mucous membranes and non-intact skin. • Surgical mask, Eye protection with Goggles/Visor: When performing procedures that are likely to generate aerosols and/or droplets/splashes of blood/body fluids e.g. suctioning, bronchoscopy, chest physiotherapy, etc. • Eye protection with Goggles/Visor must be worn when placing a catheter or injecting material in the spinal or epidural space. • Apron/Gown: When clothing is likely to be soiled with blood/body fluids.

Reference: WI-NIC-INF-021 Standard Precautions WI-NIC-INF-022 Transmission-Based Precautions

PCI Prevention and Control of Infections - FAQs Questions

Answers

Tell me, how do you know that the negative pressure room is working?

• Ensure the exhaust fan switched on. • Check negative pressure gauge range (refer range indicated next to gauge) • If it alarms or out of normal range, to call FCC at 8822. •Test with a piece of tissue paper: Place tissue paper at the gap at the base of the door. Tissue paper will be drawn into the room if it is working.

What would you do If you were pricked by a used needle or had a blood/body fluid exposure?

• Do first aid by washing the puncture site or affected area with soap under running water. • Inform supervisor, team doctors to do risk assessments, ensure source patient’s blood is taken (If source patient is known) • Seek medical attention (OHC/ED if after OHC operating hours) • Raise IRIS. Reference: WI-NIC-INF-020 Sharps and Needle Stick Injuries/Occupational Blood & Body Fluid Exposure

Tell me, what happens after the needle stick injury when the staff returns from OHC?

The doctor will follow up with the staff clinically and appropriate care will be given. The supervisor will be informed and will keep track of the progress of the staff while observing confidentiality.

The Occupational Health Department will also be involved in caring for the staff. Reference: QP-NIC-INF-005 Employee Health, WI-NIC-INF-020 Sharps and Needle Stick Injuries/Occupational Blood & Body Fluid Exposure

PCI Prevention and Control of Infections - FAQs Questions Tell me, what happens if you witness a blood or body fluid spill?

Answers Spot/Small blood spills • Wear Gloves • Wipe area immediately with paper towel followed by disposable alcohol wipes. Large spills in a ‘Wet’ Area (e.g. Toilet) • Don PPE (Gloves, Apron, Eye protection) • Carefully hosed off the spill into the sewage system • Flush area with water and detergent • Disinfect area with NaDCC (10, 000ppm available chlorine) Large spills in ‘Dry’ Area • Blood and body fluid spill kit should be used • Don PPE (Gloves and Apron) • Contain and decontaminate the spill by pouring NaDCC granules • Ensure that the spill is fully covered by the granules • Leave for at least 2 minutes or as per manufacturer’s recommendation • Using the disposable scoop, which is available in the “blood and body spill kit”, scoop the granules into a biohazard waste bag. If glass or other sharp materials is involved, scoop them into the sharps container • Clean area of spill with mop, water and detergent • Disinfect area with NaDCC (10,000 ppm available chlorine) Reference: WI-NIC-INF-024 Management of Blood and Body Fluid Spills

PCI Prevention and Control of Infections - FAQs Questions Tell me, how do you know that the items are good to be used?

Answers • Check expiry dates & packaging integrity before use. • Do not use expired products/consumables • Expired pharmaceutical items are collated and returned to pharmacy as per policy Expired products/consumables are collected and returned to MMD as per policy • Earliest-Expiry-First-Out (EEFO) for items with expiry dates and First-In-First-Out (FIFO) is practiced for items with no expiry dates Reference: QP-PHA-INV-006 Disposal and Returns Of Expired/Deteriorated Goods, QP-MMD-MCS-001 Receiving And Storage, QP-MMD-MCS-003 Return To Store (RTS)- Return To Vendor (RTV) and WI-NIC-INF-021 Standard Precaution

Tell me, how do you clean your equipments?

We use 70% alcohol impregnated wipes for cleaning surfaces of machines and equipment.

SQE Staff Qualifications & Education - Important Points Organization commitment to training

Staff evaluation programme

Our hospital achieved its mission and meet our patients’ needs through:

Evaluation starts at the time you begin work. All staff are evaluated on their work performance, key job competencies, roles and responsibilities.

• A coordinated, uniformed and consistent process in areas of recruitment, evaluation, appointment and orientation of staff • Education and learning opportunities offered to staff in advance personally and professionally • Staff health and safety programme provided to maintain health

Recruitment and appointment • License, education and training of nurses are gathered and verified before appointment. • Every nurse must have a valid SNB license to practice in the hospital and it is to be renew yearly.

Assessment of work performance is done: • During orientation and at the end of the probation period • Continuous monitor, evaluation and feedback through verbal and annual Total Performance Management (TPM) by supervisors • Documentation of evaluation and evidence of staff competency through •

Nursing Competency Checklist for new Nurses (NCC). NCC will be submitted together with the staff’s confirmation report to HRM and will be retained in staff’s Personal file in HR

•

Competency assessment Checklist (CAC) will be used for specific competency assessment, for example haemodialysis and will be kept in the department

Staff orientation Programme Orientation programme is essential to induct staff to their new appointment and role in order for them to perform well. New nurses go through: • Onboarding programme for new employees by HR(P)D • Hospital and Unit-based orientation programme for new nurses

SQE Staff Qualifications & Education - Important Points Ongoing learning & development Hospital provides our staff opportunities to learn and advance personally and professionally through in- service education and other learning opportunities such as advanced diploma, bachelor and master degree and PHD. Learning needs are identified through: • Yearly learning need analysis exercise (LNA) • Adhoc requirement such as new services, equipment There must be records of these trainings and captured in the hospital training date base (SAP)

Competency in resuscitation technique Basic Cardiac Life Support (BCLS) • Compulsory for all medical, nursing and identified allied health staff • Recertification is every 2 years

Hospital’s staff health and safety programme All new staff undergo a pre-employment check-up by an appointed doctor. It includes physical medical examination, blood screening and chest X-ray. All new staff need to complete a form to declare their medical conditions, if any. Applicant applying for position in departments that perform exposure prone procedures (EPP) must declare their Hepatitis B status and should be immunised if they are not immune. It is compulsory for all staff to be vaccinated with • Hep B • Varicella • MMR Hospital provides education, counselling and follow up for staff who may be second victims of adverse or sentinel events.

Heart-saver • HCAs Advanced Cardiac Life Support (ACLS) • Medical doctors 28

SQE Staff Qualifications and Education - FAQs Questions Tell me how do you know about your job scope

Answers We have a JD and it is shard with us upon appointment or if revised. The JD is reviewed every 3 years. *Staff must be able to articulate own JD

Or Do you have a job description (JD)?

Staff to show JD in NOOG (Nursing Portal) -> Nursing Service -> Job Description

Tell me how the hospital prepares you to perform the work you are doing?

We will go through onboarding programme for new employees by HR(P)D, nursing hospital and unit-based orientation programme.

Tell me how soon you are enrolled for the onboarding programme / department induction Programme / nursing hospital orientation programme when you joined the organization?

• Department Induction: Within the 1st month (It covers the broad strategies and hospital-wide rules and guidelines in Infection Control, Fire Safety and Fire Evacuation, managing/ handling difficult or abusive situations, and IQEHS) • Hospital Onboarding Programme: scheduled within 3 months • New nurses will attend the nursing hospital orientation on their first day of work

SQE Staff Qualifications and Education - FAQs Questions Tell me the key competencies to work in this unit

Answers The Key competencies are: • BCLS • Department Core competencies – Staff is assessed on the Department’s Core Competencies once he/she commence his work and on Annual basis

Tell me who need to be BCLS certified and how frequent it is being done

All nurses, doctors, allied health professionals who have direct patient contact are required to have a valid BCLS certification.

Tell me how do you maintain or advance your skills and knowledge to meet patient needs and/or continuing education requirement?

Through: • Attend identified Courses after Learning Needs Analysis (LNA) exercise

Recertification is required every 2 years.

• Attend department / nursing in-services (CNE) and OJT sessions

Or How do you receive ongoing development for your skills and clinical knowledge? How do you ensure that the staff clinical knowledge and skills are consistent with patient needs?

Staff work performance is evaluated during the probation period and annually during Total Performance Management (TPM) Exercise using the clinical core competencies

* For Supervisors 30

SQE Staff Qualifications and Education - FAQs Questions

Answers

Tell me is there any staff health and safety programme for you as employee?

Yes, for example, • Annual flu vaccination / health screening for staff • Staff abuse talks to the departments • Safe manual handling programme during hospital orientation • Education and support for workplace violence • Education and support for staff who may be second victims of adverse or sentinel events

Tell me the measures hospital has put in place to reduce the risk of workplace violence

We have panic buttons, CCTV to monitor hospital premise and signages to discourage perpetrators.

Tell me the help a staff will receive after workplace violence.

• Staff can seek treatment or medical assistance at OHC Service/ED • If the injury/trauma affected the staff’s mental and emotional state, the staff may be referred to the volunteers under the Staff Support Staff (3S) programme or to the relevant clinical departments for psychological treatment/follow-up. • Staff will be advised that they have a right to legal recourse

Or How can staff seek treatment or receive counselling and followup for injuries related to workplace violence

SQE Staff Qualifications and Education - FAQs Questions

Answers

Do you have counselling and follow-up treatment for staff who are second victims of adverse or sentinel events.

Yes, we do.

At Hospital level, there is a tiered model and available resources to help our staff if professional help is required.

Tell me the safety programme available for staff who may be second victims of adverse or sentinel events

Staff-Support-Staff (3S) Helpline: 9720 8515 (Mon – Fri 8am – 6pm) Psychiatric Medicine: 6889 4343 Care & Counselling: 6357 8222

Does nursing staff participate in the hospital’s quality improvement (QI) activities?

Yes. Individual staff participation in QI is evaluated in TPM.

Do you receive education or training about your roles in providing a safe and effective patient care facility?

Yes, we received training on our roles in the hospital programmes for:

For Nursing, the respective supervisor will provide emotional support if staff display signs/symptoms of distress and will review alternate work arrangements/environment if necessary.

• Fire safety • Security • Hazardous materials • Emergency • Medical equipment • Utility system

QPS Quality and Patient Safety - Important Points -

TTSH Quality Principles • Patients are our top priority • Quality is achieved through people • All work is part of a process • Decision making by facts • Quality requires continuous learning and improvement Promotion of Safety Culture • Patient Safety Leadership Walkabouts • Patient Safety Workshops • Open Communications Workshops • Non-punitive Incident Reporting • Patient Safety Climate Survey

TTSH Quality Improvement & Patient Safety Framework 1. Detection • Voluntary Incident Reporting System • Patient Feedback System • Morbidity & Mortality Review • Nursing Audits • Clinical Indicators Tracking • Enterprise Risk Management 2. Analysis Analysis of patient safety incidents or trends from indicators is done through Quality Assurance Committees (e.g. Falls Prevention Committee, Medication Safety Team), department Supervisors, Quality Review Officers (QROs). Methodologies for analysis • Root Cause Analysis (within nursing, a local RCA is initiated for all falls with major injuries, wrong patient medication administration errors and medication administration errors involving high alert medications)

3. Methodologies for Improvement TTSH adopts the PDSA (Plan, Do, Study, Act) Cycle, Lean Methodologies and Apple Philosophy for improvement and are incorporated into our Clinical Practice Improvement Programme (CPIP) and ‘MyCare’ Program. Skills and knowledge of improvement methodologies are taught to improvement teams through a network of improvement facilitators and faculty. Quality Improvement Tools Some tools include: • PDSA (Plan, Do, Study, Act) cycles • Root Cause Analysis (RCA) • 6S • Job Breakdown Sheet (JBS) • Standard Work (SW) Communication Channels • Various communication channels where quality issues are discussed & communicated include: • CEO townhall meetings • Management Review • Unit Council Meetings/UBQIC • Ward meetings • Roll call e.g. when a fall has happened during the shift • Hospital Conference • Safer Practice Alerts • Regular features on quality improvement are disseminated via the TTSH Tribune for general communications. Organisational Learning and Training • Quality & Patient Safety trainings include: • Patient Safety & Quality in orientation programme • Root Cause Analysis (RCA) & Failure Mode Effect Analysis (FMEA) workshops • CPIP, MyCare & Service with Excellence workshops • Risk Management For Nurses courses • IRIS café for supervisors 33

QPS Quality and Patient Safety - FAQs Questions

Answers

Who is responsible for Quality and Patient Safety in the hospital?

The Chairman, Medical Board (CMB) [A/Prof Thomas Lew] oversees the implementation of the hospital’s Quality Improvement and Patient Safety Programme and chairs the Quality Council (QC) QC assumes overall authority for the direction and drives all the quality programmes in the hospital. He is assisted by Assistant Chairman, Medical Board (Clinical Quality & Audit)[Dr Tan Hui Ling]. The Assistant Director of Nursing (Quality) [Hoi Shu Yin] is a member in the Quality Council and provides leadership in nursing quality matters.

What are your hospital’s quality principles?

TTSH quality principles include: • Patients are our top priority • Quality is achieved through people • All work is part of a process • Decision making by facts • Quality requires continuous learning and improvement

How do you translate and apply them in your daily work?

Articulate how the principles are applied in your daily work. E.g. [Decision making by facts] Hand hygiene data is used to identify gaps in practice. ‘Before patient contact’ is the worst performing moment and we are initiating improvements to improve that.

What are your department’s quality improvement projects?

Articulate your priority indicators. Demonstrate how you are trending data (use of run chart/column graphs), analyzing data (use of RCA to identify root cause), and improving including key actions based on your analysis (use of PDSA, 6S, CPIP).

QPS Quality and Patient Safety - FAQs Questions

Answers

Where can you get the data? Do you know where to find it?

