Interdisciplinary Practice Committee

September 17th, 2012, 0800 Volunteer Conf. Rm

Present: Kate McCord, CNO; Peter Walsh, MD, VP Medical Affairs, SFMC; Mike Force, Director Pharmacy; Kelly Saucerman, RN, Director of Clinical Effectiveness/Patient Safety; Kathy Guy, RN, Director Professional Services; Andi McDonough, Rehab; Brian Sarpy EVS, Security; Diane DeMasters, RN, CM GI Lab; Jeff Oram-Smith, MD, CMO; Helen Graham, RN Cardiology; Olinda Spitzer, RN, CCU Educator; Nancetta Westcott, Director Medical Services; Sylvia Kurko, RN Education; Evelyn Angeles, RN, CVU; Renee Ward, Director Imaging; Sharon Cerrone, ED Assid CM-PH; Mike Elginton, RN, Cath lab; Kristin Varnes, Director OR; Evelyn Angeles, RN, CVU.
Agenda Items / Discussion / Action / Who Responsible
Reflection / Kate McCord – Journal Article

MEC

/ Presented Code of Conduct at last MEC. / Awaiting feedback.
Sterilization and Environmental Cleaning Procedures / To infection control committee for approval before coming here. / Kristin Varnes
Students, Medical PA, etc / Other Centura facilities have this policy within their Rules and Regulations. Focus on medical staff.
Prefer this be policy and not R&R so staff has access.
Is the orientation process in policy? Medical students to go through orientation.
Application to shadowa physician was discussed; Nursing has stopped shadowing. Isn’t this a double standard? Person shadowing still needs to have background checks, and contract with school in place as well as current flu shot validation.
We do have contacts with all Colorado Springs high schools.
OR has visitation policy which outlines their guideline for outside person in the OR.
Students are issued a badge with expiration date. / Approved.
Students scope of activity / Draft distributed. / Approved.
Student Rotation, S-02-l / Centura will be placing studentpolicies in the HRD section. Reference to Medical Staff process is this policy.
Students must be in a clinical program already. Do not allow people to follow clinical staff / Approved
Student Contracts, S-03-a / Centura placing in HR policies. Specific to how contract set up. Once Centura policy in place we would not need to keep ours. / Approved
Student OBS--form / Approved by MEC.
Visitor if OR—need to review and add to this form. / Will take back to MEC not approved.
Visitor family involvement, V-02-p / Recommend adding visitor behavior.CSPD may be called if intervene. Children must be supervised—adults may be asked to remove children from hospital. / Approved
Order Clarification, Chain of Command.
O-02-k / Reviewed draft. Do we need to define timeframe?
Need to move # 5 before # 2 so that CMO is notified before questionable treatment or order is carried out. / Chain of command needs to be clarified in the beginning of the policy.
Approved with changes
Laser / Reviewed draft. Will have certified laser person in the OR. / Policy has been to several committees. Will send out online. Send any feedback to Kristin.
Order, Stat, ASAP / Reviewed draft.Pharmacy added now as are seeing a lot of now orders. / Need to clarify definition of LIP. Approved
Metered Dose Inhalers, M-08-k / Draft out online and feedback was received. / Approved.
Code Silver, C-01-k / Guideline states to repeat code hourly overhead after code is first called. This is to let people that entered hospital after initial call the code is still going.
Recommend to word “Code Silver Continues” and page every 30 minutes / Approved with changes
Code Blue, C-01- / L&D asked that cancel of code blue can be called by the L&D leader. / More changes from Code Blue committee forthcoming—will send out online for feedback / Kate McCord
Consents, C-03-i / Draft went out online.
Added to page one to be specific on consents.
Need to add to obtain patient consent for observer approval ( already on the consent form but not in the policy)
Cath lab takes DNR patients—included in the consent but not addressed in the policy—need to add. / Approved with changes.
Potassium Replacement-P-02-j / Out online feedback received from pharmacy—approved.
Metered Dose Inhaler, M-08-k / Out online feedback received –approved.
Sedation / Subcommittee meeting to work on thesedation policy.
Policy Naming-Centura / Centura CNO committee in process for naming all the policies—ongoing process. Partial list distributed.

Minutes by Kathy Creech, Nursing Administration

Next meeting: October 15that 0730-0900 am in the Board Room at PH.