EvergreenHealth Policy

Code of Conduct Administrative Adm 175.1 (Rev: 2)Official

Code of Conduct

BACKGROUND

A key element of the Compliance Program is our Code of Conduct. Our Code of Conduct is based on our mission and values, and re-affirms the values and professional standards that exist among all who are associated with Evergreen Healthcare. A foundation of this is our commitment to protecting the integrity of clinical decision-making based on patient assessment regardless of compensation arrangements.

Our Code of Conduct was designed to serve several purposes:

To communicate the commitment of management to comply with laws, regulations, standards of care, ethical business practices and the basic standards expected in the workplace; and

To ensure that each employee understands his or her responsibility for keeping in full compliance with these laws and regulations and specifically his or her responsibility as part of Evergreen’s Compliance Program.

Our Code of Conduct and our Compliance Program have the full endorsement of the Board of Commissioners, as well as the management team. Familiarize yourself with this document. It provides an overview of the compliance program and the general areas that it covers.

INTRODUCTION

We at Evergreen Healthcare recognize that you, our employees, are the key to providing a high-quality health-care experience for both clinical and non-clinical business activities. We also recognize that we must act in accordance with our Code of Conduct, policies, procedures, laws and regulations. Failure to do so can result in serious consequences for individual employees and medical staff members, as well as the organization. Each of you has an affirmative duty to report compliance issues—failure to do so can result in termination.

While our Code of Conduct is designed to provide overall guidance, it does not address every situation. More specific guidance is provided in Evergreen Healthcare's Policies and Procedures. These can be found on Lucidoc, Evergreen's document management site. If there is no specific policy or if a policy and the Code of Conduct provision conflict, our Code of Conduct becomes the policy.

The Code of Conduct is a "living document" that will be updated periodically to respond to changing conditions or regulations. Questions regarding our Code of Conduct, or any compliance issue, can be directed to your immediate supervisor, to the Compliance Officer or to upper management. Issues can also be reported confidentially and anonymously to the compliance hotline or directly to the Compliance Officer. For more information about the hotline and placing an anonymous call, please refer to organizational policy (Corporate Compliance Hotline).

ENFORCEMENT

Failure to comply with this Code of Conduct or to conduct business in an honest, ethical, and reliable manner can result in civil fines or criminal penalties against Evergreen and its employees and/or corrective action by Evergreen, up to and including termination. Supervisors, Managers, and Directors are responsible for ensuring that their employees receive a copy of this Code, participate in any mandatory training related to Corporate Compliance, and complete the annual Code of Conduct Attestation. Completion of the annual attestation is a condition of employment and failure to comply will result in termination. Compliance with the Code of Conduct will be a factor in evaluating the performance of Evergreen employees. (Corrective Action Guidelines)

COMMITMENT TO COMPLIANCE

Quality, honesty and integrity in everything we do are important values to all of us who are associated with Evergreen Healthcare. We are committed to providing quality health care and services in full compliance with our mission and organizational values. We live in a world of constantly changing regulations and requirements. We are committed to adhering to these laws, government regulations, third-party payor agreements and our own policies and have implemented a Corporate Compliance Program to assist in this process.

Our Code of Conduct applies to all employees, including supervisors, managers, directors and administrators. It also applies to temporary and contract employees, volunteers, physicians on the medical staff, and, where practical, to independent contractors. The terms "Evergreen", "we", "you", and "Employees" as used in this document, are meant to refer collectively to employees, Board members, providers, volunteers, students and other individuals who are authorized to act as representatives of Evergreen Healthcare.

Violations of the Code of Conduct have serious consequences for patients, Evergreen, and other employees and must be addressed.

What is my role in the Compliance Program?

Read and understand the Code of Conduct and other policies and procedures that pertain to your work.

Remember that each one of us is responsible for keeping the organization in compliance.

Complete the annual Code of Conduct attestation form

Ask questions and report concerns if you believe there is a compliance issue.