Quality indicators including falls, medication errors, pressure ulcers are provided from the Quality department. Other Quality Data e.g. Hand Hygiene data can be found in the intranet- QMIS. (Nursing supervisor- refer to the Measures Tool)

What do you do when your department has not met the target set?

If data did not show improvement, explain why and what is being done to address the issues identified. We perform analysis (if RCA is used, can show), implement targeted interventions to address the issues using the PDSA cycle (annotate your chart with the identified issues (analysis) and action plans. Improvements can be articulated as: “ We reduce variation by ….” / “We have achieved target or improvement shift…”/”We are no longer seeing the issues we have previously identified”

What aspect of patient care has your unit improved in the last 6/12 months? What do you intend to improve in the next 6/12 months?

•

How do you manage the adverse incident that happens in your area? What is root cause?

•

Share your priority indicators/department specific indicator/ground-up initiatives Show your charts and explain the trends by referring to the annotations and actions on the charts.

We performed a huddle after an incident. During the huddle, we will discuss the key issues/gaps and identify key actions to prevent the incident from happening again. We also reviewed the events that occurred in our area to identify gaps in practice and opportunities for improvement.

[Be prepared to show the documented RCA (if used), articulate the identified root cause and the resulting action plans].

QPS Quality and Patient Safety - FAQs Questions

Answers

How are staff involve in quality decisions & the resulting quality activities?

Articulate how staff participates in QI initiatives in the department. Show any posters of projects/6S/DIBs, innovations. Share the platforms where improvement suggestions/ideas can be submitted. Examples: • Daily Improvement Board (DIB) • Research /Innovation fund

What is a culture of safety?

A culture of safety is a culture that is open and fair. Being open and fair means that staff can share information openly and freely, and are given fair treatment when an incident happens.

How do you promote such a culture?

Acceptance that safety is a priority and responsibility at all levels Understanding that human make errors and that the system should be made robust in preventing and mitigating errors, while upholding the principle of accountability- Use Just Culture tool to guide management of staff post event. • Non-punitive approach to adverse events/incidents • Encouragement and recognition for error reporting • Learning from errors and sharing in a transparent and open manner • Open conversations among peers about errors and near-misses

MPE Medical Professional Education - Important Points Job description of medical students in TTSH Job descriptions on roles & responsibilities of medical students can be found in the TTSH intranet under PPEO Portal.

Hospital orientation programme for trainees* All medical students undergo a hospital orientation including the following programmes on quality care and patient safety: • Hospital quality & patient safety programme • Infection control programme • Medication safety programme • The international Patient Safety Goals • All other required hospital orientation, including at the department and unit level • Any ongoing required education

Supervision required for medical trainees • All medical students are under direct supervision of the assigned clinical teacher / faculty members. • Residents are under direct or indirect supervision according to their demonstrated competency. It is defined in JD as well. • All residents are only allowed to perform procedures and prescribed medications that they are taught and are familiar with. All medications that are new or unfamiliar will be raised to supervisors for advice.

* Trainees refer to medical students and residents

Supervisors will ensure that students participate in and have familiarised themselves with the programmes. All residents undergo residency orientations, department orientations and patient safety workshops. 37

MPE Medical Professional Education - FAQs Questions How are the residents and medical students orientated in the clinical units?

Answers Medical students All medical students undergo a hospital orientation including the following programmes on quality care and patient safety: i. Hospital quality and patient safety programme ii. Infection control programme iii. Medication safety programme iv. The International Patient Safety Goals v. All other required hospital orientation, including at the department and unit level vi. Any ongoing required education. • The medical students will be supervised by their clinical supervisor and oriented to the layout of the clinical units. • They are also encouraged to approach nursing staff if they are in doubt during the attachment to the clinical unit.

Residents • All residents undergo residency orientations, department orientations and patient safety workshops. • The residents are given an orientation checklist which has to be completed within the first week of their commencement to work period in the hospital. • The residents will need to approach the nursing staff in the clinical unit to complete their checklist requirement.

MPE Medical Professional Education - FAQs Questions How do you identify the trainees and medical students from the doctors?

Answers •

All medical students will wear their white coat and school nametag for identification at clinical areas.

•

All residents wear white name tags while senior residents wear black name tags. Their responsibility in the clinical areas are defined in the roster.

How do you know what are the procedures that the residents are allowed to do?

•

What are the procedures that the medical students are allowed to do?

•

List of doctors privileged to perform procedures can be found in intranet. The residents are allowed to performed procedures and it is noted that they are to perform any complex procedure within their scope of practice. It is their professional duty to seek supervision from a senior if they are unsure or unfamiliar with the procedure. Medical students are not allowed to perform any procedure independently but they can if they are under direct supervision of the assigned clinical teacher or faculty member.

•

MPE Medical Professional Education - FAQs Questions

Answers

Are you allowed to act on the traineesâ&#x20AC;&#x2122; instructions?

No from medical students. Yes for residents.

Are trainees allowed to write in patient records (paper or electronically)?

Medical students are not allowed to write in the patientâ&#x20AC;&#x2122;s electronic records Residents are authorised to write in patient record as defined below.

PGY=Post Graduate Year

MMU Medication Management and Use - Important Points Who provides oversight to medication management & use? The oversight is provided by the MMU Chapter and the Drugs & Therapeutics Committee.

Medication Storage Medication Preparation

For information on storage of high-risk medications and Look-alike Sound-alike medications, please refer to IPSG 3 (pg 7).

- Medication must be prepared in a safe and clean environment

Medications shall be stored using EEFO (Earliestexpiry-first-out) principle.

- IV (Sterile) medications are prepared and administered using aseptic technique.

Medication trolleys should be locked when unattended! - Weekly checks for drugs topped up by pharmacy. - Monthly checks by the department staff (using the “Drug Storage Checklist”) and quarterly audit by pharmacy staff - Dispose drugs expiring within 1 month to prevent inadvertent administration of expired drugs.

Patient’s home medication brought into the hospital are: - Identified by the Dr. or pharmacist - Clearly labeled with patient’s name & NRIC number, HAM label as appropriate - Cable tied - Placed at patient’s bedside locker For high risk patients e.g. patients with Psychiatric conditions, suicidal, confusion/cognitive impairment, home medications are kept at medication trolley.

- After preparation, medications should be administered immediately. • Medications not administered immediately must be labeled with name of medication, dosage/ concentration, date prepared and patient’s name. - Multi dose vials once opened, “opened date” and “discard date” must be indicated.

Medication Administration The 5 rights must be adhered to when administrating medication. Stat Dose

To be served within 1 hour

Once Dose

To be served within 3 hours

Regular Dose (e.g. TDS, QDS)

To be served within 2 hours before and after the standard timing 41

MMU Medication Management and Use - Important Points Medication Administration

Controlled Drug (CD) Disposal

Where only a portion of a CD is withdrawn from an ampoule and given to the patient, the remaining volume shall be discarded by a SN in the presence of a witness (a SN or NM/NC). All ampoules should be discarded into the sharps box. The contents of all syringes and infusion bags should be emptied into a biohazardous sharps boxes. For location* with large volume liquid disposals, the sharps boxes should be lined with an absorbent gel pad (photo above). Empty syringes or bags can be disposed of as general waste.

*High volume CD disposal area:

Monitoring & Reporting Adverse Drug Reactions (ADRs) should be reported via CPSS/CMIS and/or using the HSA Suspected Adverse Drug Reactions Report Form. Medication errors are reported via IRIS

- PACU - ICU (include HD) - Procedural rooms â&#x20AC;&#x201C; OT, Endo Centre, NHG 1-Health, DIR, ICL, 2B Endo. - Wards @ L11 & L12 - Wards 83 & 85 - Ward SA 9 For low volume areas with rare usage, to dispose CD content into sharps boxes. Reference: WI-ENV-HSK-007 Disposal Of Pharmaceutical Waste 42

MMU Medication Management and Use - FAQs Questions Tell me who ensures and checks the medication storage area?

Answers For areas where pharmacy performs topping up once or twice weekly, e.g. wards • Top up personal will check for proper storage conditions each time he tops up. For medications in Omnicell • Pharmacy will perform cycle count and storage check every 3 months. For other locations, the nurse will conduct monthly storage check. Reference: WI-PHA-INV-003 Storage and Transportation of Medications

Do you lock up your medications?

All medication storage area including the medication trolleys are locked.

Tell me what are your High Alert Medications?

HAMs are medications involved in a high percentage of errors and/or sentinel events, as well as medications that carry a higher risk for abuse or other adverse outcomese.g. insulins, heparins and concentrated electrolytes. They are stored separately and prescribed with extra caution. HAMs list is available on the intranet TTSH Intranet  Pharmacy Notice board  High Alert Medications.

MMU Medication Management and Use - FAQs Questions What are look alike sound alike medications?

Answers There is a list of medication sound alike medications e.g. ADREnaline & NORadrenaline; gliCLAzide & gliPIzide • Action for Name look and sound alike: convert description to Tall man lettering on dispensing labels and shelf labels, different strengths are highlighted using bold and underline. There is a list of look alike medication e.g. Haloperidol inj & Bromhexine Inj • Action for Product Look alike: Place drugs apart, where possible and highlight look-alike drugs using pink labels. The list is found on the intranet.TTSH Intranet  Pharmacy Notice Board  Drugs Storage  Sound Alike and Look Alike Drugs

How are medications requiring temperatures of ≤ 25°C stored?

Medications requiring ≤ 8°C are stored in the fridge. Other medications are in air-conditioned areas with temperature of ≤ 25°C. • FCC performs monthly Preventive Maintenance for air-con unit • Staff will report to FCC when air-con malfunctions

Why are some emergency kits and trolleys kept in nonair-conditioned locations?

This is to facilitate quick and timely access for emergencies. The integrity of the medications will be checked prior to administration (e.g. if there are any signs of instability such as precipitates). Once expired (or damaged), the emergency kit or the request for drugs in emergency trolleys will be promptly sent to pharmacy for replacement.

MMU Medication Management and Use - FAQs Questions How do you ensure that the drug fridge temperature is within range?

Or What happens if the temperature for the medication goes out of range?

Answers There is a temperature gauge that continuously monitor the fridge temperature (range is 2-8°C). • The alarm will sound if the temperature falls out of range. As the medication prep rooms in the wards have high traffic flow 24hrs a day, any activation of the fridge alarm will definitely be detected and attended to, as the alarm does not go off automatically until someone sees to it. • The door will be checked if it had been closed properly. If the problem persists; • FCC will be informed • Medications will be transferred to another fridge, if necessary. • Pharmacy (Drug information services @ 2016) will also be consulted on the need to transfer drugs and if the drugs can still be used. For outpatient areas / Areas that does not operate 24/7 After Office Hours • Alarm monitoring system will send out an SMS notification to Building Energy Management System Team and on-call Pharmacist/Nurse. • FCC will arrange with a security officer immediately to enter the department immediately to investigate and to rectify the problem. • FCC will contact the on-call pharmacist or the on-call nurse, If the temperature cannot be restored to normal range quickly. • The pharmacy staff or nurse will transfer the medications to another refrigerator. • Pharmacy (Drug information services @ 2016) will also be consulted on the need to transfer drugs and if the drugs can still be used. 45

MMU Medication Management and Use - FAQs Questions Can sample medications be used in TTSH?

Answers Yes.

•Sample medications are stored centrally and dispensed at Pharmacy for SOC.

•Sample medications are stored and dispensed from Inpatient Pharmacy for some subsidy programs.

Who is responsible for Trial drugs?

Trial drugs are usually managed by Clinical Research Unit with Pharmacy oversight. Pharmacy will conduct a drug storage check for trial drugs once every 3 months.

Or What are you required to do if there are trial drugs kept in your area? How do you document wastage of CD?

Trial drugs in the ward (in use for patient) must be labeled with patient’s name and store in locked med cart (or medication fridge, if required)

Workflow depends on type of wastage e.g. single use ampoules, tablets, patch etc. Please refer to 1. Pharmacy Notice Board, TTSH Intranet  Control Drugs (CDs)  CD Procedures (Omnicell departments) or CD Procedures (NonOmnicell departments) 2. WI-PHA-NUR-001 Handling of Controlled Drugs in The Ward, OT, Clinic and other Departments

MMU Medication Management and Use - FAQs Questions What do you do if there is a broken CD?

Answers CD in Omnicell – found in Omnicell bin 1. Remove broken CD from Omnicell 2. Perform “cycle count” to reduce the quantity. 3. Indicate “Broken CD” during discrepancy resolution 4. RN reporting breakage fills up the “Report on Breakage/Wastage/Loss of Controlled Drug(s) in the Wards/Theatres/Clinics” form 5. 3 signatures are required; a. RN who discovered and report the incident b. Witness (RN or Doctor) c. Ward/OT/Clinic manager 6. Return broken/expired drug and form to pharmacy (to bring along CD administration book) *Keep the broken drug in CD cupboard if return cannot be done immediately. CD in Omnicell – After issued to patient 1. Perform “Return to Patient” in omnicell. (DO NOT place broken / expired drugs back in omnicell) 2. During count back, count physical quantity balance/ without broken CD 3. Repeat steps 3-6 as above For Non-omnicell areas 1. Retain physical CD with drug name 2. Call for another RN or Doctor to witness 3. Repeat steps 4-6 as above (Continued on the next page)

MMU Medication Management and Use - FAQs Questions

Answers

What do you do if there is a expired CD?

Please refer to: 1.Pharmacy Notice Board, TTSH Intranet  Control Drugs (CDs)  CD Procedures (Omnicell departments) or CD Procedures (Non-Omnicell departments)

2.WI-PHA-NUR-001 Handling of Controlled Drugs in The Ward, OT, Clinic and other Departments Do you have a process for finding out what current medications a newly admitted patient is taking?

