Welcome to the Medicine Program

Nursing Orientation Package

Name _____________________________________________

Manager _____________________ Hospital __ ________ Unit__________

Patient Care Coordinator ______________ Clinical Nurse Educator_______________

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Welcome to the Medicine Program

On behalf of the Executive Director of the Medicine Program, and our Leadership Team, we are excited that you have chosen to work in our program. We are committed to a culture of quality care for our patients and creating positive workplaces for our staff. We do our best to live our values every day. Respect, caring and trust – are values that describe how we interact with our fellow employees, volunteers and physicians, and with our patients. “Home is Best,” is our philosophy of care. We know that home, not hospital, is the best place to recover from an illness or injury, to manage long term conditions and to live out final days. By ensuring that patients go home just as soon as they no longer need an acute care service, we reduce the risk of falls, pressure sores, and hospital-acquired infections. We are part of an integrated team of care providers that work as ONE TEAM, providing SEAMLESS CARE to our patients. This seamless care is essential to creating a better patient and provider experience, and also improving the health of the population and ensuring the future sustainability of the health care system. Acute Medicine Patients are:

• Complex renal patients, most requiring dialysis (acute and chronic) • GI patients • Complex diabetics • Cancer patients • Patients with respiratory illnesses • Patients with pain management issues • Patients requiring frequent and complex dressing changes • Stroke, cardiac and medical neurology patients • Patients undergoing tests, procedures and diagnostics that are too sick to wait at home • Awaiting complex placement

Model of Nursing Care Delivery: Across medicine we work as a collaborative team. The units are staffed by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Health Care Aides (HCAs). FH values education and teaching, and there will be many opportunities for you to work with students, new graduates and professionals from many disciplines. If you have concerns about your patient assignments due to competencies, please speak to your PCC or Charge nurse.

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Team Work Principles:

• Everyone is responsible for maintaining a respectful workplace: o Answering all call lights o Assisting visitors, families, and patients who come to the desk o Promoting a positive welcoming learning environment o When you have finished your work, ask your colleagues how you can help them o Ask for help when you need it o There is a possibility that you will be floated out to another unit o Restrict the use of cell phones and personal phone calls to break times. o If you are ill and cannot come to work, it is preferable that you call EARL a

minimum of four hours prior to the start of the shift. o Inform your manager for all absences that exceed three shifts

Medicine Program Dress Code –Professionals at work • Nursing uniforms and FH identification tags are the expected dress code for direct care

providers. • Shoes are to meet the Worksafe BC Standards. • Hair that is longer than shoulder length is to be tidy and pulled back • Please review the Fraser Health Dress Code policy and the Infection Control policy

IC4:0100 • COME, WEAR A SMILE! It is the best addition to any wardrobe!

Other things to find out:

• Unit Staff Meeting frequency – please make every effort to participate and stay informed.

• All unit improvement suggestions are always welcome, if you have an idea that

improves the quality of patient care, please refer to the idea sheet (pages 16 and 17) and feel free to photocopy the idea sheet and submit to your manager/PCC/CNE.

• In order to create a strong team, it is an expectation for all staff to actively participate and/or lead in the unit’s quality improvement projects. We encourage you to share your interests and talents with the team; i.e. wound care, hand hygiene auditor, Care Matters/Unit Professional Practice councils.

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Medicine Program Reporting Structure

Important Contacts EARL (Employee Absence Reporting Line): 604-605-3275 CISM (Critical Incident Stress Management): 1-866-584-7077 or 604-587-3707 EFAP (Employee and family assistance program): 1-800-505-4929 or 604-872-4929 OH&S (Occupational Health and Safety—Work Related Injury Report Line): 1-866-922-9464 My Hospital’s Main Telephone Number:________________________

Dr. Dave Williams, Program Medical

Director, Medicine

Dr. Shallen Letwin, Executive Director Medicine Program

Site Directors Clinical Medicine

Program Directors (5)