The Code of Conduct is divided into four major sections:

I. Standards of Conduct

II. Patient Care

III. Business Practices

IV. Workplace Conduct and Employment Practices

I. STANDARDS OF CONDUCT

All of Evergreen Healthcare's business affairs must be conducted in accordance with federal, state and local laws, professional standards, applicable federally funded health-care program regulations and organizational policies with honesty, fairness and integrity. You are expected to perform your duties in good faith, in a manner that you reasonably believe to be in the best interest of Evergreen Healthcare and its patients and with the same care that a reasonably prudent person in the same position would use under similar circumstances.

The standards below are not intended to cover every situation which may be encountered and you are expected to comply with all applicable laws and regulations whether or not specifically addressed in this document. Questions about the existence, interpretation or application of any law, regulation, policy or standard should be directed to your Supervisor, Vice President or to the Corporate Compliance Officer.

Let the following principles guide your behavior and conduct:

ALWAYS…

Conduct your job with truth, integrity and fairness.

Treat everyone, including patients, employees, physicians, and visitors with respect and courtesy.

Document your activities accurately and completely.

Maintain the confidentiality of all information, written and verbal, related to patients and to the business of the organization.

Report any real or suspected violation of policy or law to your supervisor or the Corporate Compliance Officer.

Disclose actual and potential conflicts of interest.

Ask if you are unsure whether your actions are allowed.

NEVER…

Make incomplete or inaccurate entries in any hospital medical record, business record, or claim for payment.

Accept any gifts of more than nominal value, or cash—including tips.

Seek or accept payment for referrals you receive; or offer to pay, or pay for referrals.

Make political contributions or engage in political activity on behalf of the organization or while on Evergreen's premises.

Misuse Evergreen assets or use Evergreen property for personal reasons.

Retaliate against another employee for voicing disagreement with an idea, proposed action, or for reporting a violation of Evergreen policy, the Code of Conduct, or law.

II. PATIENT CARE

Emergency Treatment

We follow the Emergency Medical Treatment and Active Labor Act (EMTALA) in providing a medical screening exam and necessary stabilization of all patients with an emergency condition regardless of their ability to pay. In an emergency situation or if a patient is in labor, we will not delay the medical screening exam and stabilizing treatment to obtain financial or demographic information. Patients with emergency medical conditions are transferred to other facilities only at the patient's request or if the patient's medical needs cannot be met at Evergreen and appropriate care is available at another facility that has agreed to accept the patient. (Patient Transfers to other Healthcare Facilities)

Patient Rights

We recognize the personal dignity of all patients and respect their right to participate in decisions regarding medical care and to access and control the use and disclosure of their protected health information. (Patient Rights and Responsibilities and Notice of Privacy Practices)

Patient Health Information

Patients' health care records are the property of Evergreen and shall be maintained to serve the patient, necessary health care providers, the institution and third party payors in accordance with legal, accrediting and regulatory agencies. The information contained in the health care record belongs to the patient and must be protected. All patient care information, whether it is electronic, on paper, or oral, must be regarded as confidential and available only to authorized users, such as treating or consulting physicians, employees who are involved in providing treatment, payment processing, or health care operations, and to third party payors in order to facilitate reimbursement. Patient information may never be accessed for personal reasons. (HR policies Confidentiality/Professionalism & Ethical Behavior; Information Privacy and Security Sanctions, and Access to Health Information).

Quality of Care and Patient Safety

Evergreen is committed to providing high quality, evidence-based safe care for our patients, and a safe work environment for our employees. We improve care and services by acting on information received from a variety of sources, including Quantros event reporting, patient feedback, audits and case reviews, data analysis, literature, and best practice information. We strive to meet or exceed regulatory standards with the expectation for individual and collective compliance with the standards.

Each employee is accountable for his/her own performance and practice which complies with organizational standards and expectations, and for identifying and reporting variances and opportunities for improvement. While our quality and patient safety activities focus on system and process issues, we address reckless behavior when identified.

We practice transparency by public reporting and sharing of outcome information within Evergreen and with our community.

Employees and medical staff who have concerns about patient safety and/or quality of care are encouraged to report their concerns via Quantros or to the Quality Department. Patients are encouraged to report their concerns to the Patient Relations department. Concerns may also be reported directly to the Joint Commission or the Department of Health Facility and Service Licensing.

