PROCEDURE MANUAL TABLE OF CONTENTS 1. Training Orientation - Endoscopy Procedure 2. Training Orientation 3. Safety 4. Photography 5. Patient Transfer to Acute Care Facility 6. Preoperative Holding Area 7. Release Against Medical Advice 8. Discharge of Patient 9. Procedure for the Handling of Medical/Legal Evidence 10. Patient Questionnaire (form) 11. Code Blue Procedure 12. Resuscitation Procedure in the Operating Room 13. Code Blue Nurses Notes (form) 14. Crash Cart 15. Endoscopy Center Pharmacy - Approved Formulary 16. Ventilation of Patient Using AMBU Bag Manual Resuscitator 17. Procedure to Test Defibrillator 18. Seizure Precautions 19. Responding to Vasovagal Synscope 20. Fall Prevention/Protective Devices Procedure 21. Oxygen Usage and Use of Contained Gases 22. Venipuncture Initiation, Administration and Discontinuation 23. Medication Reaction 24. Procedure for Immunoglobulin Intravenous Administration 25. Administration of Therapeutic Anticoagulants 26. Procedure for Intravenous Therapy - Piggyback Administration 27. Electro-Surgical Grounding 28. Handling Specimens 29. Percutaneous Liver Biopsy 30. Suture/Skin-Staple Removal 31. Addendum X --- X-Ray Confirmation Policy For Feeding Tube Placement 32. Cultures, Aerobic, Anaerobic, and Gram Stains 33. Procedure for Activation of Implanted Port Vascular Access 34. Procedure For Blood Sampling From Implanted Port Vascular Access Device (VAD) 35. Procedure for Discontinuation of IV From Implanted Port Vascular Access Device (VAD) 36. Procedure For Conversion of Implanted Port (VAD) To Heparin Lock 37. Procedure For PICC Line Heparin Lock Flush 38. Procedure For PH of Gastric Contents 39. Procedure For Clo-Test 40. Procedure For Test For Occult Blood 41. Occult Blood Testing 42. Colostomy Care, Appliance Change and Special Problems 43. Contrast Media Reaction 44. Blood Glucose With Soft Touch Lancet Device and Chemstrip bG (Visual Reading) 45. Enemas - Cornstarch, Retention, Harris Flush, Molasses 46. Colostomy Irrigation with Cone Tip 47. Standard Equipment for All Endoscopic Procedures 48. Emergency Endoscopy 49. Flexible Sigmoidoscopy 50. Proctosigmoidoscopy (Rigid) 51. Flexible Sigmoidoscopy 52. Colonoscopy 53. Electrocautery 54. Polypectomy 55. Generic Assisting with Biopsy 56. Endoscopy through an Ostomy 57. Esophagogastroscopyduodenoscopy (EGD or upper Endoscopy) 58. Esophageal Prosthesis 59. Position Statement 60. PEG Replacement Devices 61. Percutaneous Endoscopic Gastrostomy (PEG) - Percutaneous Endoscopic Jejunostomy (PEJ) 62. Sclerotherapy of Esophageal Varices 63. Sclerotherapy (Variceal Sclerosis) 64. Heater Probe/Bicap Coagulation 65. Foreign Body Removal 66. Esophageal Dilation 67. Dilation: Bougienage 68. Dilation: Hydrostatic Balloon 69. Dilation: Pneumatic Balloon 70. Dilation: Polyvinyl Chloride Dilators 71. Preoperative Holding Area 72. Procedure For Leak Test 73. Procedure For Sonic Energy Cleaner 74. Procedure For Soak Disinfecting System (Cidex) 75. Daily Disinfection/Sterilization Control Form (form) TRAINING ORIENTATION - ENDOSCOPY PROCEDURE STANDARD: Endoscopy room supervisor's responsibilities in reducing liability. Peri-operative nurses practice a high risk profession. Supervisors must be aware of areas of potential liability exposure to decrease the liability of the FACILITYand the nurses employed there. Documentation is one of the most important defense tools that nurses have at their disposal. During a legal proceeding, documentation can be scrutinized to determine if the patient was properly prepared before the operation or for any procedure. Adequate counting procedures in the operating room or any safety procedures also limit liability. A plaintiff's attorney usually will subpoena on operating room policy and procedures manual to determine if the policies are appropriate. These manuals should be updated and reviewed periodically to determine if the practices follow the policies as outlined in the manual. Supervisors should promote thorough orientation to gastrointestinal materials, equipment, and procedures. If training is received and the procedure room staff members know that improper materials or equipment are being used, they should object or they could be held liable in a malpractice suit. Medical facilities must properly train and orient nursing L.P.N., Gastrointestinal