Medication Reconciliation is carried out by the pharmacist upon admission.

Do you allow patients to use their own medications?

Yes, if medication is not available in the hospital. The medication must be identifiable by: • Proper labelling • Not expired • In good condition

Reference: JCI-MMU-HAP-001 Medication Management and Use WI-PHAIPT-008 Medication History Taking and Reconciliation

Pharmacist should check that the drug and dose are correct. The Doctor/ Nurse should indicate in the e-IMR “patient’s own medication”.

MMU Medication Management and Use - FAQs Questions

Answers

Do you allow patients to self administer medications?

Self-administration of medication is not allowed.

What is your process for getting medication during the night or when the pharmacy is closed?

Obtain from other wards. or Send request to Emergency pharmacy.

How do you obtain Parenteral Nutrition? (clinical nutrition team changed term from TPN)

The order is sent to pharmacy

• All medications are administered in the presence of the nurse • Patients are instructed to inform the nurse if medication is required.

• Pre-mixed bag with no alterations/additives can be obtained anytime from the pharmacy. • Orders for customized formulation or premixed with alterations/additives has to be sent to pharmacy before 11am.

How is Parenteral Nutrition Stored?

• Parenteral nutrition must be stored refrigerated (2-8°C) when not due for administration to the patient Reference: JCI-MMU-HAP-001 Medication Management and Use TTSH Intranet Pharmacy Notice Board Premixed Parenteral Nutrition

MMU Medication Management and Use - FAQs Questions What constitutes a complete medication order?

Answers 1. Two Patient Identifiers • Name, NRIC 2. Drug name (generic name preferred) • Dose or strength/concentration • Dose form • Frequency of administration • Route 3. Doctor’s name, MCR number, signature (only in paper IMR, not required in eIMR) 4. Date and Time of order Any cancellation or alteration is initialed against outpatient medication records (OMR).

Who reviews a medication order? Or What is reviewed? How is an appropriateness review conducted? Or What is the process for an appropriateness review?

Doctors & Pharmacists review an order before administration of the first dose for: • allergies • lethal drug/drug interactions • weight-based dosaging • potential organ toxicity (for example, administration of potassium sparing diuretics in patients with renal failure) * Exception: Formal Medication review is not required in an emergency or when ordering doctor is present for ordering, administrating and monitoring of the patient e.g. in the OT or ED, or with oral, rectal, or injectable contrast in interventional radiology or diagnostic imaging where the medication is part of the procedure. Reference: JCI-MMU-HAP-001 Medication Use and Administration

MMU Medication Management and Use - FAQs Questions

Answers

Do you accept verbal orders / Telephone orders?

Verbal / telephone medications orders are not accepted except in clinical settings using the paper IMR and during an emergency situation where delay in administration of medication will result in unfavorable outcome.

What do you do if you are unsure about the medication to be administered to the patient?

• Refer to pharmacy notice board • Refer e-MIMs • Call Drug information service @ ext 2016 • Consult ward pharmacist or contact on call pharmacist (through operator) after office hours

Are pharmacists available 24hrs?

Yes, on call pharmacist can be contacted through operator or HMS after office hours.

Or Are pharmacists available after office hours? Do you prepare chemotherapy here?

No, cytotoxic drugs are reconstituted at the pharmacy. Cytotoxic drugs dispensed by the pharmacy will be labeled with the word “CYTOTOXIC”.

Do you clean the medication trolley?

Yes, the medication trolleys are cleaned before and after each medication round. (Ensure medication trolleys is kept clean, neat and tidy, there will be checks on cleanliness)

MMU Medication Management and Use - FAQs Questions Do you prepare IV medications in this unit? Where do you prepare it? Show me.

Answers IV medications are prepared on the IV injection trolley in the preparation room using aseptic technique. • Remove any items not required from preparation area • Disinfect preparation area with alcohol wipes • Perform hand hygiene • Reconstitute IV medications using aseptic technique • Perform hand hygiene before patient contact

*After preparation, medications should be administered immediately. • Medications not administered immediately must be labeled with name of medication, dosage/concentration, date prepared and patient’s name References: JCI-MMU-HAP-001 Medication Use and Administration, WI-PHA-INV-003 Storage and Transportation of Medications Do you keep Multi-dose medication? What is your policy on Multi-dose medication?

Multi-dose medication, e.g. Insulin Multi-dose vials once opened need to be dated with “open date” and “discard date”. E.g. Insulin, discard period is 4 weeks once opened. Reference: Pharmacy notice board  Drug Storage Discard Date for Medications and Disinfectants: 1.List of Items, Discard Dates and References 2.Recommended Usage on Multi-Dose Vials

What precaution do you observe when administrating medications?

5 Rights Right Patient, Right Drug, Right Dose, Right Route, Right Time. Reference: JCI-MMU-HAP-001 Medication Use and Administration

MMU Medication Management and Use - FAQs Questions For areas using Guardian feature Do you set limits to your infusion pumps? What do you do if the pump alerts that the dose is out of range?

Answers Dose limit is preset when the Guardian Feature mode is selected *The doctor (registrar or above) should inform the nurse if dose prescribed falls outside the preset dosing limits, and document in the medical notes. If the pump alerts on dosing entry, the nurse will recheck if dose entered correctly. Pump “Override” is done after confirmation with Registrar. Nurse is to document the name of doctor who agrees to override and prescribed dose, in patients notes.

What do you do when a medication is recalled?

Recalls are made through pharmacy • Pharmacy will inform of product recall with details including product’s name, strength, batch number etc. Patient care areas will retrieve products from storage areas (including medication trolley) and set aside the recalled product 1. for collection by pharmacy, or 2. returned to pharmacy, together with the “Goods Return” form.

What is a medication error?

A medication error is; A preventable event that may occur at any step of the medication use process (ordering, transcribing, dispensing, administrating and monitoring). It may lead to inappropriate use or jeopardize patient safety.

What is a near miss?

A ‘near miss’ is an event or a situation that could have resulted in harm but did not, either by chance or through timely intervention. It must be monitored, documented and reported within 24hours via IRIS. Staff who are accountable for taking action on the reports are notified. 53

MMU Medication Management and Use - FAQs Questions What do you do when there is an medication error?

Answers When a medication error occurs; • Patient’s vital signs will be monitored • The doctor will be informed immediately. • The nursing officer will be informed and the event will be reported in the Hospital occurrence reporting system (IRIS) within 24hrs. Reference: JCI-MMU-HAP-001 Medication Use and Administration

What do you do If a patient has an Adverse Drug Reaction (ADR)?

If an ADR is observed, patient will be assessed (closely observed) and the doctor informed immediately.

How are drug allergies / ADR reported?

Clinically important or serious adverse drug reactions are reported within 24 hours to: • IRIS • CMIS (Critical Medical Information System)

Attending doctor documents details of: • Allergies • Expected or unexpected adverse effects • Description of the reaction • Action taken • Outcome

Attending doctor submits HSA Adverse Drug Reaction Form to Pharmacy or online and this will be forwarded to the Health Sciences Authority.

PFR Patient Family Rights - Important Points Patient’s right confidentiality

Our patients receive information on available care and services and how to access these services. They are also informed about their rights and responsibilities. These information are made available in the Patient’s Charter. Patient’s Charter is • given to all patients in the financial counselling pack • displayed in all wards • available in 4 languages (English, Mandarin, Malay, Tamil) on the TTSH Intranet  JCI Gold Seal  PFR Chapter Materials  Patient’s Charter  English/Mandarin/Malay/Tamil

privacy

and

We respect patient’s right to privacy and confidentiality in our daily care activities: • NOT holding patient-related discussion in public areas. • NOT posting confidential information on patient’s headboard. • Patient is interviewed, examined and undergo treatment in surrounding designed to give reasonable visual and hearing privacy. • Do not leave patient’s medical record unattended. • Log off any EMR when not in use. Religious and spiritual needs • All patients are screened for religious / spiritual concerns on admission (Nursing Assessment Record, NAR).

* Refer FAQs for details Translation Service Likelihood of students and participating in care process

trainees

• Resource for translation services are available in Intranet Translation Services

• This information is provided to patients in Patient’s Charter. • Patient’s permission is sought when students and trainees are involved.

PFR Patient Family Rights - FAQs Questions Tell me how the hospital address in-patient’s religious / spiritual needs

Answers Religious/spiritual needs are assessed and support is provided if required. If a patient or family member expresses spiritual/religious needs, the doctor / nurses can: • Refer the patient/ family to his or her regular place of worship. • Refer the patient to appropriate religious organisation found in Annex A of JCI-PFR-HAP-008.

• Refer the patient to an appropriate counsellor. Tell me how do you address the patient or family’s request to perform religious/spiritual ritual in the ward/unit

Religious service or worship can be carried out in Patient Care Rooms.

If the patient is isolated and required religious support, we will educate the religious leader on isolation precaution.

Or What about patient in isolation room?

PFR Patient Family Rights - FAQs Questions

Answers

Tell me how are patients protect from physical assault?

• When a patient/visitor or staff exhibits aggressive behaviour that results in substantial risk of harm to self and or others, ward staff will call security officer and or press Panic Button to call for assistance. • If the violence person is a patient, the primary doctor will be called to consider administering medication to sedate or calm the patient. • If the violence person is a visitor or member of public, police assistance will be sought when pacifying him or her is futile.

Tell me how is patient informed of any unanticipated outcome of care?

The attending doctor and team will inform the patient of his/her progress during daily round including any unanticipated outcomes of care post intervention. For severe unanticipated outcome requiring immediate measures, they would be informed by the attending doctor soonest possible.

Tell me the process when a patient/family requests for a second opinion?

• The attending specialist doctor will first offer a choice from the List of TTSH specialist doctors. • If patient/family does not wish to choose from the list, the attending specialist will offer a list of visiting consultants appointed by TTSH.

• If patient/family insists on seeking second opinion from his/her preferred Specialist doctor who is not accredited by TTSH, the attending TTSH Specialist doctor will seek approval first from the HOD and CMB.

PFR Patient Family Rights - FAQs Questions Tell me how is a DNR order issued?

Answers • Attending doctor will discuss with patient and or family. • Doctor will document the agreed extend of care

Tell me what do you do when faced with ethical dilemmas when caring for patients?

• Consult direct supervisor or HOD • Hospital Clinical Ethics Committee is available for consultation – Put up blue letter referral and call extension 8350/8342/8362 – Email case details to clinicalethicscommitte@ttsh.com.sg

Tell me the process should a patient / family have any complaints or conflict?

• Staff will escalate to Nurse Manager/Senior Nurse Manager (Unit) if unable to handle • Doctors are consulted of there is any clinical issue • Patient’s Charter is available with information on the contact number to PRS

Tell me the procedures that require written consent?

Written consent is required for • Surgery • Anaesthesia • Use of blood and blood products • Other high risk procedures and treatments e.g. chemotherapy, radiotherapy, biopsy, sedation

(Refer to JCI-PFR-HAP003 Consent taking for procedures and Treatments for details)

PFR Patient Family Rights - FAQs – Questions Tell me the process for taking consent for operation/procedure/ treatment?

Answers The following should be explained to the patient/ legal guardian during consent taking for operation/procedure/treatment: • Patient’s medical condition • Nature of treatment • Site of operation • Potential benefits of the proposed operation/procedure/treatment • Main risks and complications • Consequences of declining • Alternatives treatments • Transfusion of blood/blood products (if necessary) • Photography for medical treatment or related purposes The attending doctor must document in the case notes that the above have been explained.

What do you do if the patient does not speak English?

• Check if any staff in the ward/nearby speak the patient’s language

Do you use family members as interpreters for consent?

• Family members, are used as the last resort

• If not, refer to Intranet for internal resource of translation service

PFR Patient Family Rights - FAQs – Questions Tell me the process of consent taking when a patient is incapable of giving consent

Answers Patient’s Legal Guardian Or Emergency • 1 Associate Consultant (AC) and above can authorise the treatment Elective situation • 2 ACs and above can concur and authorise medically-indicated procedures, which are in the best interests of the patient

If the treatment is significantly complex and patient is at high risk of morbidity & mortality, the 2nd AC should be skilled in the specialty or independent of the care of the patient. After Office Hours • Registrars can sign on behalf of the AC after getting authorisation • Consultant must sign on the consent form the next working day Decisions are discussed and communicated with relatives, and made in the best interest of the patient

PFR Patient Family Rights - FAQs – Questions

Answers

Tell me the validity of the consent

Operations/Procedures • 6 months. If there is any material change in the nature, purpose or risks of the operation/ procedure within the 6-month validity period, and/or if an alternative or additional operation/procedure is proposed, a fresh consent is required.

Or How long is this consent valid for?

Chemotherapy • 12 months*, if it is a continuation of the original treatment and there is no significant change in the treatment objectives and risks. *Blood transfusions consent when taken within the context of chemotherapy is valid for a series of blood transfusions if the indications and risk-benefit considerations remain the same. If there is any material change in the patient’s disease or nature and purpose of the treatment, then a new consent has to be taken. Acupuncture • One treatment cycle Consent must be reaffirmed verbally and documented at each treatment episode. The consent should be re-obtained with a new consent form should there be any change in the clinical condition of the patient that would alter the risk-benefit considerations

PFR Patient Family Rights - FAQs Questions

Answers

Tell me about the care you provided to your vulnerable groups of patients

• The vulnerable elderly –limit transfer to reduce disorientation; assessment and management should include maintaining fluid balance; pain management; pressure ulcer risk management; falls and immobility; continence risk; depression; polypharmacy; end of life/palliative care.

(Refer to JCI-PFR-HAP-011 Care for the Vulnerable Groups of Patients for Details )

• Elderly with dementia or cognitive impairment – appropriate referral to be made to diagnose, treat and manage the condition and behaviour; facilitate career support and respite care. • Children – involve family/guardian in the care; assess family’s ability to cope and needs for support; confirm identify of career before discharge home; Where there are concerns regarding child protection, the hospital should ensure that the children are not discharged until there is a plan in place to ensure his/her safety.