III. BUSINESS PRACTICES

Anti-Competitive Conduct

Evergreen will not engage in anti-competitive conduct that could place an unreasonable restraint of trade or a substantial lessening of competition. Communications with competitors about matters that could be perceived to have the effect of lessening competition or could be considered as collusion or an attempt to fix prices should take place only with administrative approval after consultation with legal counsel.

Anti-Kickback and Self-Referral (Stark)

We shall refrain from any conduct that may violate anti-kickback and self-referral laws. These laws prohibit direct, indirect or disguised payments in exchange for the referral of patients (Anti-kickback and Self Referral).

Coding and Billing

We are committed to ensuring that coding, billing and submission of claims to Medicare, Medicaid and other third party payors be appropriate, accurate and in compliance with applicable laws and regulations. This includes billing only for services and care provided and documented, according to medical necessity guidelines. (Billing and Claims Reimbursement)

Confidentiality

In addition to patient confidentiality, the operations, activities, business affairs and finances of Evergreen should be kept confidential and discussed or made available only to authorized users for Evergreen's business purposes. (Confidentiality, Professionalism and Ethical Behavior)

Credit Balances

We comply with federal and state laws and regulations governing credit balance reporting and refund all overpayments in a timely manner.

Excluded Business Relationships

Any individual, including Employees, Board members, Physicians, Vendors, Consultants, Contract Individuals or services and other third parties that have been sanctioned by the Medicare, Medicaid, and/or other federal health care programs, are excluded from any business or other relationship with any entity of Evergreen Healthcare. Only upon reinstatement by the governing agency can a business relationship be considered. Sanctions represent a full range of

Examples of business information that must be kept confidential:

Pricing and costs

Acquisitions, divestitures and other strategic relationships

Business and marketing plans

Staffing level plans

Employee and customer lists

Research and quality data

administrative remedies and actions available to the government to deal with questionable, improper, or abusive practices under the Medicare and Medicaid programs. Sanctions results when a health care provider violates obligations and requirements governing items and services he or she renders bills for and gets paid for on behalf of Medicare or Medicaid beneficiaries. (Recruitment/Transfer/Pre-employment Screening; and Vendor Policy)

False Claims Act

We will not knowingly or intentionally submit false, fraudulent, or misleading claims to any government entity or third party payor, including but not limited to claims for services not rendered, claims for medically unnecessary services, claims which characterize the service differently than the service actually rendered, or claims which do not otherwise comply with applicable program or contractual requirements (Corporate Compliance Program Auditing and Monitoring). We will not make false representations to any person or entity in order to gain or retain participation in a program or to obtain payment or excessive payment for any service. (False Claims Act)

Financial Inducements

We shall not offer any financial inducement, gift, payoff, kickback, or bribe intended to induce, influence, or reward favorable decisions of any government personnel or representative, any customer, contractor or vendor in a commercial transaction or any person in a position to benefit Evergreen or the employee in any way.

Appropriate commissions, rebates, discounts and allowances are customary and acceptable business inducements provided that they are approved by Administration and that they do not constitute illegal or unethical payments. Any such payments must be reasonable in value, competitively justified, properly documented, and made to the business entity to whom the original agreement or invoice was made or issued. Such payments should not be made to individual employees or agents of business entities. Commission, rebates, discounts and allowances shall be accurately reflected on Evergreen's annual Cost Report.

Financial Reporting

All financial reports, accounting reports, research reports, expense accounts, time sheets and other documents must accurately and clearly represent the relevant facts of true nature of a transaction. Improper or fraudulent accounting, documentation or financial reporting is contrary to Evergreen policy and a violation of applicable laws. Sufficient and competent evidential material or documentation shall support all cost reports.

Fraud, Waste and Abuse

We are committed to preventing, detecting and correcting fraud, waste and abuse related to health care benefits, regardless of whether those benefits are paid by the government, a commercial health plan, or an employer. If you are aware of or suspect health care fraud, you are responsible for reporting it to the Corporate Compliance Officer or Internal Auditor.

