UAB Synopsis, Vol. 27, No. 13, April 7, 2008
The UAB Health System’s (UABHS) Standard and Clinical Resources (SCR) Web site has been updated in preparation for The Joint Commission (TJC) site visit. SCR is a secured intranet site that contains the official standards, policies, and resources for all UABHS entities. To access the Web site, click on the SCR icon on Centernet computers or go to https://scr.hs.uab.edu. No password is required. You cannot access this site from home.
References Changes
Among the new material added to UABHS references are these new pages and the task force facilitator responsible for developing each:
Procedures Individual Resident Physicians Are Allowed to Perform Either Supervised or Unsupervised (Click Health System-References-Medical Residents): Users can search this page by resident name or by clinical service. The information includes each person’s postgraduate year status, starting and finishing dates, and the procedures they are allowed to do. James E. Johnson, MD, senior associate chief of staff.
Infection Control (Click Health System-References-Infection Control): This page supports the work of the UABHS Infection Control Committee. It is the first SCR page to have a training video, Coughing, which demonstrates the proper way to cough and sneeze without spreading infection. The new hand washing program, Partners in Your Care, also is in this section (Click PIYC-UAB’s New Hand Hygiene Improvement Program). All staff should review the coughing video and hand hygiene program. Alan M. Stamm, MD, and Mariann Schmitz, Infection Control Practitioner.
Guest Relations (Click Health System-References-Guest Relations): This page includes UAB Hospital and The Kirklin Clinic® maps and local lodging information for guests. Charlotte L. Beeker, Food and Nutrition and Guest Services director.
Medical and Dental Staff (Click Health System-Reference-Medical and Dental Staff): This page offers a quick retrieval of the Medical and Dental Staff Bylaws and Rules and Regulations documents. All medical and dental staff should know how to access these important documents. Two TJC documents recently were added. All medical and dental staff should review TJC Visit Guidelines, which cover essential information physicians must know for TJC visits. TJC information for medical directors also is on this site. Cynthia G. Brumfield, MD, UAB Hospital chief of staff.
Revisions of standards and rules and regulations include:
Informed Consent (Click Health System-Reference-Medical and Dental Staff-Medical and Dental Staff Rules and Regulations for UAB Health System Clinical Facilities and scroll to Section 16-Informed Consent): Informed Consent now complies with new rules to allow the person performing the procedure to obtain the consent. Certified registered nurse practitioners may obtain their own consents if it is part of their collaborative SCR Update agreements. RNs who are approved to perform specialized procedures, such as peripherally inserted central catheter insertions, may obtain their own consents. The Informed Consent standard is revised to align with this change and to address serial consents. Informed consent may be for more than one — or serial — administrations of the same procedure or course of treatment.
Blood Utilization Management (Click UAB Hospital-Standards and enter “Blood Utilization Management” in search box): This standard is revised as an outcome of the Blood Management Project. It includes revised criteria for transfusions.
Restraints (Click UAB Hospital-Standards-enter “Restraints, Use of,” in the search box): Definitions for “Restraint” and “Chemical Restraint” are revised. “Standard Medication” and “Dosing and Delirium” are added to the definitions section. The new Geriatric Consult Service is identified as a resource, between 8 am and 5 pm, for prevention or management of delirium without the use of restraints in patients ≥65 years.
Red Rules Accountability (Click UAB Hospital-Standards and enter “Red Rule” in the search box): This standard establishes Red Rules (must-do rules) obligations and accountability for all clinical staff for delivering safe patient care for all procedures and the consequences for noncompliance. The moment a patient’s clinical care is identified as not meeting the application of required procedures all activity must cease in order to verify the required safeguards are followed.
Clinical Escalation Guidelines (Click UAB Hospital-Standards and enter “Clinical Escalation Guidelines” in the search box): This standard establishes guidelines for obtaining medical assistance when a patient experiences acute changes in condition that warrant urgent medical attention.
Dratha Neumann, RN, is manager of UAB Hospital’s Policies and Standards Resources department, which oversees the SCR Web site.