• Individual with development disability - be sensitive and responsive to the needs of these patients, and render appropriate assistance; referral to relevant healthcare professionals to provide a more comprehensive evaluation for patients. • Disabled patient - communicate with them, assist in feeding and familiarise with specialised aids and equipment.

• Comatose patients - Refer to JCI-COP-HAP-004 • Elder mistreatment –if a case is suspected, doctor in-charge will engage other health care professionals to assess the need for care/protection. Patient is encouraged to lodge police report if warranted. • Child abuse and neglect – referral to arrange for professional assistance.

PFR Patient Family Rights - FAQs Questions Tell me how the hospital safeguard patient’s belonging?

Answers * Refer to following documents for details: • WI- NUR-GEN-008 Collecting Patient’s Property in the Ward (Itemised and Non-itemised Process) • WI-ADS-ADM-001 Safekeeping of Patient’s property • WI-EMD-DOC-006 Collecting Patient’s Property in the Emergency Department • WI-EMD-DOC-009 Safekeeping of Patient’s Valuable Property from Ward/Emergency Department • WI-NUR-1Health-007 Safekeeping of Patient’s Property at Endoscopy Centre • WI-NUR-DSC-007 Safekeeping of Patient’s Property at Day Surgery Centre • SD-NUR-PAC-004 Safekeeping of Patient’s Property in Post Anaesthesia Care unit • Patient/family are advised to bring home valuables or have the valuables be sent for safe keeping • Each property bag should be sealed • Patient’s NRIC, work permit, driving license and passport shall be placed separately in a clear plastic bag and transfer to Security office • All staff must wear ID • Registration is required for all visitors entering the wards. Suspicious visitor will be approached.

Management of Information(MOI) - Important Points -

Maintain privacy and confidentiality of information • • •

• •

Protect medical records from loss, destruction, tampering and unauthorized access. No records should be left unattended. Access to electronic clinical information systems is via unique user IDs. Sharing of individual user IDs and passwords is prohibited. Clinical system should be logged out when not in use to ensure the security and confidentiality of patient information. Only authorised personnel can make entries in patient record.

Abbreviation (Intranet JCI icon TTSH abbreviation list) • • •

Use only abbreviations and symbols from the approved “Master” list Do not use abbreviations in the “Do Not Use” list. Abbreviations are not allowed in consent forms and documents that patients and families receive from the hospital about patient’s care, e.g. discharge summary and education material.

Reference: JCI-MOI-HAP- 002 Clinical Documentation & Information Management

Good documentation practice • • •

•

• •

Medical records should be up-to-date, legible, complete and accurate at all times. All the entries shall be documented legibly with date, time, name (use name stamp on hardcopy form) and signature. Any alteration to the medical record should be indicated with a single line drawn through the incorrect entry and initialled. The original entry should readable. Any additional notes may be added as part of the medical record with explanation for the addition. The additional notes should be dated, timed, with the author’s name and signature. It must not be written in between existing entries. All sections of the medical record should be filled. Fill in with “NA (Non Applicable)” for section not required to complete. Entries by students should be countersigned. 64

Management of Information(MOI) - Important Points To Do: • Verify information belongs to the correct patient using 2 patient identifiers • Ensure the information accurately reflects the patient’s current status. Content should be verified to avoid incorrect or unnecessarily long entries • Attribute to the appropriate provider or record for any materials copied. (E.g. State date, time, original author and note location if this information is essential for continuity of care).

“Copy and Paste” guidelines • •

• • • • •

Involves selection of data from an original or previous source to reproduce it in another location. Associated with risks of inaccurate information leading to potential harm when the information pasted was not reviewed and updated to reflect the correct patient and current status of the patient. Healthcare providers documenting in the electronic medical record are responsible for verifying the accuracy of the information. Do not copy and paste freely If inaccuracies are discovered, the original author, care team or consultant in charge of the patient is to be notified. If the electronic record is locked, a new record is to be created to state the mistake in the original record. If the electronic record is not locked, the content should be rectified with date, time and author clearly stated to reflect the authorship of the correction.

Not To Do: • Copy the signature block of a completed note into a new note. • Copy data or information in such a way as to imply that a healthcare provider is involved in the care of the patient when the healthcare provider is not. • Copy entire laboratory, pathology, radiology or other information in the health record verbatim into progress notes when it is not specifically addressed or clearly pertinent to the specific current patient problem. Reference: JCI-MOI-HAP- 002 Clinicat Documentation & Information Management

Management of Information(MOI) - Important Points Health Information Technology System Downtime •

• •

System downtime can occur as planned/scheduled or unplanned/unscheduled. It is a part of staff orientation program and is conducted for every new nurses. Downtime procedure will be included in the training for any new clinical system deployed.

Downtime communication Workflow a)

Level of downtime contingencies process for key clinical systems

a) Planned/scheduled downtime ITD will circulate announcement w via internal email 7 days before downtime. Supervisors to disseminate the information to the ground staff during roll b) call. Unplanned/unscheduled downtime Department key users and Point of Contact (POC) will be notified through HMS who will in turn inform the ground staff to start downtime workflow.

Staff can refer to treatment/medication orders via local backup laptop for CCOE/eIMR, and C-doc direct login App for Read access only. If documentation is required, • Print the eIMR-iMAR and CCOE eOrders downtime report from local backup laptop and document any changes on the printed report. • Print relevant hardcopy forms from DES (Xerox photocopier) for documentation. • Refer to data recovery process of individual system on workflow of filing hardcopy report or transcribing to clinical systems. In the event Document Efficiency System (Xerox photocopier) is also not available, retrieve the hardcopy forms from the Downtime Kit.

Reference: WI-NUR-GEN-027 Downtime Procedure for Inpatient Health Information Technology Systems

Management of Information(MOI) - Important Points Document Retention Period Medical Record Category

TTSH Retention Period

Paper Records (Not Digitized) Inpatient Medical Records

Lifetime + 15 Years

ED Medical Records

6 Years from Visit Date

Outpatient Medical Records

Lifetime + 15 Years

Outpatient Allied Health / Pharmacy Medical Records

6 Years from Visit Date

High Risk (eg. Medico Legal, PRS Complaint Cases)

Lifetime + 15 Years

Mental Incapacitated (eg. PSY Cases)

Lifetime + 15 Years

VIP Medical Records

Lifetime + 15 Years

Clinical Trial & Research

Lifetime + 15 Years Paper Records (Digitized)

All digitized versions of Inpatient / Outpatient Records

Destroy 1 year after scanned (Applicable medical records which are EA certified and uploaded by DDU)

Others Diagnostic Radiology Images

6 Years from Visit Date

Computerized/electronic medical records

Lifetime + 15 years, to de-identify thereafter

Reference: QP-HIS-RET-001 Medical Records Retention Guidelines 67

Management of Information(MOI) - FAQs Questions Tell me what happens when a patient request for their medical records?

Answers • •

•

How do you ensure only authorized person enters the patient’s record?

•

• • • •

Are you able to access all the files of the patient?

• •

Patients can request for their medical records through HIS. Copies of Lab and X-ray reports may be released upon patient's request. It is not the usual practice of the hospital to release entire medical records to patients. Patient's medical records are provided to the Court/Police/other government registries/agencies under the Law. Only authorized persons (identify by badge) are allowed in the wards. Anyone without badge ID will be questioned & identity will be verified. Access to electronic clinical information systems is via unique user IDs. Sharing of individual user IDs and passwords is prohibited. Unattended computers are logged off. All staff should use their name stamps when making entries on hardcopy forms. Regular medical records audit is conducted . Individuals are authorized to gain access to patient’s clinical records based on need and defined by job title and function. Read-only access for staff not involving in patient care but require access to the systems.

Management of Information(MOI) - FAQs Questions

Answers

Tell me, how do you protect patient’s confidential information?

•

How is the use of abbreviations being monitored?

•

Tell me, how are you notified in an event of system downtime?

•

• • •

•

Do not disclose, whether directly or indirectly, patient’s information to any unauthorised persons. Do not leave records unattended in open areas. Unattended computers are logged off. Where possible, computer screens are displayed such that they are not readily viewed by passers-by.

The hospital has a list of approved abbreviation which is available on TTSH Intranet. The use of non-approved abbreviations will be picked up during medical record audits.

Staff will be informed of system downtime by department supervisor. For scheduled downtime, ITD will circulate announcement via internal email 7 days before downtime. For unscheduled downtime, key users will be notified via HMS. Document on hardcopy forms printed from DES or local backup laptop (for treatment and medication orders). If DES is also down, retrieve the hardcopy forms from Downtime Kit.

Rule 1. 2. 3. 4.

Be familiar with the escape route plan of your unit/area Know location of fire extinguisher, hose reel and fire alarm. (Type of fire extinguisher) Follow fire warden’s instruction Do not go near fire scene. Take alternative route to designated assembly area. All staff attends the annual fire drill.

Rescue all person in immediate danger

Activate fire alarm with breakglass callpoint. Call FCC or FRC Hotline: - Main block: Ext 5555/6357 8822 - Annex 1: Ext 8823 - Annex 2, CDC1/2, 144/142, FLC, Blk 101: Ext 3988 - Renci security/FCC: 6355 6444 - AMKH FCC: Ext 200/6450 6200 - NHG 1 Health: 995

from side to side

Fire Evacuation and Assembly Place In the event of an evacuation, proceed for: • Horizontal evacuation (Designated holding area) then • Vertical evacuation (Designated assembly area)

Designated assembly area for TTSH are: Contain fire by closing doors

Extinguish fire with appropriate extinguisher if safe

• Annex 1 & 2: CDC 2 Open Carpark (Behind guard house) • Atrium/Podium, Medical Centre & NNI: Irrawaddy Road (Covered Walkway) • CDC 2, Tower Block: Annex 2 Open Carpark (In front CDC 2 Guard House) • Emergency Block: CDC Open Carpark (In front of the screening centre) • FLC (Blk 101): Jalan Tan Tock Seng Walkway • TBCU: Open Field Keep Fire Safety Card with you at ALL TIMES! Everyone is a FMS Staff! 70

Security Stay Safe Principle (Terrorist Attack) Run away from danger if escaping is not possible Hide and stay out of sight Tell by calling 999 or SMS 71999 if unable to talk (provide nature of emergency and location)

Blood Spills/Cytotoxic Spills Kits Know where the blood spill/cytotoxic spill kits are kept. (Refer to E copy @ NOOG) Know how to use items in the various kits to contain blood/cytotoxic spills. There is a preventive maintenance (PM) program for equipments. “Scheduled date” and “Date checked” must be clearly legible on the PM card. Staff is trained to operate and safely use these medical equipments: • Baxter Pump • Dinamap with MDI • Syringe Pump • Pulmo Aid • Pulse Oximetry • Continuous Feeding Pump • Thoracic Pump • Glucometer (Others as relevant to job requirement)

Safety Data Sheet • Informs a list of hazardous materials and handling of spills • Found at all nursing units • Updated and accessible to all staff including housekeeping Can be found at: Intranet Noticeboard Pharmacy Notice Board Drug Storage SDS

Ensure all items are not expired and in good condition.

Proper disposal of waste Clinical waste must be properly segregated, handled, transported and disposed to: • Ensure appropriate and safe disposal of hospital waste • Protect healthcare workers and handlers from exposure to infectious diseases • Ensure no cross infection or outbreak of diseases through improper handling of hospital waste 71

FMS Facility Management and Safety - FAQs Questions

Answers

Tell me, what would you do in the event of fire?

Rescue all person in immediate danger Activate fire alarm with breakglass callpoint Contain fire by closing doors Extinguish fire with appropriate extinguisher if safe

Tell me, how would you do when a non ambulant patient caught fire?

• Wet a large piece of linen and put out the fire by covering the patient. • Close off supply of oxygen to any equipment involved if it would cause harm to the patient.

What comes next after you rescued the patient?

Break the “breakglass” call point with a hard object and press the button to activate the fire alarm.

Tell me, how do you know the fire extinguisher is suitable for your department?

We will check the expiry date and the last check as labelled on it. Operating theaters and Clinic B1B Halotron fire extinguisher and ABC Dry Powder MRI Suites Non-Metalic Halotron All other areas *ABC Dry Powder Do Not Use Water! *ABC refers to Class A (carbonaceous), Class B (flammable liquid) & Class C (flammable gas) fires. It is also suitable for use on live electrical fires.

Tell me, how do you know if the hose reel could extinguish the fire at your location?

The hose reel can be extended to 30meters and the projected water could reach up to 6 meters.

Tell me, how do you know it is suitable to evacuate your patient?

We will listen for the Public announcement system. Instruction can also come from Fire Safety Officer, Fire Warden, Company Emergency Response Team and Reporting officer. Designated holding area for horizontal evacuation Designated assembly area for vertical evacuation.

FMS Facility Management and Safety - FAQs Questions

Answers

Show me, where would you go in the event of fire?

• Articulate and be familiar of the fire escape route in your department. • Ensure the “exit” signs are lit and leads to the escape route. • Be familiar to your fire escape doors. They only opens one way. • Escape route shall not be blocked.

Tell me the last fire drill in your hospital.

It is compulsory for all staff to attend the fire drill. Articulate and share when did you last attended a fire drill.

Tell me, how do you prevent the fire from spreading?

• We will contain the fire if possible and turn off the medical gas valve when patients are evacuated from the fire zone. • The fire ambassador/warden/supervisor on duty are authorized to turn it off.

Tell me, how are you juniors prepared in the event of fire outbreak.