Medicine Unit Managers

Medicine Unit Patient Care Coordinators

Front Line Staff

Clinical Nurse Educators

Clinical Nurse Specialist Team (3)

Kim Hawrylecki, Administrative

Assistant

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Your Medicine Leadership Team Contact Numbers Unit:_____________________

Manager:_____________________ Contact Number:____________________

PCC:________________________ Contact Number:____________________

CNE:________________________ Contact Number:____________________

Program Clerk:________________ Contact Number:____________________ Unit:_____________________

Manager:_____________________ Contact Number:____________________

PCC:________________________ Contact Number:____________________

CNE:________________________ Contact Number:____________________

Program Clerk:________________ Contact Number:____________________

Unit:_____________________

Manager:_____________________ Contact Number:____________________

PCC:________________________ Contact Number:____________________

CNE:________________________ Contact Number:____________________

Program Clerk:________________ Contact Number:____________________

Other:______________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

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New Employee Orientation Guide

Administrative/OHS Date Initial I am aware of who my leadership team is i.e. Manager, PCC and CNE I have contact information for my manager and program staffing clerk, CNE and patient care unit

I can access EARL I have completed my on-line NEO module and submitted my certificate

I have completed the NEO Administrative OH&S Checklist and submitted to my manager

I have access to Outlook I have completed a Meditech class (N/A for ESNs) I have access to Meditech I can access myFHinfo.fraserhealth.org (FH Pulse homepage and internet access)

I have my Fraser Health Picture Identification I have obtained parking pass information (temp pass available) I am aware of the dress code I understand the Patient Safety Learning System (PSLS) and its purpose – tutorial available on the FH Pulse

I know how to access the IT help desk for computer issues Professional Development I am competent to practice within my scope and understand my role under the Health Professions Act and the CRNBC & CLPNBC

• CRNBC Self- Learning Modules Available

I understand the relationship between the HPA/CRNBC/FHA and how they guide my practice (RN only)

New Graduate LPN/RN Staff: I have received my CAPE* tool and using this tool:

• I have completed my Self Evaluation • I have started a self-learning plan • I have set up a meeting to review my CAPE with the CNE

I can navigate my way to the FH Pulse intranet homepage from work and home

I have set up my profile on Course Catalogue Registration System-CCRS through FH Pulse and/or general internet access

I have reviewed the recommended medicine program education template and have marked the renewal requirements (annual/biannual)

I have access to the library and learning resources through the FH Pulse – (Library access available from home with special code)

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FHA Policies and Procedures Date Initial I can navigate FH Pulse to find Mosby’s Skills for patient care clinical procedures (complete tutorial if needed)

I can access the FH Clinical Policy Office for evidence-based Clinical Decision Support Tools (CDSTs)

I can access the online FH Parenteral Drug Therapy Manual (PDTM) I understand the infection control policies and procedures and have completed the related education:

• FH Hand Hygiene Module (CCRS) • FH GI and CDI Module (CCRS) • Other:

I have located the Emergency Code Manual via FH Pulse and Unit binder

I understand Safe Client Handling and have reviewed the policy I have an awareness of the policies and procedures for the Provincial Violence prevention program (PVP) via FH Pulse/CCRS

• Search: Violence Prevention • Self-Learning Modules 1-9 “ Violence Prevention” (CCRS) • 4hr PMAB attendance training session • Complete within 3 months

Orientation/Buddy Shift Schedule I have completed all relevant components of the Regional Orientation Scheduled site/unit orientation (2 days)

1. Date:_____________________________________ 2. Date:_____________________________________

Interdisciplinary Sessions as available: 1. Physiotherapy (PT) Date/time: _________________________ 2. Respiratory Therapy (RT) Date/time:____________________ 3. Occupational Therapist (OT) Date/time:__________________ 4. Home Health Liaison Date/time:________________________ 5. Social Work Date/Time: ______________________________ 6. Speech Pathology/Dietician, other Date/time:_____________ 7. Unit Clerk Date/time:_________________________________ 8. PCC Date/time: ____________________________________ 9. Others:___________________________________________

Scheduled buddy shifts (2 days/1 nights) 1. Date:_____________________________________ 2. Date:_____________________________________ 3. Date:_____________________________________

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During My Buddy Shifts, I Need to Discover….

