SARASOTA MEMORIAL HOSPITAL POLICY

Transcription

1 PS1070 SARASOTA MEMORIAL HOSPITAL POLICY TITLE: CHAIN OF COMMAND POLICY #: EFFECTIVE DATE: REVIEWED/REVISED DATE: POLICY TYPE: 4/1/85 12/31/14 Clinical 1 of 5 Job Title of Responsible Owner: Director, Education, Professional Development, and Research Non-Clinical PURPOSE: POLICY STATEMENT: EXCEPTIONS: DEFINITIONS: To establish a written policy for the use of the chain of command within the hospital and to define circumstances and mechanisms to use when unable to contact a physician when needed, concerns for unsafe practices, or there is unresolved concern about the plan of care proposed by a health care provider. When there is a concern about patient care such as orders written, or change in patient condition it is to be brought to the attention of the attending physician. If unable to reach the physician, unresolved concerns remain, or concerns are not addressed, utilize the chain of command as outlined in the policy. In the event the responsible clinical manager/communicator or nursing administrator determines the established time frames for physician contact may inhibit effective patient care, he/she may override these and personally proceed with contacting the medical administrator on-call. Qualified Personnel: Sarasota Memorial Hospital personnel who are licensed, registered and/or certified in a health care profession. Contacting Physician STAT: The attending physician is to be contacted (by using pager, office number, mobile phone, home phone if available or answering service) under the following STAT situations (includes, but is not limited to, these situations). Contact the physician every 15 minutes (x 2) at a minimum for a total of 30 minutes, or more frequently as dictated by patient condition. When calling the answering service, direct them to contact the physician STAT. a. Death (unexpected) b. Suicide attempt c. Acute/serious change in medical condition d. Fall with serious injury e. Serious/adverse reaction to blood or drugs (see Blood and Blood Components-Ordering, Obtaining, ID and Administration, Reactions nursing procedure or Corporate Policy 00.RSK.58 Adverse Drug Reaction Report available on Pulse). f. Critical results (refer to policy 00.PAT.12 Reporting of Critical

2 2 of 5 Results as could be an emergency situation) g. Combative behavior requiring restraint and/or 1:1 attendant care h. Request or threat for leaving against medical advice (AMA) i. New patient admission orders j. Acute episodes of unrelieved symptoms (for example: acute pain, vomiting) k. Abnormal radiology results requiring intervention l. Medical condition requiring change in current orders/regime m. Unable to start IV on patients requiring continuous/immediate IV therapy. n. Refusal of treatment, patient or family o. Active alcohol or drug abuse while hospitalized p. When qualified personnel encounter an illegible or incomplete order, or one that in his/her judgment could be harmful to the patient, he/she has an obligation to contact the physician who wrote the order and ascertain what was intended 1. Chain of Command: PROCEDURE: If the physician does not respond within 30 minutes for a STAT situation (refer to the STAT list in the Definitions above), contact Nursing Supervision/your supervisor to initiate the Chain of Command. Call Stat operator line X3911 and state STAT Chain of Command and provide the unit location and call back number (for example: STAT Chain of Command 10WT x7610 ). This process is available 24/7. If the Medical Administrator on-call does not respond in 15 minutes, repeat call to x3911 (this call can be made a maximum of two times, not to exceed 30 minutes). If unable to contact the Medical Administrator on-call after 30 minutes, call the Nursing Supervision/flow coordinator to utilize the other contact numbers for administrative support. Continue to page the attending physician even after calling the Medical Administrator on-call. a. If after contacting the physician, qualified personnel question the order, there still remain issues, or there are questions about orders received, he/she should contact their immediate supervisor (communicator/clinical manager/nursing supervision) for assistance/intervention. b. The following elements will be documented in the medical record each time an attempt is made to contact the attending physician: Date Time The name of the physician or administrator called Legible or electronic signature and professional designation of recorder

