Norris Inpatient Resident Orientation

• Introduction to Norris Units

• Nursing Organization Structure

• HIPPA

• Admissions

• Orders

• Procedures

• Documentation

• Physical Therapy

• Clinical Social Work

• Infection Prevention

• AYA

• Clinical Nutrition

• Pharmacy

Outline

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3rd Floor Telemetry

4th Floor ICU

4th Floor Telemetry

Norris Units

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** Resident workroom is located on the 4th floor for your convenience**

• Provided by the Pulmonary Critical Care Team; attending, fellow, Nurse Practitioners and ICU nurses

• A Nurse Practitioner is on duty 24 hours/day

• Please refer with the Nurse Practitioner before escalating to ICU level of care.

ICU Services

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Nursing Organization Structure

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• (323) 528-1553

CAS (House Supervisor)

• Richard Lawrence

Nurse Manager

• Anabel Cantero

Assistant Nurse Manager

• One charge nurse per unit per shift

Charge Nurse

• Please be mindful when discussing sensitive patient information in double occupancy rooms

• Also please ask permission to discuss a patient’s plan of care in front of any visitors

• Do not leave any daily patient documentation loosely in unsupervised or patient care areas

HIPPA

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• Enter orders as soon as patients are admitted to avoid delays in care

• Review and sign off on Present On Admission (POA) within 24 hours

• If patient has a CVC please document the necessary reason daily

• For all urgent and Outside Hospital admissions, please contact House Supervisor (CAS)

• Rule out Cord Compression (“Code Spine”) – notify CAS immediately when a patient is identified as a possible cord compression so Code Spine response team can be activated. CAS will assist to ensure policy is followed

• Clarify any Observation and 24 hr overnight stays with case managers if not sure when to flip patients to inpatient status

Admissions

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• Chemo can only be entered by a fellow and DNR/DNI orders must be co-signed

• Specify if blood draw is Lab vs. Nurse Draw

• Please bundle your lab orders as much as possible, this is to limit accessing the Central lines frequently and decrease CLABSI in our vulnerable patients

• Convert any IV meds to POs as soon as feasible

• Notify primary RN when any stat orders or pain management orders are initiated in order (i.e. PCA) to prioritize

• Blood consent – needed on every admission

• Any orders that require transport – please notify the primary RN or nurse lead on the unit so transportation can be arranged (i.e. MRI, PET scan etc.)

Orders

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• MRI

• There are no MRI capabilities at Norris so patients must be transported via ambulance to Keck

• Please notify House Supervisor or lead nurse and/or patient’s primary nurse in order to ensure timely transportation

• GI, Bronch, Epidural, TEE, or any other procedures

• Please consider 24 hours in advance for scheduling

• After appropriate specialty consult, all requested procedures must be approved by the House Supervisor to ensure appropriate staffing and resources are available to accommodate your request.

Procedures

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Documentation

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• Consult PT as soon as possible if there has been an acute change in the patient’s physical mobility, strength, endurance or balance. Consider PT even if patient is in the ICU.

• All patients admitted for BMT/SCT must have PT consult orders on admission

• PT Wound Care: Consult specifically for surgical wounds, diabetic/vascular ulcers, stage 3 & 4 pressure injuries. Otherwise, most other wound management is through Nursing Wound Care.

• Note: Pressure Injuries Stage 1 & 2 treatment orders are required

• To see which patients are being treated by PT today, a schedule is posted daily on the Keck Care Intranet PT Schedule

• PT documentation in Cerner: Reports and Documents Multidisciplinary Notes Physical Therapy• Please check your message center to approve initial evaluations. Hospital policy requires

your signature prior to PT providing F/U for the patient

Physical Therapy

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• Psychosocial assessment/education

• Hospice discharges

• Referrals for community resources

• Suicide assessment/Crisis intervention

• Abuse or neglect reports

• Behavioral contracts/Plan of care

• Mental health concerns

• Facilitate family meetings

• Fertility process

• Advanced health care directives

• CSW is on call 24hr/day

• Contact via operator for after business hours (business hour contact available on last slide)

Clinical Social Workers

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• Hand hygiene before and after entering all patient rooms• C.difficile requires the use of soap and water - not gel

• When possible please remove white coats when entering C.diff isolated rooms

• Observe isolation signage on unit. Wear proper Personal Protective Equipment. Please observe all signage posted per patient.