• They are being briefed during the hospital orientation and unit based orientation on RACE, PASS, PORTS, horizontal and vertical evacuation. • They will also participate in the annual fire drill.

Tell me, what are the possible hazards that are likely to happen in your hospital?

Fire hazards, Electrical failure, Chemical spillage, Blood spillage and Needle stick injury

Tell me what happens if you see someone smoking in the hospital?

• Smoking is not allowed in the hospital

Tell me what happens in a event of power trip?

Our critical equipments are plugged into: GW: Emergency supply socket (Red switch) ICU/OT/HDU: Uninterrupted Power Supply (UPS) (Green Switch)

• We would ask the person to stop smoking. • We will activate security if the person do not comply.

FCC will be notified.

HRP Human Research Program

Important Points

1. General Information Ethics Before any research can commence, the proposal has to be reviewed by the institutional ethics review board, in our case, the NHG Domain-Specific Review Board (NHG DSRB) or Singhealth Centralised Review Board (Singhealth CIRB). Consent taking in research Consents are taken by Principal Investigator (PI)/designated study team member. This is done using the standard consent form.

2. Ward Nurses “Clinical Trial Alert” in CPSS Patients who are enrolled in clinical trials will have a ‘Clinical Trial Alert’ in CPSS. Nurses could refer for PI and study coordinator’s contact details. The alert will have the following information: This patient is participating in a clinical drug trial (Short name of study) from (consent date) to (expected end of follow up date). If the patient is admitted to the ward or being seen in ED or if you have queries, please contact Dr (Investigator’s name) at xxxx or study coordinator Ms (xx) at xxxx. Patient Information Sheet (PIS) Nurses can refer to PIS filed in the patient’s medical case notes for PI’s contact details & the potential side effects related to the study drug. Responsibility during an Adverse Event Perform necessary assessment. Inform primary team, as part of standard care. Inform study PI/study coordinator.

Participant withdrawal Refer participant to contact Principal Investigator (PI)/study coordinator as found in PIS.

3. Principal Investigator (PI) Training and qualifications PI will ensure that all team members are qualified and trained for designated tasks & fulfill the minimum training requirement for research and are familiar with hospital standard operating procedures found on intranet. Subject recruitment and screening PI or study coordinators will carry out recruitment and screening activities. Only those healthcare personnel that is involve in the patient’s clinical care can make the first contact with patient with regards to research. If the PI or study coordinator is not involved in the patient’s clinical care, they should work with individuals who are involve in the patient’s clinical care to make the first contact. New Investigator Refer to Investigators manual which can be found in the intranet and all research polices and guidelines that are found in the intranet for information on proper conduct of research.

More information available at www.research.nhg.com.sg

4. Patients and Families Information available for patients and family: Clinical Research and Innovation Office (CRIO), URL: http://www.ttsh.com.sg/clinical-research-unit/ E-mail: CRIO@ttsh.com.sg 74

HRP Human Research Program - FAQs Ward Nurses

Questions Tell me, how do you know if a patient is recruited in a research program?

Answers If patient is recruited in Outpatient, It would be indicated in the clinical alert system that patient is on clinical trial. If patient is recruited in Inpatient, the study coordinator will indicate the patient’s participation in Cdoc and also indicate in the clinical alert system. Nurses are to document that patient is in a research programme in the Nursing Kardex. Also, the nurses can refer to the Patient Information Sheet (PIS) filled in the patient’s medical case notes as a reference.

Show me more about the research protocol your patient is involved.

Show the PIS in the casenotes. Nurses can access the PI/Study coordinator contact details to enquire further on the research protocol.

Tell me, what are the possible adverse events related to the study drug/medications?

Nurses may refer to the section on ‘Possible Risk and Side Effects’ in the Patient Information Sheet (PIS) as filed in the patient’s medical case notes.

Tell me, what happens when your junior informs you that the patient deteriorated?

Nurses will first perform the necessary assessment and inform the primary team as part of the standard care, and the PI/Study Coordinator. The study coordinator will be responsible to report the adverse event in hospital reporting system as well as to submit a UPIRSTO (Unanticipated problems involving risks to subjects or others) to DSRB.

Tell me, what happens when a patient informs you about their unwillingness to participate in the study?

The nurses can refer the participant to contact the PI/Study coordinator as stated in the PIS on his/her decision to withdraw from the research study.

HRP Human Research Program - FAQs Principal Investigator (PI)

Questions

Answers

Tell me, how do you know the research team member are qualified to embark on a research study?

PI will be the key person to ensure that all team members are adequately qualified to perform the tasks that they are designated to do and are adequately trained to embark on a research study and had fulfilled the minimum training required for research and are familiar with hospital standard operating procedures pertaining to research work.

Tell me, how will the PI be informed when the research participant is admitted to hospital?

- Patients are required to carry a research card to indicate that they are in research and to inform the study coordinator when they go to A&E and when they are admitted. Once informed, coordinator will inform the PI - Clinical Trial Alert in CPSS with contact details. Ward staff or primary doctor will inform PI or study coordinator when clinical alert indicated that patient is on a clinical trial.

Who is involved in the subject recruitment?

The PI, investigators or the study coordinators will be responsible for patient recruitment. The PI will discuss with study team on the recruitment and screening strategy which need to be approved by the IRB. Any informed consent process will be done in a conducive environment which provides potential subject the privacy and confidentiality required.

Tell me, how does the patient receive further information regarding the research?

The PI or study coordinator will explain the study requirement through the Patient Information Sheet as a reference.

Patient and Family Education - Important Points Patient and family education •

Helps patients better understand & participate in their care & make informed care decisions. Begins as patient enters the health care institution and continues throughout the entire hospitalization. This information is shared among multidisciplinary healthcare team

•

• •

•

Educations includes knowledge • during the care process • after discharged to another site or home PFE needs to be available in various formats to meet the education needs of the patient population. All health care professionals must be able to locate education documentation of other family group

Nurses assess patient’s and family’s education, language, learning capacity and barriers in the revised PFE form . Medical, Allied Health and Pharmacist can refer to ‘Section A of inpatient PFE form’

*Out patient PFE form remains unchanged

Patient and Family Education - FAQs Questions

Answers

Tell me who does the patient and family education

The doctors, nurses, therapists and staff providing direct patient care.

Tell me who assesses patient’s & family’s education, language, learning capacity and barriers

The nurses. Medical, allied health and pharmacist can refer to ‘Section A of inpatient PFE form’

Tell me how do you conduct patient’s & family’s education?

We identified learning barriers, needs, willingness to learn and preferred learning method.

Tell me how do you assess patient’s & family’s ability to learn & willingness to learn?

Patient and family are asked if they are willing to learn.

Show me where do you document PFE

*Show the surveyor PFE form

•

Nursing to document in the inpatient PFE form. Allied Health and Pharmacy to document education their respective case-notes.

Multidisciplinary healthcare team is able to share and refer to the PFE information in the documents to coordinate care and focus on what patient’s needs How do you conduct PFE for patients who are uncommunicative?

Identify and educate alternate learner. Assess alternate learner’s learning barrier, need and preferred method.

ASC Anesthesia and Surgical Care - Important Points Procedural Sedation Is performed by doctors who have been certified after undergoing a procedural sedation course. Patients on procedural sedation are monitored by nurses who has been trained likewise. Prior to sedation administration, the following must be completed: • Pre procedure assessment • Pre sedation assessment • Time Out Upon completion of procedure, Sign-Out must be done. (IPSG 4)

Anesthesia Care Pre-anesthesia assessment is performed for patients undergoing anesthesia. Patients / NOKs are educated on risks, benefits, and alternatives of anesthesia. The anesthesiologist provides such education. Informed consent is required for: • Surgery • Anesthesia • Transfusion of blood & blood related products • Other high risk treatment and procedures stipulated in TTSH policy e.g. chemotherapy, radiotherapy, allergy challenge test & invasive scopes. JCI-PFR-HAP-003 Consent Taking For Procedures and Treatment (Annex 1-9)

List of Doctors accredited to perform Moderate sedation

ASC Anesthesia and Surgical Care - Important Points Workflow of Implantable Medical Device Recall in TTSH

For OT, Endo, DI, ICL and Dental JCI-ASC-HAP-003 Management of Medical Implants in TTSH

Workflow for administration and monitoring of intravenous sedation in the General Ward For invasive procedure in General Ward

Planned under IV procedural sedation?

Pre-procedure, Registered Nurse to perform the following: • Print procedural sedation form from Xerox. • Confirm with Dr if he/she is accredited with a valid certificate to administer procedural sedation. • Ensure qualified nurses are around to monitor the patient. • Ensure patient is fasted 2 hours (clear feeds) or 6 hours (milk/solids) and consent for procedural sedation is taken prior to procedure.

• Procedurist to perform and document the pre procedure & pre-sedation assessment. • Put patient on ECG, SpO2, pulse rate and BP monitoring. • Assist in procedure, conduct time out for the procedure During procedure, Trained Nurse to: ▪. Perform continuous monitoring of ECG, pulse rate, oxygen saturation. Chart BP, pulse rate and SpO2 every 5 mins. ▪ Check and chart level of sedation every 5 -15 minutes where appropriate. Post procedure, Trained nurse to perform 5 mins monitoring of the patient until patient is awake, BP within 20% baseline, stable respiration with SPO2 >95% Patient meets criteria for discharge from procedural sedation

Dr/Trained Registered Nurse is to discharge the patient from sedation monitoring and to complete documentation

In the event that procedure cannot be done without IV procedural sedation (e.g: patient becomes restless) Registered Nurse to 1. Inform Dr of the Procedural Sedation policy. 2. Confirm with Dr if he/she is accredited with a valid certificate to administer procedural sedation. 3. Ensure patient is fasted for 2 hours (clear feeds) or 6 hours (milk/solids) prior to procedure and that consent for procedural sedation is taken prior to procedure. 4. Make sure qualified Nurse is available to monitor the patient. 5. Prepare equipment ECG and SPO2 monitoring. 6. Know where to get reversal drugs.

This Workflow applies to IV administration of sedative for procedure ONLY (e.g M&R, lumbar puncture or minor surgery) This workflow does not apply to sedatives used in certain clinical scenarios such as resuscitation, cardioversion, delirium, confused patients etc.

Inform Dr, continue monitoring, standby reversal agents

Continue monitoring for 30min if patient receive reversal agents and record in IRIS

The criteria for discharge from monitoring Time - 10 min since the last top of IV sedation Reversal of sedation - patient is awake or awakens to gentle calling or back to baseline Stable hemodynamics - blood pressure and pulse rate within 20% of baseline Stable respiration – spontaneous breathing with O2 saturation back to baseline or >95% on room air /  2L/min oxygen. 81

Workflow for administration and monitoring of oral/intramuscular sedation Request for oral/intramuscular procedural sedation Pre-procedure check 1 Print out procedural sedation form from Xerox. 2 Check with the doctor the time for procedure to be done. 3 Check if doctor has been trained to manage patient on sedation. 4 Ensure that a qualified nurse is available to monitor the patient. 5 Doctor to complete the pre-procedural assessment and pre sedation assessment.

Administer oral/intramuscular sedation 1 Registered Nurse to administer oral/intramuscular sedation according to hospital policy. Monitoring of patient 1 Take one reading of BP, pulse, respiration, pulse rate and SpO2 immediately before administration of oral/intramuscular sedatives. 2 Put patient on continuous pulse oximetry to monitor SpO2 and PR for at least 2 hours. Check BP and record the parameters at every 15-30 mins interval. No Procedure to be done in the ward

Transportation of patient 1 If the procedure is to be done off site, Nurse /STAR TEAM transporting the patient must be trained. 2 Continue monitoring patient’s SpO2 & Pulse Rate using pulse oximeter enroute to the procedure site.

yes

Intra-Procedure 1. Chart the patient’s blood pressure, pulse rate and SpO2 every 15-30 mins during the procedure. Check sedation level of the patient whenever appropriate.

Post Procedure Care 1. Continue to monitor patient’s parameter every 15-30 mins for at least 2 hours from administration of oral /intramuscular sedation.

Discharge from monitoring 1.Monitoring of patient can be discontinued if the following criteria is met: a. At least 2 hours from administration of oral/intramuscular sedation. b. Patient is awake or awaken to gentle calling or back to baseline c. Blood pressure and pulse within 20% of baseline d. Stable respiration with SpO2 back to baseline or > 95% on room air/ ≤ 2L/min oxygen.

Ward Nurse/STAR TEAM handover to the staff at procedural area 1 Handover according to hospital policy. 2 Inform the staff at procedural area: - the type and time of oral/IM sedation given and - the follow-up instructions

For procedure done off-site: If patient is not discharged from sedation monitoring yet at completion of procedure, continue monitoring patient’s SpO2 & Pulse Rate using pulse oximeter enroute back to ward. Qualified nurse shall be responsible to transport this patient back to the ward.

Procedural Sedation Form (NUR-GEN-99-00)

Printed via the Xerox Printer

ASC Assessment Of Patients - FAQs Questions

Answers

Tell me, how are the family involved in the anaesthesia plan of care?

During the pre-anaesthesia assessment, risk, benefits and alternatives related to anaesthesia and post operative pain control will be discussed and informed to the patient and family, it will be documented in the pre-anaesthesia assessment form. The anaesthesia care plan is documented in the anaesthesia record.

Tell me, when would a informed consent be required?

Informed consent is required for: • Surgery • Anaesthesia • Transfusion of blood and blood products • Other high risk procedures stimulated in TTSH policy. Such as chemotherapy, biopsy, invasive scopes, radiological procedures and allergy challenge test.

Tell me, how do you ensure the safety of the patient during procedural sedation?

Sedation is only performed by Doctors who has been certified after undergoing the moderate sedation course. Patients with such procedures are monitored by nurses who has been trained likewise. JCI-ASC-HAP-001 Care of Patients Under Sedation.