Investigations

We are committed to investigate all reported concerns promptly and confidentially to the extent possible. The Corporate Compliance Officer coordinates any findings from internal investigations and immediately recommends corrective action or changes that need to be made. All employees are expected to cooperate with internal and external investigation efforts. Evergreen cannot and will not retaliate or discriminate against an employee or other individual who, acting in good faith, reports a violation of the Code of Conduct, Evergreen policy, or law. (System Resolution of Identified Problems)

What is a "good faith" report?

If you make a report about something that you believe to be true and that you believe violates the Code of Conduct

or another organizational policy or law, it's a good faith report. A report that is made maliciously or frivolously is not in good faith.

Research

All research and other extramurally funded projects conducted by Evergreen employees, or with the use of Evergreen resources or facilities, must be approved by the Department of Research and comply with relevant policies and guidelines. (Research at Evergreen Healthcare)

IV. WORKPLACE CONDUCT AND EMPLOYMENT PRACTICES

Behavorial Standards and Disruptive Conduct

As a critical component of our success, we expect each member of our workforce to provide excellent customer service to our patients, visitors, and each other. This includes treating all of our customers with respect, understanding, and caring, as well as demonstrating a positive, "can-do" attitude in all interactions and situations. (Behavioral Commitments in each job description)

All persons within Evergreen are to be treated with courtesy, respect, and dignity and all employees and medical staff members shall conduct themselves in a professional and cooperative manner. Employees and Medical staff members who engage in unacceptable disruptive conduct shall be subject to disciplinary action in accordance with Evergreen's corrective action procedures (Medical Staff Disruptive Conduct Policy, Behavioral Commitments in each Job Description and Corrective Action Guidelines).

Business Ethics

Employees must accurately and honestly represent Evergreen and should not engage in any activity or scheme intended to defraud anyone of money, property or honest services.

Conflict of Interest

In order to perform their duties with honesty and fairness and in the best interest of Evergreen Healthcare, all employees must avoid conflicts of interest in their employment. A conflict of interest or the appearance of a conflict of interest may exist when employees, by reason of their position, authority or knowledge, allow or cause themselves, friends and relatives or anyone with personal ties to benefit directly or indirectly by their actions on behalf of the organization, or allow or cause the organization to be adversely affected in any way.

Conflicts also may arise in other ways. If an employee has any doubt or question about any of his or her proposed activities, guidance or advice should be obtained from his or her supervisor or Human Resources (Conflicts of Interest, and Conflicts of Interest in Research).

Duty to Report and Cooperate in Investigations

As a member of Evergreen's workforce, you have an affirmative duty to report compliance issues. Evergreen cannot and will not retaliate or discriminate against an employee or other individual who, acting in good faith, reports a violation of the Code of Conduct, Evergreen policy, or law. In addition, you have a duty to cooperate in compliance investigations. (See also Response to Subpoenas below).

Equal Opportunity Employment

Evergreen Healthcare is an equal opportunity employer. As such, Evergreen Healthcare offers equal employment opportunity without regard to race, creed, color, sex, marital status, religion, age, physical, mental or sensory disability, disability, veteran's status or any status protected under applicable local, state, or federal law. Equal opportunity shall pertain to hiring and firing; compensation, assignment, or classification of employee; transfer, promotion, layoff or recall; job advertisements; recruitment; testing; use of company facilities; training and apprenticeship programs; fringe benefits; pay, retirement plans, and disability leave; or other terms and conditions of employment. Unlawful discrimination will not be tolerated. (Equal Employment Opportunity; and Equal Opportunity Employment)

Gifts and Entertainment

You may not accept gifts from patients of cash, cash equivelents (such as gift certificates), or gifts of more than nominal value for your own personal use. With the exception of events which directly benefit Evergreen Healthcare, employees will not solicit gifts of any nature from current or potential vendors. Gifts, trips, dinners, or other offers with a nominal fair market value (as per Evergreen's Gift Acceptance policy) may be accepted by Evergreen Healthcare employees as long as the gift is not an enticement to influence a purchase decision. (Gifts - Acceptance and Giving).