Handover Date Initial Receive report (verbal/written) Review and Update the patient kardexes Utilize unit Nursing Worksheet for team notes Review and Update Patient Care Plans Discuss workload and team allocation (Collaborative Nursing model)

Give overview of patient status to PCC when prompted Room Safety Check Each RN and LPN is responsible for making a safety check of their assigned patient rooms at the beginning of each shift. The following MUST be present:

1. Airway adjunct and bathroom key 2. Oxygen:

• Flow meter • Nipple connector • Simple O2 mask

3. Suction: • Regulator • Canister • Tubing • Yankeur suction • #14 suction catheter

***IT IS IMPERATIVE THAT YOU ENSURE YOU HAVE THE EQUIPMENT YOU NEED IF A CODE BLUE WAS TO OCCUR. CHECK EACH ROOM EACH SHIFT*** You are responsible for checking the function of O2/suction equipment and replacing non-functioning or dirty pieces for your assigned rooms.

Way of Working Allocate appropriate patients within the team PCC to review need for existing added care and/or workload Ensure HCA has appropriate workload and support within the team Coordinate breaks among the team Boost patients and perform AM/PM care together as a team Ensure bedsides are decluttered and safety supplies are available Share call bell responses Mobilize all patients regardless of whether PT is coming or not Assist each other with new admissions

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Date Initial Throughout check the workload status of the unit and assist as necessary

Medication Administration Familiarize yourself with the MAR system at your site Practice Safe Medication Administration

Aim for medication administration times 30 minutes before or after MAR time – document exact time for medications that are timed (Gent/Vanco)

Pour one person’s medication at a time in a quiet zone Practice all of the rights of medication administration Practice independent double checks when indicated Do not leave drugs at patient’s bedside (witness them swallow) Sign off medication immediately after it has been administered by you

Ensure medication carts are locked between use Contact pharmacy in a timely manner for missing meds- Do not delay

Familiarize yourself with the FHA Medication Administration Policy Complete pharmacy documents as needed to refill ward stock (night & prn) and MAR discrepancies

Find the unit medication ward stock Find process to access medications at night (i.e. night cupboard) Narcotics Familiarize yourself with the narcotic book/Pyxis system and routines for narcotic count (i.e. per shift, daily, weekly, etc.)

Demonstrate how to document, co-check, and co-sign carry over Familiarize yourself with the FHA policy around co-checking and dispensing of waste as well as the students & ESN role and rules around carrying of narcotic keys

Be aware of similar sounding medications (examples: Morphine and Hydromorphine; Oxycodone/Oxycontin/Oxycocet, diphenhydramine/dimenhydrinate, etc)

Familiarize yourself with the High risk/high error medications Patch disposal: fold and put in sharps container and sign where needed

Check Narcotic supply, order more using medication refill sheet Lab/Bloodwork Routinely check and evaluate patient bloodwork Address abnormal CRITICAL VALUES from lab immediately i.e. call Most Responsible Physician (MRP)

Initial and file normal lab results Locate lab and processes for packaging and transporting specimens

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Date Initial Review process for drawing blood (Mosby’s): Peripheral pokes first before CVC/PICC access unless otherwise indicated

Phoning the Physician Locate Physician’s list of phone numbers Mentor to show mentee process of contacting physicians. MRP? Hospitalist? Consulting Specialist? Etc.

Note time the call is made, if physician does not return call in the time frame required for your patient, call again – review escalation process for you unit

Use SBAR (Situation, Background, Assessment, Response) when communicating with health care providers

Skin and wound Familiarize yourself with where to find wound care resources: manuals, procedure guidelines, products etc.