Tech, and axillary personnel, regarding various equipment, gastrointestinal materials, and procedures so they are knowledgeable and can use good nursing judgement to question when something is done inappropriately. If not, future cases could involve the FACILITY as a defendant for inadequate staffing. Effective communication, familiarity with procedure room policies and procedures and trust can help peri-operative supervisors manage change and decrease the liability exposure of health care providers in the operating room. SAFETY DESCRIPTION The following conditions and directions are general guidelines for maintaining safety. Universal blood and body fluid precautions are practiced for each patient. Institution policies and guidelines should be followed. (135.10.b-c) ENVIRONMENTAL SAFETY 1. Hallways and doorways free of equipment and carts 2. Rooms neat and orderly 3. Electrical cords, cables, and tubing placed so personnel do not trip and fall. 4. Adequate ventilation in all rooms 5. Compliance with OSHA standards ELECTRICAL SAFETY Maintain electrical cords in safe working order. Ascertain that all electrical equipment is properly grounded Do not use multiple-outlet adapters or two-wire extension cords. Do not remove ground pins from three-pin plugs. Avoid routing power lines through heavy traffic areas. Follow manufacturer's recommendations and standards for all equipment. Report and have repaired any malfunctioning equipment or potential hazard immediately. Inspect all cables frequently for breaks or frays. Always use lowest acceptable power settings. Perform and document periodic checks on all electricalequipment. Because liquids are excellent conductors of electricity, never place a container of liquid on electrical equipment. EQUIPMENT SAFETY Perform and document inspection of all equipment on set schedule. Inspect mercury-filled dilators on set schedule to ensure that they are intact and expiration dates have not passed. Pre-procedure endoscopy checks should include the following: a. Turn on light source and suction to make sure both are functioning properly. b. Check air/water channel. c. Look through scope for broken fiber bundles, presence of fluid or poor visualization. d. Test endoscopes for leakage per gastrointestinal unit policy. e. Check for bite marks or indication of damage on scope. f. Manipulate all controls. 4. Electrocautery precautions: a. Test equipment prior to procedure per manufacturer's instructions. POST-SEDATION SAFETY 1. Monitor vital signs per institution guidelines. 2. Keep patient NPO until gag reflex returns following local throat anesthesia. 3. Keep side rails in place. 4. Assist patient with ambulation as needed. 5. Provide continuous observation for sedated patients. 6. Instruct outpatient not to drive, operate heavy machinery or drink alcohol post-medication per drug manufacturer guidelines. 7. Provide post-procedure written instructions for outpatients, and provide verbal report to nurse responsible for inpatient's care. 8. Follow all other institution guidelines for the sedated patient. EMERGENCY SITUATION SAFETY 1. General - Follow institution policies for fire, severe weather and other disasters. 2. Endoscopy unit a. Oxygen available b. Crash cart with appropriate equipment and medications c. CPR trained personnel d. Personnel knowledgeable in the use of medications, recognizing side effects and types of antagonists to be used. PHOTOGRAPHY DESCRIPTION The primary purpose of endoscopic photography collections of all types is to build a depository of information permitting review of cases for training, research, teaching and clinical consultation. These collections become permanent visual documentation for possible future legal references as to what procedures were performed and what techniques were used. There are four essentials for taking good photos: a powerful light source, camera, film and endoscope. The light source must be of sufficient intensity to yield a correct color image through all endoscopes. Photography equipment in all its forms is available for all current endoscopes and can be mounted using adapters directly to flexible and rigid endoscopes. The available techniques are still, instant and video with tape recording systems. STILL PHOTOGRAPHY 35mm still camera are recommended because of the adaptability to any