The Foundation coordinates all gift acceptance activities and donor records on behalf of all fundraising activities for the District. (Gift Acceptance and Fund Dispursement)

Harassment and Workplace Violence

Physical conditions are only one component of the work environment. Evergreen must also be free of discrimination and harassment. Actions, words, jokes, or comments based on an individual’s gender, race, ethnicity, national origin, age, religion, disability, veteran status, or any other legally-protected characteristic will not be tolerated. A prompt investigation will be conducted, and we will take appropriate corrective action where it is warranted.

Sexual harassment is a form of misconduct that undermines the integrity of the employment relationship. No male or female should be subject to unsolicited and unwelcome sexual overture or conduct, either verbal or physical. Sexual harassment does not refer to occasional compliments of a socially acceptable nature. It refers to behavior that is not welcome, that is personally offensive, which undermines morale, and therefore interferes with work effectiveness. Sexual harassment committed by any individual associated with Evergreen is specifically prohibited as unlawful and against Evergreen policy. Any individual who has reason to believe that he or she is the victim of harassment or discrimination should promptly report the facts of the incident. (Harassment Free Work Environment; Workplace Violence Prevention Program)

Health and Safety

We are all responsible for making Evergreen a healthy, safe, and caring work environment. You must exercise good judgement with regard to the environmental aspects of the use of buildings, equipment, and supplies, including proper discharge and disposal of any hazardous materials used and/or generated in performing your duties. (Hazard Communication Program)

Infection Control policies and procedures have been developed for your safety and the safety of patients we all serve. Failure to follow prescribed policies could place you and others at risk. We are committed to meeting or exceeding all industry standards established for the control of infectious diseases and your adherence to those standards is an essential job responsibility. (Infection Control Operational Guidelines; Hand Hygiene)

Inspection and testing of all equipment is also essential. You are expected to be aware of and exercise this responsibility, as your duties may require. Equipment inspections and testing must be done in a timely manner and in accordance with the manufacture’s maintenance guidelines. (Minimizing Risks)

Information Technology

We have established policies that govern the appropriate use of our information technology resources, including personal use of the internet and Evergreen e-mail systems, security mechanisms, and downloading of software. (Appropriate Use of Computing Resources)

What can I do to help protect our information?

Never share your computer passwords with anyone for any reason

Lock or log off your computer work station before you walk away

Don't open email attachments that are suspicious or come from someone you don't know

Secure mobile computing devices, such as laptops, cell phones, PDAs, and thumb drives.

Intellectual Property

Employees will not disclose or misuse any confidential or proprietary information or trade secrets that they have access to during the course of their employment with Evergreen and even after their employment at Evergreen ends.

Employees may, during the course of their work at Evergreen, develop or be part of a team that develops a new invention, published work, software program or other type of intellectual property. If an employee develops intellectual property within the time and scope of their work at Evergreen, because Evergreen pays their compensation and provides all facilities and resources for their work, Evergreen owns the rights to the invention. (Intellectual Property at Evergreen)

Political Activity

As a public hospital district, Evergreen cannot engage in any political activity that promotes or opposes a particular point of view or candidate, except in certain limited situations. You may not participate in political activity on Evergreen premises or as a representative of Evergreen Healthcare. (Prohibition on Use of Federal Dollars for Direct Political Activities)

What kind of political activity can an employee participate in?

You may, as a private citizen, participate in political, charitable, community, and other similar organizations, so long as:

Your participation does not raise a conflict of interest, and

you do so as a private citizen and do not imply endorsement by Evergreen.

Protection of Assets

Evergreen will make available to employees assets and equipment necessary to conduct Evergreen Healthcare business including such items as computer hardware and software, billing and medical records (hardcopy and/or in electronic format), fax machines, office supplies, copy machines and various types of medical equipment. Employees should use these assets in a prudent and effective manner. Evergreen property should not be used for personal reasons or be removed from our facilities without appropriate approval. Employees are expected to report time and attendance accurately. (Timecards)

Employees are also expected to adhere to Evergreen's policies regarding Record Management, Retention, and Destruction. (Records Disposition Management; Records Retention)

Response to Subpoenas

Evergreen has a specific policy about responding to a subpoena or search warrant. In general, employees should not accept service of a subpoena and should contact Administration immediately. (Response to Subpoenas and Search Warrants; Legal Investigations; and Court Orders)

Substance Abuse

Evergreen Healthcare is a drug free environment. You must report to work on time and free of any drug or alcohol that can impair your job performance or risk the health and safety of patients, other employees or guests. Unlawful manufacture, distribution, dispensation, possession or use of drugs and/or alcohol is prohibited on Evergreen grounds or during work time and will result in disciplinary action, up to and including dismissal.