How to contact the wound care clinician Find out process for obtaining pressure relief products including ordering a KCI specialty mattress

Medications & Checking new MARS Compare new MAR with the old MAR closely, ensuring that:

- all new medication orders from earlier today are on the new MAR exactly as ordered

- discontinued medications have come off the new MAR

- any changes ordered in dosage, frequency or route of medications are on new MAR

- all active medications are on the new MAR, - (Note: on some units, nurses write saline lock

flushes & G/J Tube flushes & feeds on MAR) - old MARs are filed into chart and new ones are

placed in the MAR binder. Discard old Medication Profile.

- You sign off the remainder of the chart; including signature record, flow sheets, etc.

For sites without Pyxis: check to ensure you have enough meds for next 24 hours. If not, fax refill sheet to pharmacy.

Outdated or discontinued medications are returned to Pharmacy Dispose of empty patient labeled medication baggies/IV bags in confidential plastic disposal bin

Medication carts cleaned and restocked with new garbage bags, syringes, and sharps container changed prn.

Documentation Complete all in and outs, flow sheets and documentation prior to leaving your shift

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Date Initial Kardexes completed & updated each shift Complete CVC checklist (if applicable), ensure line measurement is done once a day

File labwork, reports, discarding any interim or duplicate copies Ensure charts have blank charting forms (VS, Flow sheets, order sheets, etc.)

Ensure all supplies are stocked i.e. linen, IV and other procedure carts etc.

Other Essential Duties Using your Safe Client Handling passport, familiarize yourself on how to operate the different transferring equipment and lifts i.e. Z-slider (ask buddy to demonstrate)

Tidy ward, patient rooms, nursing station and declutter hallways All electronic lifts, IV pumps, Vital Sign monitors and all electronic equipment are plugged in (to charge battery and prolong overall battery life)

Check that all ceiling lifts are in “docked” position (orange light is on)

Ensure urinals and commodes are empty before leaving your shift

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Medical Unit Orientation Clinical Learning Scenarios

Use the following case scenarios to find the needed resources on your unit. Return

completed form to CNE.

1. Mrs. P has been admitted with CHF. You have called the Physician because she has crackles to both lungs and is short of breath. They order Furosemide 40 mg IV STAT and a foley catheter.

- Locate the online Parenteral Drug Therapy Manual (PDTM) for the drug monograph for Furosemide

- According to the Client Monitoring Levels in the PDTM, is it appropriate to give this via the IV Direct route on your unit?

- Locate IV insertion supplies and the vital sign equipment - Is a catheter required? - Does an RN need a physician’s order to initiate a peripheral IV or oxygen? - Location of foley catheters & insertion kit - Would you use a regular drainage bag or an urometer and why? - What else might this patient need?

2. Mr. T is Day 2 post left-sided ischemic CVA and hasn’t been able to void in the last 8 hrs.

- Locate the Regional Pre-Printed Orders Acute Ischemic Stroke/TIA orders and the Stroke care path (not to be confused with the Regional PPO for Ischemic Stroke IV Alteplase).

- What do the orders say we should do for Mr. T related to voiding? - Locate CAUTI (catheter associated urinary tract infections) and the RN imitated

Urinary Retention guidelines online - Locate the Bladder Scanner - Locate the Bladder Scanner Patient Care Guideline online - Mr. T would also like a warm blanket and another pillow. Where are they

located? - What other members of the multi-disciplinary team need to see Mr. T?

3. Mr. H is in alcohol withdrawal and on the CIWA (Clinical Institute Withdrawal

Assessment of Alcohol Scale) Protocol. His last score was 27. - Locate the CIWA Pre-Printed Protocol and the CIWA Assessment form - Locate the Alcohol Withdrawal Patient Care Guideline online - How often does he need to be assessed? Would you wake him if he is sleeping? - What medication might he need and how often? - What safety precautions might he need? Find where they are located - Would it be more appropriate to assign Mr. H’s primary nurse as an RN or LPN?