Tell me, what is procedural sedation?

Procedural sedation is defined as the technique of administering sedatives or dissociative agents with or without analgesics to induce an altered state of consciousness that allows the patient to tolerate painful or unpleasant procedures while preserving cardio-respiratory function. This is regardless of the medication, dose, or route of administration

ASC Assessment Of Patients - FAQs Questions

Answers

How could you ensure safety to the patient who has just receive IV sedation

Before procedure: - There must be an informed consent taken - Ensure patient is fasted During & post procedure, - Monitored by qualified clinician or nurse - There is continuous monitoring of ECG, pulse rate and oxygen saturation. Chart blood pressure every 5 min intervals. Check level of sedation at 5 to 15 minutes interval whenever, depending on the procedure, clinical condition and level of sedation. The respiratory rate should also be monitored if available

Tell me, when do you know the patient is fit for discharge from monitoring after IV sedation?

Time: 10mins since the last top up of sedative or narcotic drugs Reversal of sedation: Patient is awake or awakens to gentle calling or back to baseline. Stable hemodynamic: Blood pressure and pulse rate within 20% baseline Stable respiration: Spontaneous breathing with O2 saturation back to baseline or >95% on room air/ <2L/min oxygen. The assessment of these criteria must be performed and entered into the patientâ&#x20AC;&#x2122;s chart. JCI-ASC-HAP-001 Care of Patients Under Procedural Sedation

How could you ensure safety to the patient who has received oral sedation?

There is continuous monitoring for at least 2 hours from the time of administration of sedation. The level of sedation should be checked whenever appropriate. Oxygen saturation (SpO2), pulse rate and blood pressure should be charted at 30 minutes interval, or more frequent (eg. 15 minutes) when clinically indicated, from the time intramuscular/oral sedative is administered. Qualified nurse is responsible to transport and provide continuous monitoring enroute to the department.

ASC Assessment Of Patients - FAQs Questions

Answers

Tell me, when do you know the patient is fit for discharge from monitoring after oral sedation?

The criteria for discharge from monitoring will require fulfilling all the following criteria: • At least 2 hours from administration of oral/intramuscular sedation. • Patient is awake or awaken to gentle calling or back to baseline • Blood pressure and pulse within 20% of baseline. • Stable respiration with SpO2 back to baseline or > 95% on room air/ < 2L/min oxygen.

Tell me who can discharge patient from sedation monitoring?

The assessment of fitness for discharge from monitoring can be performed by the qualified clinician or Registered Nurse who has undergone an instructional module on the evaluation of patients for sedation; actions and side-effects of sedation and sedationreversal drugs.

Ambulatory Areas Tell me, when do you know the patient is ready to be discharged?

Patient is discharged from procedural sedation if he/she meets discharge criteria. If the sedated patient had received a reversal agent or agents, i.e. Flumazenil and/or Naloxone, the patient must be monitored for at least 30mins after the time of administration of the reversal agent AND a qualified clinician must review and document the patient’s condition at the point of discharge. The nurse may discharge the patient when authorized by the physician.

ASC Assessment Of Patients - FAQs Questions

Answers

PACU Tell me, how do you know the patient is fit for discharge?

Check if anaesthetist review is required before discharge. If review is not needed , a qualified RN (complete procedural sedation course) can initiate discharge of the patient from PACU after 20 mins if the following criteria are met: - PADS is at least 15points. - No zero score in any of the discharge criteria. - Patient has no complications that require urgent review. - Patient with spinal anaesthesia level of sensation is below the umbilicus (T10). - Patient completed minimum of 30mins monitoring in PACU. (Anaesthetist can overide the minimum of 30mins PACU stay by signing off in the PACU record)

Endoscopy Tell me, how do you know the patient is fit for discharge?

The RN is to discharge the patient at EDC who have undergone Endoscopic procedures except for the following situations: • Patient who has undergone GA/ deep sedation. • Patients who received reversal drugs for sedation. The patient can be fit for discharge by qualified nurse if • The patient meets the PADS score of at least 9. • Vital signs return to baseline • Patient has been monitored for an hour or more The doctor shall review the patient if: - Ordered by the Endoscopist/ Anesthetist in the POT. - Reversal drugs or agent is given to patient. - Patient cannot pass urine after the cystoscopy procedure. - Pain score of 7 and above. WI-NUR-EDC-008 Guidelines on Nursing Discharge Procedure for Patients at Endoscopy Centre

ASC Assessment Of Patients - FAQs Questions Diagnostic Imaging Tell me, how do you know the patient is fit for discharge?

Answers Only the RN is authorized to discharge patient if criteria is met. Discharge patient who has been sedated only when parameters meet the following criteria: - Inpatient - Monitor at least 30 minutes. - Outpatient - Monitor at least 1 hour. - There is return of ambulatory activity to pre-sedation level. - Stable BP, pulse rate and respiratory and oxygen saturation. Doctor must review and authorize the discharge if reversal drug is given to the patient.

Invasive Cardiac Lab Tell me, how do you know the patient is fit for discharge?

Patient with normal Coronary Angiogram can be discharge from ICL if they meet the following criteria: - Absence of excessive pain, nausea, vomiting, headache and giddiness. - Absence of chest pain and respiratory difficulty. - Absence of bleeding or enlarge haematoma from the arterial puncture site. - Orientated to time and place. - Stable vital signs for more than 4 hours. - Mobility status remains the same when compared to admission.

ACC Access to Care and Continuity of Care - Important Points Triage Emergency Department triage patients base on Patient Acuity Categorization. The Patient Acuity Categorization (PAC) scale is determined according to MOH’s guidelines.

Admission to Hospital •

During admission to inpatient wards, patient and family will receive education and orientation to the inpatient ward, information on the proposed care and any expected cost of care and the expected outcomes of care.

•

Polices related to admitting patients to the inpatient units includes:

Triage process to for recognition of communicable diseases • Screening will be performed by either ED staff or paramedics. • All patients and accompanying visitors will be screened prior to entry to the care areas i.e. EDC or EDX. • Three or more patients presenting with similar symptoms, from the same location and at approximately the same time will be segregated until a clinical management decision is made by the ED physician or nursing officer. • All patients with fever and/or respiratory symptoms will be directed EDX to await consultation. • The following are documented: – – – –

Name Contact number Temperature Travel history (patients only)

•

JCI-ACC-HAP-015 Admission and Discharge Policies of Acute Areas (ACA)

•

QP-NUR-GEN-001 Admitting a Patient to the Ward

•

WI-NUR-ICU-001 Admission or Transfer of Patient into Intensive Care (ICU)/High Dependency (HD) Units

Transfer of patient •

Polices related to transfer includes: • •

•

JCI-ACC-HAP-008 Transportation of Patients QP-NUR-GEN-003 Transfer of Patient From One Ward to Another WI-NUR-ICU-001 Admission or Transfer of Patient into Intensive Care (ICU) / High Dependency (HDU) Units. WI-NUR-ICU-003 Transfer of Patient from Intensive Care (ICU) / High Dependency (HDU) Units to General Ward WI-NUR-GRM-001 Transfer of Patient to Geriatric Monitoring Unit

Nurses must be familiar with the policies on patient admission & transfers. 89

ACC Access to Care and Continuity of Care - Important Points Accompanying Health Personnel For Transport 1.

2. 3. 4. 5.

6. 7. 8. • •

Selection of healthcare professional who should accompany the patient depends on the patient’s illness severity and stability such as life-sustaining measures required, patient’s AWAS and the risk of deterioration during transport. In addition, the level of care required during transport and the equipment required. Accompanying doctor, nurse and healthcare professional must be certified in BCLS and competent to care for patient on transportation. Patient may be accompanied by porters based on assessment by the nurse. In transit, porter to seek help from nearest healthcare professional or clinical areas if indicated. Healthcare professional forming the transport team should be freed from their duties during the period of transport. If another team assumes responsibility of care, there should be a proper handover to the receiving team; the transport team should remain with the patient until this process is complete. MO(and above) to review patient if wishes to override on accompanied personnel, equipment and drugs. For AWAS 3 or patient on comfort Care, RN can transfer alone if approved by MO (and above). Patients who are transferred to another institution for PCI (from general ward) maybe accompanied by an RN paramedic (AED trained) Not requiring or on Low level life-sustaining measures (e.g. FiO2 < 50%, not on Inotropes) Stable patient with catheter, tubes or drains AWAS 0 AWAS 1-2 AWAS 3-5

AWAS ≥ 6

On Moderate to High level lifesustaining measures (e.g. Intubated / ventilated, home ventilator / BIPAP, Inotropes, FiO2 ≥ 50%)

To STABILIZE patient before transfer Accompanying Dr, Nurse and HCA •Must be BCLS certified, and •Competent to care for patient

RN or EN or HCA or Porter*

RN plus HO#

RN plus MO and/or Registrar

According to patient’s needs

According to patient’s needs. Refer to A List of Equipment and Drugs for Transport of a Patient JCI-ACC-HAP-008

Patients on Telemetry (exclude PAF monitoring) To be accompanied by RN or EN or STAR team HCA

Equipment & Drugs

According to patient’s needs

ACC Access to Care and Continuity of Care - Important Points Personnel involved in the transportation (Transportation of ICU and HDU patients) • Minimum of two clinical staff should accompany the patient. • All ventilated patients need to be accompanied by a trained doctor. • For non-ventilated patients, the necessity for an accompanying doctor may be waived at the discretion of the senior doctor on duty, based on the acuity of the patient and exigency of need. • Patients being transferred out of ICU/HDU to a lower level of care may be accompanied by one nurse. • • • • •

Surgical HDU (SHDU) patients requiring only low level support e.g. Fraction of Inspired Oxygen (FiO2) < 50%, Not requiring inotropes, with stable vital range - 50bpm>Heart Rate <110bpm, - 90mmHg>Systolic Blood Pressure <180mmHg, Respiratory Rate <24breaths/min, oxygen saturation in peripheral circulation (SpO2)>93%)

may be accompanied Enrolled Nurse for procedures outside the SHDU

ACC Access to Care and Continuity of Care - Important Points -

List of Equipment and Drugs for Transport of a Patient The equipment and drugs to accompany a patient during transport should be decided after evaluation of the patientâ&#x20AC;&#x2122;s condition prior to transport and individualized to his/her specific needs. 1. Equipment for airway management (airway, face masks, resuscitator bag, intubation equipment). 2. Oxygen Supply: Cylinders must be full to provide for projected needs and oxygen delivery devices (e.g. nasal prongs, mask) 3. Equipment for basic monitoring of ECG/heart rate (cardiac monitor/defibrillator), BP and oxygen saturation (pulse oximeter) 4. All electrical devices/monitors with battery packs should be fully charged to provide for projected duration of transport and a functional check done. 5. Basic resuscitation drugs e.g. adrenaline, atropine, lignocaine, 50% dextrose, diazepam. 6. Supplemental medications e.g. sedatives should be considered on an individual case basis. 7. Adequate supply of patientâ&#x20AC;&#x2122;s drugs, drug infusions and intravenous fluids. 8. All intravenous lines, catheters and drains should be functioning, secured and periodically checked during the transport process. 9. Patient with tracheostomy tube: Tracheostomy box, a spare inner cannula (if applicable), an obturator of the current tracheostomy tube, equipment for airway management as stated in Point 1, Oxygen supply (if required). 92

ACC Access to Care and Continuity of Care - Important Points Home Leave •

•

• • •

• •

All request for home leave must be endorsed by either the consultant or Registrar in charge of the patient and should be documented in patient’s notes. Home leave should end by 10pm on the same day. Overnight leave needs to be approved by HOD (except Rehab patients). Home leave starts only after the patient is seen by the Dr. at the morning ward round. The patient/next-of-kin is advised on patient safety and care issues and time of return prior to home leave. Patient is advised to return immediately if unwell and ward’s contact number is given. The contents of ‘Letter of Undertaking For Patients Going On Home Leave’ is explained to patient/next-of-kin and patient/next-of-kin is requested to sign the form. Patient should be provided with sufficient medication during home leave. The abscondment policy will be invoked in the event that the patient fails to return at the stipulated time.

Reference: JCI-ACC-HAP-010 Management Of Patients Requesting For Home Leave

Discharge • Senior doctors evaluate and determine the patient's readiness for discharge. • Estimated discharge date (EDD) will be communicated to patients and/or family once EDD is confirmed and documented in the medical notes: ➢ The staff nurse will verify the EDD by checking the medical notes & treatment sheet. • Preparation of discharge documents should commence immediately after the physician has confirmed that the patient is medically fit for discharge on the day before the planned discharge date. • Discharge education should also be documented in case notes

Related polices for patient discharge Includes, • QP-NUR-GEN-002 Discharge of A Patient From The Ward • WI-NUR-ICU-002 Discharge of Patient From ICU /HDU Nurses must be familiar with the policies on patient discharge.

Discharge education and follow up Includes, • Safe and effective use of medication (potential side effects, potential interactions with other medications) • Safe and effective use of medical technology • Diet and nutrition • Pain management • Rehab techniques 93

ACC Access to Care and Continuity of Care - Important Points Discharge against Medical Advice Approval may be given by the Consultant in-charge (IC) of the patient. If not, approval may be obtained from the covering or deputizing clinician (AC or above). Without the relevant Consultant’s approval, discharge AMA cannot be granted and this administrative/legal position should be explained to the person requesting such discharge. Upon discharge, the RN shall • Document the following on AMA form • Patient’s condition upon discharge • The date and time which patient left the hospital premises • Name and signature of RN • Ensure appropriate medication ( if applicable) and discharge summary (patient’s copy) is given to the patient. Provide discharge advice where appropriate. • Document events in the notes.