light source and any type fiberscope. Avoid direct sunlight when loading and unloading film. Recheck batteries often. Always check camera for correct settings; 1/4 second is the usual shutter setting. Two accessories are available for still camera: a record data back that registers date, number and alphabetical code directly on the picture, and an automatic motor winder to replace the advance lever INSTANT Polaroid instant still cameras produce brilliant full-color instant photography through an endoscope. Polaroid 779 type super fast film with an EC3 camera and xenon light source will produce optimal quality results and is immediately available. To improve the quality of instant photographs, these tips may help to minimize drawbacks in the system: Stay close to the subject; try to get perpendicular to the subject; try to reduce motion; use the shutter release cable; squeeze the shutter release until the photo starts to eject; use a bright xenon light source; use a bright (large) telescope. TIPS FOR IMPROVING ENDOSCOPIC PHOTOGRAPHS 1. Keep lenses clean, both the eyepiece and distal tip. Use lens cleaner or a cotton swab moistened with alcohol to carefully wipe lenses. 2. Clean distal lens as necessary during procedure. After washing the lens during the procedure, be sure to blow air across the lens to remove all drops of water. 3. Match film type to light source for best color. For xenox lamps and flash tubes use film balance to daylight. For tungsten lamps use film designed specifically for tungsten lamps. 4. Minimize exposure of fiberscopes to harmful radiation. Prolonged radiation exposure will cause glass fiber bundles within the scope to darken and discolor. 5. Reduce blurring due to motion. Relative motion will cause blurring. Faster shutter speeds obtained by high intensity light sources will help reduce this problem. 6. Check all settings and electrical connections. If photos are consistently dark, use a lower numbered setting. If they are too light, use a higher numbered setting. If the light source fails to flash or operate properly, check electrical contacts on camera adapter, the pin connectors in the light guide plug and the shutter sync cord which plugs into the camera. SPECIAL CONSIDERATIONS The taking of photographs should not interfere with patient needs and should be postponed if it endangers the safety of the patient during the procedure. PATIENT TRANSFER TO ACUTE CARE FACILITY PURPOSE: An appropriate transfer mechanism from the FACILITY serves to assure a minimal disruption of care while transferring a patient from the FACILITY to the hospital. With pertinent medical and nursing data accompanying the patient, continuity of care is insured. POLICY: A patient shall be transferred to an acute care facility when the need arises, at the discretion of the physician and anesthesiologist. RESPONSIBLE PARTY: San Antonio Digestive Disease Endoscopy Personnel ACTION: 1. Call ambulance for transfer. a. State name, FACILITY and doctor sending, hospital and doctor receiving. b. If acute emergency, specifyconditions and type of situation. 2. Inform the patient and/or family members of the need for transfer. If his condition permits, explain reason for necessary of transfer. 3. Put patient's belongings in a plastic or paper bag and label clearly with the patient's name. Special attention must be given to glasses, dentures, hearing aids, etc. 4. If possible, patient's property will be sent home with the family. 5. Complete patient's chart. Record meds, treatments and observations on nurse's notes and attach copy to chart. 6. Notify nurse's staff at admitting hospital regarding the transfer and relate pertinent data. 7. When the ambulance arrives, transfer the patient via wheelchair or stretcher with all belongings, records, etc. 8. Assist the transfer of the patient from the FACILITY to vehicle. 9. If accompanying patient, give a verbal report to the nurse and physician receiving the patient, including the following: a. diagnosis b. medical care and orders c. general condition and vital signs d. medication administered and treatment 10. If not accompanying patient, the receiving emergency department nurse is to be notified of patient's arrival and above information given. 