• CHG wipes are administered every 24 hours to decrease infection. If patient has an allergy it must be documented in their medical record

• No food or drink at the Nurses Stations. Please use hydration area provided. Closed containers only.

Infection Prevention

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• Ruling out TB

• 3 consecutive AFB’s – sputum not BAL – 1 specimen every 8 hours for each of the 3 collections

• If red sheet on chart or Cerner heading “Reported TB” or “Rule out TB”, discharge must be approved by TB control

• For unsuccessful sputum collection attempts please document appropriately

• Blood Cultures - Central Blood Stream Infection is a big challenge on the units

• Blood cultures are peripheral only

• At least 24 hours between blood cultures sets

• C-Diff

• Please consider clinical judgement before ordering PCR

• Once PCR is ordered the following labs, GDH, EIA and CCNA will be ordered to determine likelihood of C-Diff infection.

Infection Protection

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• Shingles

• Immunocompromised patients must be on contact AND airborne precautions

• Surviving Sepsis Protocol

• RNs must screen patients each shift and a standard practice is followed per our Sepsis Policy (i.e. drawing lactate levels when patient meets SIRS criteria and the activation of Severe Sepsis)

Infection Protection

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• 15 – 39 year old Oncology Patients

• From diagnosis through transition to Survivorship

• AYA Social Worker• Extensive psychosocial assessment

• AYA Nurse Navigator • Fertility preservation education and initiation of sperm

banking/egg/embryo freezing

AYA – Adolescent and Young Adult Cancer Program

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• To order a nutrition consult, search for “consult to Nutrition Services” order. Click DONE to see the selected order. In the comment box, write the reason for the consult.

• To order a diet, search for the preferred type of diet. Add modifiers to the diet. Ex: renal. Modifier, mechanical soft. You must cancel a diet in order to change to a different diet.

• An MD order has to be placed for patients requiring isolation trays.

• When ordering a calorie count, make sure the patients is not NPO or has to be NPO for any testing. Calorie counts are done for 3 days then discontinued.

• When ordering a tube feeding, type the name of the feeding under orders and fill in goal rate and type of feeding. The dietitian can help you by proposing the tube feeding order. We no longer check for residuals on tube feeding unless they are above 500 mls. Or signs of intolerance like abdominal distention or vomiting occur.

• TPN: prior to ordering TPN, the dietitian has to be consulted, to see if the TPN is indicated or if a tube feeding is the best choice.

Clinical Nutrition

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• Dietitians are able to order supplements for patients as well as pro-stat. Will propose to you: vitamins or minerals, TF orders and request for blood test to check for nutrition deficiencies.

• Dietitians are performing malnutrition physical assessments on patients (NFPA’s). NFPA is being documented in their assessments and recommendations. Please add that to your admitting diagnosis for adequate reimbursement.

• Hematology residents information is available on the use of glutamine to help prevent mucositis.

• Dietitian notes and recommendations can be seen under reports and documents Nutrition Forms.

• A list of Norris supplement and tube feeding is available to you from the dietitians. Please refer to it when ordering supplements or tube feedings.

• To contact the dietitians: Phone: (323)865-3893

Clinical Nutrition

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• The standard PCAs (1mg/ml) are designed for opioid-naïve patients and thus have hard maximum settings (see below). If the ordered dose is for amounts larger than the hard max, the PCA order will need to be changed to the non-standard concentration (5mg/ml) which has no hard max limit.

Pharmacy

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(626) 622-5489Awa Jones, Nurse Executive

Richard Lawrence and Anabel Cantero: (323) 865-3640Nurse Management

(323) 528-1553 (Mobile) x53114 (Office)CAS

Seble x59727, Edgar x59795, Veronica x59794Case Management

Vinita Kahanna (Hematology & BMT) x53586, Justine Jose (Medical Oncology) x53578Social Work

(323) 865-3893Dietitians

(323) 865-3782 or aya@med.usc.eduAYA

x53601Pharmacy

x53276Norris Lab

x53333Norris 3rd Floor

x53444Norris 4th Floor

x53465Norris ICU

x53339Norris BMT

Important Phone Numbers

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