3 3 of 5 If the physician is contacted, returns the telephone call(s), or comes to the facility, document the time and date and response. CHAIN OF COMMAND CONSIDERATIONS: 1. An employee s first responsibility when concerned over the progress of a patient is to bring the matter to the attention of the attending physician. When satisfaction is not obtained, he/she must follow the appropriate chain of command as outlined. 2. When qualified personnel encounter an illegible, unclear, or incomplete order, or one that in his/her judgment could be harmful to the patient, he/she has an obligation to contact the physician who wrote the order and ascertain what was intended. 3. If personnel encounter a situation where they feel patient safety may be compromised due to such issues as: lack of training/experience, or inability to care for patients, they need to bring their concerns to the attention of their immediate supervisor (clinical manager, communicator, director) and follow the chain of command as indicated. 4. An Occurrence Report should be completed describing the event. RESPONSIBILITY: 1. It will be the responsibility of all clinical personnel to adhere to this policy. 2. It will be the responsibility of the department directors to ensure staff is aware of, and adhere to, this policy. REFERENCE(S): REVIEWING AUTHOR(S): Sarasota Memorial Health Care System Policies. (00.PAT.32) Telephone/Verbal Orders Receiving and Documenting. (00.PAT.12) Reporting of Critical Results. Jean Lucas, PhD, Director, Education, Professional Development, and Research Janet Steves, MBA, RN, BSN, Director, Nursing Resources ATTACHMENTS: Chain of Command Quick Reference Sheet

4 4 of 5 APPROVALS: Signatures indicate approval of the new or reviewed/revised policy. Committees/Sections/Departments: Date Director/Responsible Owner: 12/22/14 Vice President/Executive Director: Chief of Medical Operations: (if clinical policy or appropriate) Chief of Staff: (if clinical policy or appropriate) Medical Executive Committee: (if clinical and review requested by CMO and COS) Chief Executive Officer: Jean Lucas, Director Jan Mauck, VP/CNO R. Stephen Taylor, CMO 12/23/14 12/23/14 David Verinder, CEO 12/24/14

5 5 of 5 Sarasota Memorial Health Care System Chain of Command If the physician does not respond within 30 minutes for a STAT situation, initiate the Chain of Command: Inform your immediate supervisor (i.e. charge nurse) to initiate the chain of command. To initiate chain of command, call the operator X3911 and state STAT Chain of Command. Provide the unit location and call back number (for example: STAT Chain of Command 10WT x7610 ). (The nursing supervisor will automatically be alerted with this page call). If the Medical Administrator on-call does not respond in 15 minutes, repeat call to x3911 (this call can be made a maximum of two times; not to exceed 30 minutes). If unable to contact the Medical Administrator on-call after 30 minutes, call the nursing supervisor/flow coordinator to utilize other contact numbers for administrative support. Continue to page the attending physician even after calling the Medical Administrator on-call. If after contacting the physician, qualified personnel question the order, there still remain issues, or there are questions about orders received, he/she should contact their immediate supervisor (communicator/clinical manager/nursing supervision) for assistance/intervention. All Chain of Command calls must be documented in the HAS (Healthcare Advisory System) as soon as possible. STAT situations for initiating the Chain of Command could include the following: Death (unexpected) Suicide attempt Acute/serious change in medical condition Fall with serious injury Serious/adverse reaction to blood or drugs (see Blood and Blood Components nursing procedure or Corporate Policy 00.RSK.58 Adverse Drug Reaction Report available on Pulse). Critical results (refer to policy 00.PAT.12 Critical Test Result Reporting as could be an emergency situation) Combative behavior requiring restraint and/or 1:1 attendant care Request or threat for leaving against medical advice (AMA) New patient admission orders Acute episodes of unrelieved symptoms (for example: acute pain, vomiting) Abnormal radiology results requiring intervention Medical condition requiring change in current orders/regime Unable to start IV on patients requiring continuous/immediate IV therapy. Refusal of treatment, patient or family Active alcohol or drug abuse while hospitalized Contact the physician every 15 minutes (x2) at a minimum for a total of 30 minutes, or more frequently as dictated by patient condition using a pager/mobile phone/home phone/office phone or answering service (if using the answering service, tell them to contact the physician STAT).