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4. Miss H is admitted with a new diagnosis of Type 2 Diabetes.

- Locate the Inpatient Diabetes Education Resources online - Locate the glucometer - What type of diabetic education would this patient require? - Her blood sugar is 2.5 mmol, the meal tray has just been delivered to her

bedside. What would you do? - Locate the Hypoglycaemia Protocol. - Do you need a physician’s order to treat her hypoglycaemia? Why? - As an LPN, are you able to treat the hypoglycaemia? - 15 min after you have treated her, her blood sugar is 1.7 mmol. What would you

do next? - The blood glucose level is still below 4.0 mmol, what will you do now?

5. Mrs. R is 90 years old and awaiting ALC (alternate level of care) placement. She has had delirium since her hip fracture repair 2 weeks ago and keeps trying to crawl out of bed.

- What would you assess for this patient? - What was her previous routine/baseline? - What is a CAM instrument? Would it be appropriate for this patient? - What is PRISME? Would this apply to this patient? - CCRS: Adult Urinary Incontinence/ CAUTI - What supports are in place for challenging responsive behaviours and need for

added care? Does this person meet the requirements for added care? If so, how would you assign care to this patient and why?

- Locate the “Client 7 day observation record” and “Behaviour Pattern Record” - Would it be appropriate to use one for this patient? Where is it located and who

can fill it in? - Locate the Least Restraint Policy online - Locate the Least Restraint Monitoring & Documentation Tool online - Locate the FH approved restraints. What type(s) might be appropriate for use

with Mrs. R? - Locate the purple GENI (geriatric emergency network initiative) binder and

review the resources & information available

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6. Mr. M is being treated for community acquired pneumonia. He normally

smokes 2 packs per day and is insisting on going for a smoke. - Locate FHA Smoke Free FH Pulse webpage and resources - Locate the Nicotine Replacement Therapy (NRT) Pre-Printed Orders- who can

use these and what are the implications for use? - Should we offer NRT to Mr. M? If so, how do you calculate how much? - Does Mr. M have any medication considerations needed if he chooses to use

NRT? - Where can Mr. M go to smoke? - Can Mr. M smoke while using NRT? - How does the FH Oral Hygiene guideline apply to this patient?

7. Mrs. J was admitted with liver failure and is doing poorly.

- Where would you find her MOST (Medical Orders for Scope of Treatment) status?

- You have discovered Mrs. J is a CPR C2. What does this mean? - What safety equipment would you ensure is located in her room? - You find Mrs. J unresponsive and in respiratory distress. What would you do?

Who would you call? - How would you call a Code Blue? Find out how these are run at your site. - Despite the efforts of the Code Team, Mrs. J passes away. Locate the forms for

Death and Donor Management.

8. Mr. C needs to have blood work and IV medication. He tells you he has an IVAD (Intravenous Vascular Access Device) and asks that you access it.

- Locate the CVC Patient Care Guideline on Mosby’s. - Locate the Supply list on Mosby’s. - Find the Regional CVC Maintenance Worksheet. - Locate the equipment needed to access the IVAD and draw blood work. - Once accessed, how often will his dressing need to be changed? - Do you need a physician’s order to access an IVAD? - How often does the access needle need to be changed? - The IVAD is now accessed and capped, how often will you flush the line? - Locate the room where the IV pumps are stored.

9. Mrs. B is on a Heparin drip post pulmonary embolism.

- Find the correct pre-printed heparin protocol. - Locate heparin monograph and infusion chart in the PDTM online. - Locate all documentation required for Mrs. B’s chart. - How often will Mrs. B need regular blood work? - What lab test(s) will need to be ordered? - Are there mobility considerations for Mrs. B?