Reference: JCI-ACC-HAP-012 Discharge Against Medical Advice (AMA)

ACC Access to Care and Continuity of Care - FAQs Questions

Answers

Tell me, how would you admit this patient?

Tell me, do you accept any patients in your unit? If no, why not? Show me where was it written to tell you what type of patients can be admitted to your unit?

Staff from these areas need to • be familiar with their units’ admission/discharge criteria • know where to retrieve the admission and discharge policy Intensive Care Unit (ICU) and High Dependency Unit (HDU): • JCI-ACC-HAP-002 • JCI-ACC-HAP-003 Non-Invasive Ventilation Unit (NIVU): JCI-ACC-HAP-011 Acute Care Areas (ACA): JCI-ACC-HAP-015 Acute Haemodialysis Unit (AHU): JCI-ACC-HAP-016 Medical Psychiatric Care Unit (MPCU): WI-PSY-MPC-001 Geriatric Monitoring Unit (GMU): WI-GRM-GMU-001 95

ACC Access to Care and Continuity of Care - FAQs Questions

Answers

Tell me, what type of care do you give when sending patients to another ward/unit? (Intra-hospital transfers) Or

How frequent do you monitored your patient?

Tell me, what type of care do you give when sending patients to another ward/unit? (Inter-hospital transfers) Or How frequent do you monitored your patient?

ACC Access to Care and Continuity of Care - FAQs Questions What information gets transferred with the patient during a transfer to another hospital? (Inter-hospital transfers)

Answers • • • • • • •

Who evaluates patient’s readiness for discharge?

• • • •

•

Name of the receiving health care organisation Name of the individual agreeing to receive the patient Reason(s) for transfer Medication, supplies, and medical technology required during the transport. Any special conditions related to transfer Any change in condition or status during transfer Vital signs and conscious level of patient before transfer

Senior doctors evaluate and determine the patient’s readiness for discharge Estimated discharge date (EDD) will be communicated to patients and/or family once EDD is confirmed and documented in the medical notes The staff nurse will verify the EDD by checking the medical notes and treatment sheet. Preparation of discharge documents should commence immediately after the physician has confirmed that the patient is medically fit for discharge on the day before the planned discharge date. Discharge education should also be documented in medical notes

ACC Access to Care and Continuity of Care - FAQs Questions

Answers

When is the discharge summary completed?

Discharge summary is to be completed within 48 working hours after patient’s discharge

What does the discharge summary contain?

Discharge summary includes: • Reason for admission • Principal diagnosis • Secondary diagnosis • Procedures with significant risks (which require consent) • Drug allergy • Medical alert • Treatment given • Discharge date • Status upon discharge • Follow-up instructions. • As far as possible, all relevant medications to be taken at home should be included

What education or followup instructions do you provide to patients at discharge?

• • • • •

Safe and effective use of medication (potential side effects, potential interactions with other medications) Safe and effective use of medical technology Diet and nutrition Pain management Rehab techniques

ACC Access to Care and Continuity of Care - FAQs -

Questions

What is given to patients upon discharge?

Answers

• • • • •

Discharge summary* (EDSS) Medical certificate Medication Outpatient follow-up appointments Referral forms/letters where appropriate

* Exception: Patients from department of Psychological Medicine, and those with HIV infection. What is the process for patients who request to go for home leave?

• • • • • • • • •

The patient’s consultant or registrar confirms approval and documents in patient’s notes. Home leave should end by 10pm on the same day. Overnight leave needs to be approved by HOD (except Rehab patients). Home leave starts only after the patient is seen by the Dr at the morning ward round. The patient/next-of-kin is advised on patient safety and care issues and time of return prior to home leave. Patient is advised to return immediately if unwell and ward’s contact number is given. The ‘Letter of Undertaking For Patients Going On Home Leave’ is explained to patient/next-of-kin and patient/next-ofkin is requested to sign the form. If medication is required during the period of the home leave, a prescription is sent to the pharmacy and medication is supplied to patient/NOK. The abscondment policy will be invoked in the event that the patient fails to return at the stipulated time.

Reference: JCI-ACC-HAP-010 Management Of Patients Requesting For Home Leave

ACC Access to Care and Continuity of Care - FAQs Questions What is the process for managing patients who notify staff they wish to leave against medical advice (AMA)?

Answers • • • • • •

For Outpatient What is the process for managing patients who leave against medical advice (AMA) without notifying staff?

Approval may be given by the Consultant in-charge (IC) of the patient. If not, approval may be obtained from the covering or deputising clinician (who must be an AC or above). Without the relevant Consultant’s approval, discharge AMA cannot be granted and this administrative/legal position should be explained to the person requesting such discharge. The following information needs to be provided to patients at discharge: Appropriate prescriptions/medication (if applicable) Discharge Summary (patient’s copy) Discharge advice

Defaulted specialist outpatient appointments: •A reminder letter and/or SMS containing details of rescheduled appointment will be issued to the defaulter •Attempts would be made to contact the patients based on risk assessment For patients who did not turn up on the day of surgery (cancellation / no show) for endoscopic procedures: •Attempts will be made to reschedule the patient for surgery/endoscopic procedures

100

ACC Access to Care and Continuity of Care - FAQs Questions

Answers

For Inpatient What is the process for managing patients who leave against medical advice (AMA) without notifying staff?

101

COP Care Of Patients - Important Points Nursing Care Plans • Individual patient’s nursing care plan is based on nursing assessment and problem list. • Standardized problem specific care plans are available in the PCR •

•

Document plan of care in progress notes using; A – Assessment P – Problem I – Intervention/s E – Evaluation Care plans are to be revised and reviewed each shift and when necessary.

High Risk Patients Patients identified as high risk are, a) b) c) d) e) f) g) h) i) j) k)

Patients who require emergency and/or resuscitation services Patients on life support or who are comatose Patients with communicable diseases and immunosuppressed conditions Patients who require dialysis Patients who require the use of restraint Patients receiving chemotherapy Elderly patients Disabled individuals Children Population at risk for abuse Patients at risk of suicide

Care of high risk patients are supported by policies JCI-COP-HAP-002: Care of Emergency Patients JCI-COP-HAP-003: Emergency Resuscitation JCI-COP-HAP-004: Care of Patients on Life Support or Who Are Comatose JCI-COP-HAP-006: Care Of Patients On Dialysis JCI-COP-HAP-007 Policy On Use Of Physical Restraint

JCI-COP-HAP-008: Care For The Vulnerable Older Patients JCI-PFR-HAP-011 Care of the Vulnerable Group of Patients JCI-ASC-HAP-001: Care of Patients under Procedural Sedation WI-NIC-INF-003: Hand Hygiene WI-NIC-INF-004 : Disinfection WI-NIC-INF-013: Prevention Of Surgical Site Infections WI-NIC-INF-022: Transmission-Based Precautions WI-NIC-INF-023: Infection Control In The Operating Theatre WI-NIC-INF-026 : Protective Isolation SD-NUR-GEN-004: Administration of blood and blood products SD-NUR-ONC-001: Cytotoxic Drugs; Safe Handling and Administration CG-PSY-PMT-01: Management of inpatients with suicide risk and those who have attempted suicides.

102

COP Care Of Patients - Important Points How to access Nursing Care Plan in C-DOC

How to access Care Plan in ICU ICCA

103

COP Care Of Patients - Important Points -

How to access Allied Health Care Plans? S/No

Department

Speech Therapy

Care and Counseling

Podiatry

Prosthetics & Orthotics

Psychology Services

Physiotherapy

Occupational Therapy

Nutrition & Dietetics

Respiratory Therapy

Respiratory Therapy (ICU)

Location

C-doc  Plan

Occupational & Physiotherapy Initial assessment form  Page 2 (Goals)

C-doc Nutrition Intervention

C-doc Ventilator or Rx ICU flowsheet Resp/O2 ICU Mutidisciplinary  Plan

104

COP Care Of Patients - Important Points Recognition of changes to patient condition

Blood and Blood Products Administration

Aggregated WArning Score (AWAS)

Staff Training

is used to guide early recognition and response to deterioration in a patient’s condition.

All RNs are required to complete E-learning and achieve 100% passing mark for post course Quiz before they are allowed to administer blood / blood products.

Resuscitation Services

• Code blue services are available 24/7. • Activate ext phone number: 1599, for Code blue team. • Code blue team will arrive within 5 mins upon activation.

Code Blue Coverage

Reference: E-learning At NHG (Blackboard)

‘Severe’ Pain Score is now 7 and above.

Monitoring during blood / blood product administration Monitor the patient’s temperature, blood pressure, pulse rate and respiratory rate for the first 15 minutes and then hourly onto the hourly monitoring chart throughout the transfusion. E.g. 1145hrs : Monitor and document baseline vital signs 1200hrs : Commence blood transfusion 1215hrs : Monitor and document vital signs 15 minutes after commencement of blood transfusion 1315hrs : Monitor and document vital signs hourly until end of transfusion. Monitor and document vital signs 1 hour post transfusion. • Observe the patient periodically throughout the transfusion. • Instruct the patient to report anything “unusual” experience immediately.

In the event of occurrence of transfusion reaction Stop the transfusion immediately if signs / symptoms of adverse reactions is suspected. Inform the attending physician immediately and notify BTS. Please refer to Pain Crisis management protocol which is in place in all dinamap machines when necessary.

Reference: JCI-COP-HAP-106 & SD-NUR-GEN-004 Administration of Blood and Blood Products 105

COP Care Of Patients - Important Points Organ Transplant Services Brain Death Coordinator will be informed for patients identified as potentially brain dead to arrange for brain dead certification (Brain Death Coordinator HP no. is available on HMS) Certified brain-dead patients are then referred to the transplant coordinator from the National Transplant Unit.

Organ Transplant Live organ donation is not carried out in TTSH. TTSH supports cornea harvesting and organ transplant services (Brain death certification). Cornea Harvesting Services All inpatient deaths are referred to the Eye Donation Counselor (EDC) within 1 hour from time of cardiac death. HEDP (Hospital Eye Donation Program), Operating hours: 07:00hrs – 22:30hrs (Monday – Friday) After operating hours: Unless patient is a pledger or relatives request to donate cornea – to refer to National Organ Transplant Unit (NOTU) tel: 62314390 or contact on-call transplant coordinator indicated in HMS.

Care of high risk patient (Suicide Risk) Please access video and slides in NOOG > Nursing Education > Training Resources > • Video > ‘Suicide Prevention’ • Powerpoint Slide > ‘Introduction to suicide prevention’. Reference: CG-PSY-PMT-01 Management of Patients with Suicide Risk and Those who Have Attempted Suicides 106

COP Care Of Patients - FAQs Questions What is the care plan for this patient?

Answers

(Show Problem list and PCR / Carepath) Articulate assessment, interventions and evaluations. PCR should be done within 4hrs of admission. *Ensure documentation is complete.

Are there any reassessments?

Patient is reassessed at least once per shift (or when condition changes) and the plan of care is revised accordingly.

Who are your high risk patients?

High risks patients includes, a) Patients who require emergency and/or resuscitation services. b) Patients on life support or who are comatose c) Patients with communicable diseases and immunosuppressed conditions d) Patients who require dialysis e) Patients who require the use of restraint f) Patients receiving chemotherapy g) Elderly patients h) Disabled individuals i) Children j) Population at risk for abuse k) Patient at risk of suicide

Or What is the process for caring for such high-risk patients/services?

Staff caring for such patients should know the protocol/process well for such patients.

107

COP Care Of Patients - FAQs Questions

Answers

Tell me what would you do after identifying a patient with nutritional needs?

During admission, nurses carry out Inpatient NAR within 4 hours of the patient’s arrival in the General Ward and Acute Care Area (ACA) and if nutritional screening ≥ 4: • Nurses can refer Dietician in Aurora • Weigh patient if medically fit, and update patient’s weight into the Smartsense.

Tell me what are some of your initiatives for patients at end of life care?

“Comfort Care Room” is a room specially catered to those who are intermittently dying and their loved ones who desire some privacy. Inclusion Criteria • Patient in subsidized wards (B2 and C class only) • Patient with an estimated prognosis of less than 48 hours. • Family members/NOK requested for privacy to spend time with patient. • Patient with symptoms (e.g. dyspnoea, confusion, death rattle) which is/are distressing to other patients in the same cubicle. Exclusion Criteria • Patient who requires medical equipment(s) which cannot be supported in the Comfort Care Room.(e.g. Ventilators / BiPAP Machines / Chest tubes / Bladder Washout) • Patient who requires close monitoring which cannot be fulfilled by the nursing staff in-charge. (Not more than 4 hrly parameters) • Patient should ideally be for Comfort Care and not for active management including starting or escalating Dopamine. • Patients on Dopamine may still be admitted on a special case basis but dopamine should not be started or escalated. • Patient who needs to be isolated because of infectious disease reason. • Family member/NOK refuses to give consent for the transfer.

(Continued on the next page) 108

COP Care Of Patients - FAQs Questions

Answers Workflow for Admission into Comfort Care Room • Primary / ED Team Senior Resident / RP / Registrar/ Consultant makes decision to admit to Comfort Care Room. • BMU is informed and will allocate a Comfort Care Room to the patient. • Team Doctor to inform Ward Nursing Officer (NO) of receiving ward about the details of the patient to be transferred. • Handover of patient’s medical condition between health care professionals using hospital handover guidelines prior to transfer of patients into Comfort Care room. • In cases where it is unclear, Palliative Care Consultant (Office Hours) can be consulted.

Reference: JCI-COP-HAP-014 End-of-life care – Annex E, Comfort Care Room.

109

COP Care Of Patients - FAQs Questions

Answers

How often do you check your e-trolleys? For depts that function every day e.g. inpatient

For depts that do not function everyday e.g. SOC

E-trolley lock number - Check and document lock number in checklist *lock number on the emergency trolley must tally with the previous number documented in the Checklist if the trolley is unused.