11. Record procedure in patient's chart, affix signature and title. PREOPERATIVE HOLDING AREA PERSONALIZING PATIENT EXPERIENCE: An assembly line approach can be avoided by ensuring that there is adequate staff to provide time with the patient and pleasant surroundings. The physical setting of the preoperative holding area is an important factor in reducing patient stress. Make the area as personal and as soothing an area as possible. Pleasing colors, art work, relaxing music and privacy are all ways to decrease the confusion in the holding area and to make patients feel more relaxed. Nurses must do everything possible to personalize patient's experiences and avoid making them feel like part of an assembly line. Patient must not feel rushed preoperatively. They need time with the staff members to express themselves and ask questions. More importantly to the patients is the response and treatment they receive from the caring nurses in the holding area. A slow, unrushed pace and quiet atmosphere give the impression of competence and consideration. Humor plays an important part in the holding area atmosphere. It is a therapeutic communication technique and is useful in reducing a patient's anxiety and even pain. Nurses in the holding area must have: 1. Interpersonal skills 2. Relate to all types of people 3. Be empathetic 4. Self control 5. Acute assessment 6. Rapid accurate assessment of patients 7. Be able to communicate Remember nothing can replace the security derived from caring nurses. Remember, "Admit a stranger but discharge a friend, all in one day." RELEASE AGAINST MEDICAL ADVICE PURPOSE: To document that the patient action is with full understanding that the physician recommends continued hospitalization. SUPPORTIVE DATA: A release against medical advice form is completed when a patient desires to leave the FACILITYagainst his physician's advice. It indicates that the patient is competent and fully understands that it is not in his best interest to leave but he accepts responsibility for his actions. May be done by RN or LPN. EQUIPMENT LIST: Release Form STEPS: 1. Action prior to release a. Notify nurse manager or house supervisor and physician that the patient and/or relative intend to leave against medical advice. b. Communicate to patient that insurance may not pay FACILITY bill with this action. c. Have patient and/or guardian read and sign release form. 1) Be sure form is clearly understood 2) Signature must be witnessed by a licensed personnel. 2. Action at time of release a. If patient refuses to sign AMA form, immediately notify nurse manager or house supervisor and physician. b. Document in NCFR that the patient action is with full understanding that the physician recommends continued hospitalization. c. Document if patient signed or refused to sign AMA form. DISCHARGE OF PATIENT PURPOSE: To facilitate the dismissal of a patient from the hospital. STEPS: Approved Discharge: 1. Action prior to discharge KEY POINTS a. After discharge has been written, notify business office of the discharge.. b. Return unused meds to pharmacy. c. Complete Discharge Instruction sheet for patient's home care, including: 1. Medications - give prescriptions to patient or relatives. 2. Treatments as ordered. 3. Diet instruction by diet sheet. 4. Follow up with physician. d. If patient discharged to nursing home, complete 2-page Patient Transfer Form and send pink copy to physician's box. 2. Action at the time of discharge. a. Assist patient with personal belongings. Get any valuables that may have been placed in locker by patient. b. Complete record: 1) Patient's chart: c. Chart patient's condition, ability to do own ADL's, or who will assist patient, any treatments or equipment needed. Chart all medications to be continued at home by the patient. d. Place MAR and all patient records from bedside in patient's chart. Unit secretary will remove old chart and/or folder from file cabinet and place with the current chart and place current and old chart in designated spot for courier pick up to Medical Records at midnight. 2) Discard all temporary records. e. Instruct relatives to stop by business office; they will bring computer discharge slip back to nurses' station. If necessary, the patient may be taken by the business office for checkout. d. Accompany all patients with their personal effects (unless discharged by ambulance) by wheelchair to entrance for dismissal.