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10. Mr. A has a triple-lumen percutaneous CVC and is receiving (Total Parenteral Nutrition) TPN. He also is on isolation for C-Difficile.

- Locate the CVC patient Care Guideline online. - Locate the TPN Patient Care Guideline. - Which lumen should the TPN be administered through? - Where do you locate the Pre-Printed Orders for TPN? - How long does the lipid solution run? Do you infuse the whole bag? - How often do you change TPN tubing? - Locate the Infection Control Guideline for C-Difficile online. - Locate any relevant applicable forms. - What Personal protective Equipment (PPE) to you wear with C-Difficile? - Which isolation sign do you post? - What room accommodation is appropriate for this patient?

11. Mrs. X’s physician has ordered her to have a blood transfusion.

- Locate the Blood Transfusion Guideline. - Locate the blood product information sheets on the FH Pulse Laboratory website. - Who has to sign the Transfusion Consent? - The physician did not leave an order for a peripheral IV. What should you do? - How can an LPN assist in caring for this patient?

12. Mr. V has been admitted with sepsis. His vital signs are BP-100/70, P-100, R-26, T-38.7 C. His oxygen saturation is 80% on 4 L\min via nasal prongs.

- Is this patient appropriate with an LPN as the primary nurse, an RN as the primary nurse, or a collaborative approach with the LPN & RN sharing the care?

- What oxygen device would be appropriate? What flow rate should be used? Who should you contact?

- Does the RN need a physician’s order to initiate oxygen? - What are the patient’s immediate care needs? - Mr. V’s vital signs are now BP-76/40, P-125, R-32, T-39 C, and O2 Saturation

86% on 10L/min mask. Who should you contact?

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Idea Sheet FAQ

What is an “Idea Sheet” and what is it used for? As the name implies, the Idea Sheet is a way of collecting ideas and presenting them in a standard format. Idea Sheets are used to harness the ideas of staff and provide the raw materials for making quality improvements. The premise behind the Idea Sheet is to make it easy to submit an improvement idea.

Drawings or pictures of your idea help others visualize the issue and your ideas about improvement. If you wish to draw, use stick figures or basic sketches—this is just a tool to get your ideas on to paper. You can combine it with pictures of the current state (i.e. before)—anything that makes your idea clear will help. If you find it easier to describe your idea instead, use the before and after boxes to write out your improvement idea. Are you interested in small improvement ideas or just big ones? Both are valuable, but small improvement ideas are encouraged because they are easy to test and implement. Smaller scale changes can multiply and result in big improvements. What happens after I submit my idea? Your idea will be reviewed by your manager and/or your quality improvement team. If you add your name to your idea, you may be contacted for further follow-up. A quality improvement initiative may be developed from your idea. Do I need to be involved if a quality improvement initiative is developed from my idea? You do not need to be involved after submitting your idea but your participation in quality improvement initiatives is helpful and is strongly encouraged.

What information do you want about my idea? There are four steps to presenting your idea:

O Design it: draw, describe or picture how things will look before and after your idea

Why do you want drawings or pictures of my idea? O Deliver it: give your idea to your improvement team

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Design it: draw, describe, or picture how things look before and after your improvement idea

Idea Sheet

Adapted from: http://andrewboynton.com/wp-content/uploads/2011/05/MyIdeaSheet.jpg

Deliver it: give your idea to your improvement team for consideration (add your name to this sheet if you would like further follow-up)

AFTER

BEFORE

Describe it: briefly describe your improvement idea

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Orientation Evaluation (Submit one copy per shift)

Name: Date: Buddy:

Best part of today…

Most important thing I learned…

My next steps…i.e. Professional goals

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Orientation Evaluation (Submit one copy per shift)

Name: Date: Buddy:

Best part of today…

Most important thing I learned…

My next steps…i.e. Professional goals

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Orientation Evaluation (Submit one copy per shift)

Name: Date: Buddy:

Best part of today…

Most important thing I learned…

My next steps…i.e. Professional goals