Once Daily in the afternoon

Once daily on operational days

Defibrillator - Operational check - Quick pacer check (ICU / HDU / PACU / OT / DSC (ward and OT) / ICL.)

Once Daily in the afternoon

Respiratory resuscitator - Resistance test

- Once Daily in the afternoon

- Once daily on operational days

ED: Every shift

- designated day (once a week) and/or new assembly

Unlocked items

ED: Every shift

Once daily on operational days or once weekly for Heartstart XL+

ED: Every shift

-Functional check

- Saturday Afternoon and/or new assembly

Emergency Drug Kit (if applicable) - Check that the lock on the emergency drug kit is intact. - Ensure the disposable lock number tallies with the number indicated on the drug kit.

Once Daily in the afternoon

Once daily on operational days

*Exchange the drug kit with the Pharmacy Department after each use or when the disposable lock is broken.

110

COP Care Of Patients - FAQs Questions

Answers

How often do you check your e-trolleys? Locked Items

When Lock is broken OR At least once every week on Saturday afternoon, unless the disposable lock was broken and items were used within the preceding 6 days.

When lock is broken OR Designated day (once a week).

Reference: WI-NUR-GEN-001 Checking of Emergency Trolley Are all emergency trolleys equipped with pediatric equipment? The resuscitation trolley with paediatric resuscitative equipment can be found at the following locations: • Clinic B1A • TTSH Eye Centre (Eye Atrium, Level 1) • Clinic 1B • Clinic 1A • Health Enrichment Centre (HEC) • Clinic 2B • Clinic 4B • Clinic 5B Centre for Advanced Rehabilitation Therapeutics (CART) • Clinic 6B Complementary Integrative Medicine Clinic / Dental • Day Surgery Ward • Operating Theatre • Post Anaesthesia Care Unit • Pre Admission Counselling and Evaluation (PACE) • TB Contact Clinic • Foot Care & Limb Design Centre (FLC) *All paediatric resuscitation items are checked once a week / when lock is broken / after each use. Paediatric items are kept at the side compartments of the emergency trolley

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COP Care Of Patients - FAQs Questions What is the response process for resuscitation?

Answers Resuscitation services are available and provided 24/7 (Call 1599 and ask for Code Blue Team) Process to activate Code Blue: •Nearest trained healthcare professional will initiate BCLS •Other staff members will call 1599 to activate Code Blue Team *Code Blue Team must arrive within 5 minutes of activation ICU, OT complex on Level 3, ED and CDC-1 Resusitation is provided by care team working on site, during office and non office hours.

Do you have a policy on the use of restraint?

•Physical restraints are only used with specific indications, such as risk for self harm, or risk of pulling out essential medical devices. (refer Restraint Monitoring Chart)

Or What is your policy on the use of restraint?

•A Doctor/Nurse Clinician/Nurse Manager’s order is necessary for restraint use.

•This order needs to be evaluated every 24 hours. A new order must be written and reason/s for restraint must be indicated. •During the period of restraint, the patient’s behavior, comfort, circulation and skin integrity will be monitored every 2 hours. Reference: JCI-COP-HAP-007 Policy on Use of Physical Restraint SD-NUR-GEN-009 Guidelines on Use of Physical Restraint

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COP Care Of Patients - FAQs Questions

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Do you have a process for organ donation?

Live organ donation is not carried out in TTSH. TTSH supports cornea harvesting and organ transplant services (Brain death certification). Cornea Harvesting Services All inpatient deaths are referred to the Eye Donation Counselor (EDC) within 1 hour from time of cardiac death. •HEDP (Hospital Eye Donation Program), Operating hours: 07:00hrs – 22:30hrs (Monday – Friday) •No need to refer death cases on Sat, Sun and PH, unless patient is a pledger or relatives request to donate corneas. Organ Transplant Services For potential brain-dead patients in ICU, we will call the hospital Brain Death Coordinator (HP no. is on HMS on intranet) to arrange for brain death certification. Certified brain-death patients are then referred to the transplant coordinator from the National Organ Transplant Unit.

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AOP Assessment Of Patients - Important Points Point of Care testing (POCT) e.g. Blood Glucose monitoring

Initial Nursing Assessment Includes: • General Information • Psychosocial and Economic Data • Nutrition Screening • Oral Assessment • Functional Status Assessment • Pressure ulcer risk (Braden Scale) • Fall Risk Assessment

*Nursing assessment results in a list of specific patient nursing need/s or problem/s list that require nursing care, interventions, or monitoring.

• • •

All staff who performs POCT are trained competent Yearly re-certification Quality Control checks are performed as per policy.

Laboratory Turn Around time

Dietitian Referrals GW • Patients scored 4 or more for Nutrition screening are referred to dietitian. • Assessment by dietitian should be done within 1 working day from notification of referral ICU/CCU • All patients admitted to ICU/CCU are screened by intensivist or team Drs within 24hrs of admission regardless of initial screening • Patient identified at nutritional risk are referred to dietitian. • Assessment by dietitian should be completed within the next working day.

STAT/URGENT Chemistry, Hematology and Blood Transfusion Services Tests

1-2hrs

Routine Chemistry, Hematology and Blood Transfusion Services Tests

4-8hrs

Preliminary Results for Microbiology, Routine Cytology, Routine Histopathology

24-72hrs

Other laboratory investigations’ turn around times are available on the Intranet, TTSH Intranet  e-Laboratory Service Guide  General Information  Turn around time

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AOP Assessment Of Patients - Important Points Pain Assessment

Pain assessment is carried out, • In all inpatient • In all patients presenting with pain at the ED and Outpatient clinics • When Procedures are performed Frequency of Assessment • At least once per shift • When there is a report of pain • According to the interval specified by the doctor • Within 2 hrs after pain intervention (for effectiveness of medication served) • Hourly or according to interval specified by the doctor for patients who are under the APS/PCS (if “Prescription and Observational Pain Chart” is used)

Pain Documentation Clinical Chart • Highest pain score obtained at rest OR movement PCR • P – Presenting history, presentation / area of pain • A – Aggravating / relieving factors, associated symptoms • I – Intensity (pain scales), impact on mobility/ADL/Life • N – Nature of pain (e.g. sharp, shooting, aching, burning)

Pain Management Inform primary Dr if the patient: - Self-reports new pain - Self-reports pain scores of 7/10 or above - Exhibits evidence of distress (noncommunicative patient) - Pain score persists 7/10 or above after the prescribe medication has been served. - Self-report unsatisfactory pain relief (regardless pain scores). - Demonstrated ineffective pain relief and thus indicating need for review of existing analgesic.

• Reassessment PFE When pain is expected, provide patient and family education (PFE) 115

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AOP Assessment Of Patients - Important Points Additional Assessment for Special Population Terminally ill patients • Assess patient’s preference on hygiene and feeding needs • Start assessment upon starting EOL status • Document patient’s preference onto Nursing Kardex

End of Life Dying patients and their family are assessed and reassessed according to their individual needs using the Comfort Measures Patient Care Record.

Areas affected: Palliative wards and wards receiving EOL patients

Discharge Planning Pre-Planning for discharge should be completed with in 48 hrs from admission to ward. Discharge planning includes identifying education needs and developing and implementing a plan to address those needs.

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AOP Assessment Of Patients - FAQs Questions Tell me, what do you check for when patients admitted to your ward?

Or Who performs the assessment? Or What is the timeframe for these assessments to be completed?

Answers Initial Nursing Assessment includes; • General information • Psychosocial and Economic Data • Nutrition Screening • Oral Assessment • Functional Status Assessment • Pressure ulcer Risk - Braden Scale assessment • Fall Risk Assessment General information, Psychosocial and Economic Data, Nutrition Screening, Oral Assessment, Functional Status Assessment and Braden Scale assessment • By RN/EN Fall Risk Assessment, Components of “Assessment” of PCR • By RN The NAR is to be complete within 24hours upon admission.

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AOP Assessment Of Patients - FAQs Questions Tell me about your nutritional assessment. Or

Answers GW All patients are assessed using the nutritional screening tool. • Patient with nutritional risk score ≥ 4 will be referred to dietitian

When would you refer a patient to the Dietitian?

ICU/CCU All patients admitted to the ICU/CCU are screened by the intensivist or team Drs within 24hrs of admission regardless of outcome of initial screening • Patient identified at nutritional risk are referred to the dietitian for a formal assessment • Once the patient is referred to the dietitian, a formal nutrition assessment and recommendations should be completed by the next working day • Changes in the patient’s medical condition will often necessitate a reassessment of nutrition support by the dietitian; who will be informed of these changes by the doctors or nurses in charge.

What do you do if a patient / family member expresses financial problems?

Referral to a Medical Social Worker for assessment / financial assistance can be made, if a patient / Family member expresses financial problems.

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AOP Assessment Of Patients - FAQs Questions

Answers

Tell me about functional assessment, are anyone else involved? If so, how are they involved?

GW All patients are assessed if they can perform key activities independently, with assistance or is dependent • The dr will be consulted to consider a referral to PT/OT if the patient is assessed “Assisted” or “Dependent” and is clinically stable. • If the patient is not clinically stable, nurses will document in the Kardex and follow-up when the patient is clinically stable (Show Kardex, ensure documentation is complete.) ICU/CCU PT All patients admitted to the ICUs (Except CCU) are at risk requiring a full PT assessment – no screening required • Patients will be assessed by PT upon admission CCU patients are screened by cardiologist in-charge and referral is made if the patient is at risk. • Patient will be assessed by PT within 1 working day upon referral OT All patients are screened by intensivist or cardiologist, a referral will be initiated when indicated. • OT will assess patient within 1 working day ST All patients are screened by intensivist or cardiologist, a referral will be initiated when indicated • ST will assess patient within 1 working day

Reference: CG-ICU-GEN-12-V1 Functional Screening and Assessment in the ICU/CCU 120

AOP Assessment Of Patients - FAQs Questions

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Do you assess patients for pain?

Pain assessment is done, • Upon admission • At least once per shift • When a patient complains of pain • According to intervals specified by the doctor • Within 2 hours after pain interventions (for effectiveness of medication served) • Hourly or according to interval specified by the doctor for patients who are under the APS/PCS (if “Prescription and Observational Pain Chart” is used)

How often do you do pain assessment? Or How do you assess pain?

Use (in order of preference); Tool 1. Numerical Rating Scale (NRS) Ask Patient: “ if 0 is no pain. And 10 is the worst possible pain, how much is you pain right now?” Tool 2. Verbal Descriptive Scale (VDS) Ask Patient: “Is your pain mild, moderate or severe?” Mild: 3, Moderate: 6, Severe: 9 Tool 3. Wong-Baker Faces Pain Rating Scale (FPRS) Show patient the FPRS Ask patient: “Which Face best describe your pain now?”

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AOP Assessment Of Patients - FAQs Questions

Answers If unable to use 1-3, use Tool 4: Modified Distress Pain Behaviours Vocal complaints

Non-verbal expression of pain: moans, groans, grunts, cries, gasps, sighs

Facial grimaces/ winces

Furrowed brow, narrowed eyes, tightened lips, jaw drop, clenched teeth, distorted expressions

Bracing

Clutching/ holding onto side rails, bed, tray table, or affected area during movement

Restlessness

Constant or intermittent shifting of position, rocking, intermittent or constant hand motions, inability to keep still

Rubbing

Massaging affected area

Verbal or words expressing discomfort or pain

“ouch”; ”that hurts”; cursing during movement or exclamations of protest; “stop”; “that’s enough”

“ND” - Denote “Not in Obvious Pain” “D” – Denote “Evidence of Distress” in any of the above signs. What do you do if the patient has pain?

• Serve analgesia as ordered by doctors. • Review pain level within 2 hours after analgesia and after painful procedure (e.g. Surgery). • Highlight pain, which is persistently ≥ 7/10 (despite analgesia) to primary team doctors. 122

AOP Assessment Of Patients - FAQs Questions

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Do you do reassessment of Pain?

Pain reassessment is done within 2 hours after pain interventions (for effectiveness of medication served) • Obtain pain score • Assess adequacy of pain relief (patient’s subjective impression and overall condition of patient) • Inform doctor if pain relief intervention is unsatisfactory or patient has persistent pain with score ≥ 7/10 (despite analgesia)

How do you document your pain assessment?

Clinical Chart • Highest pain score obtained at rest OR movement PCR • P – Presenting history, presentation / area of pain • A – Aggravating / relieving factors, associated symptoms • I – Intensity (pain scales), impact on mobility/ADL/Life • N – Nature of pain (e.g. sharp, shooting, aching, burning) • Reassessment Reference: TTSH Pain Ruler, Pain Taskforce SD-NUR-GEN-014 Nursing Guidelines on Pain Assessment and Management.

Do You do point of care testing/(POCT) here?

Examples of POCT includes, • Blood Glucose monitoring (“Hypocount”) • Arterial Blood Gas

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AOP Assessment Of Patients - FAQs Questions Who has over sight of the glucometers (or other POCT)?

Do you know the turn around times for Lab investigations?

Answers The Head, Department of Laboratory Medicine (HOD Lab Med) • Provides oversight and supervision of the POCT program POCT Committee • Assist the HOD Lab Med in the oversight and supervision of POCT Supervisors of individual units • Supervises the daily POCT operations in their area STAT/URGENT Chemistry, Hematology and Blood Transfusion Services Tests

1-2hrs

Routine Chemistry, Hematology and Blood Transfusion Services Tests

4-8 hrs.

Preliminary Results for Microbiology, Routine Cytology, Routine Histopathology

24-72hrs

Other Lab investigation Turn around times is available on the Intranet TTSH Intranet  e-Laboratory Service Guide  General Information  Turn around time

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