We recognize drug and/or alcohol dependency as a major health problem and encourage you to seek rehabilitation referral through our Employee Assistance Program and to access your health insurance benefits if you need help with dependency. All referrals are confidential.

If you are convicted of a drug related crime occurring at the workplace must notify Human Resources within five days of the conviction. (Substance Abuse)

ADDITIONAL STANDARDS

Evergreen Healthcare has adopted a number of other organization-wide policies and procedures. Employees may obtain copies from the Lucidoc document repository (Policies/Lucidoc) on the EverLink intranet site. There may also be additional standards and policies that are applicable to particular departments and copies may be obtained from supervisors, managers, or directors in those departments.

CONTACT INFORMATION

Richard Meeks, Corporate Compliance & Privacy Officer 425-899-2011 or RAMeeks@evergreehealthcare.org

Compliance Hotline 425-899-5599 Compliance@Evergreenhealthcare.org

EvergreenHealth Policy

Work Restriction Policy Infection Control & Employee Health

12203 (Rev: 4)Official

POLICY

Persons with an infectious disease or who are susceptible and exposed to an infectious disease shall be restricted from direct contact with patients when transmission of the disease to the recipients of care or others in the workplace can occur in that particular job environment and/or the disease can cause serious illness.

All healthcare workers are strongly encouraged to receive recommended vaccines including influenza. There is a zero tolerance policy regarding employees working with febrile illnesses or uncontrolled cough. However, in the event of accidental person to person transmission or an illness or an outbreak, appropriate follow up can be received in Employee Health Services.

INCLUSIONS:

Evergreen Healthcare employees, physicians, students, volunteers and vendors employed or contracted by Evergreen Healthcare.

REGULATORY REFERENCE: Washington Administrative Code (WAC) 248-100-186 Washington Administrative Code (WAC) 246-215-260

PURPOSE

To prevent transmission of infectious diseases to patients, visitors and staff within Evergreen Healthcare.

PROCEDURE

Employee Health (425.899.2282) or after hours the Healthline (425-899-3000) should be consulted if there are questions concerning the safety of allowing employee to return to work.

1. An employee who believes he/she may be in the early stage of an infectious illness must remain home and consult their health care provider. See table of work restrictions for specific diseases.

2. Employees should not report to work if they have:

a. Fever of 100.5 or more, by itself or with any of the following symptoms:

Cough, runny nose, or sneezing

Sore throat

Swollen glands

b. Eye infections c. Vomiting d. Diarrhea (more than one loose stool per day) e. Uncontrollable cough f. Undiagnosed rash and / or (+/- fever) g. Jaundice h. Lesion containing pus that is open and draining

If the employee has an illness diagnosed by a Health Practitioner due to:

a. Norovirus

b. Hepatitis A virus

c. Shigella spp.

d. Enterohemorrhagic or Shiga Toxin producing Escherichia coli

e. Salmonella Tiphi

They should report this to their employer and not return to work until cleared by a health care provider and Employee Health Services.

The manager or supervisor should report this to Employee Health Services immediately.

3. If the employee is already at work, he/she must take protective measures to prevent transmission until the situation can be evaluated and they can be released from their work duties. Arrangements for the employee to be relieved of duty as soon as possible must be made through the manager or designee. The manager or employee may call Employee Health Services (EHS)or Infection Control if they have questions.

4. A physicians release and approval by EHS may be required for an employee to return to work after an illness.

Guidelines for managing employee work restrictions are listed in the table. The Medical Director of Infection Control and/or Employee Health may be consulted if needed.

SECTION I. An employee with an infectious illness or exposure to an infectious disease may not work in the hospital environment during the known period of communicability.

Chickenpox (Varicella zoster)

Active

Post exposure

(susceptible employee)

Until all vesicles are dried and crusted.

From 10th day after first exposure through 21st day (28th day if varicella-zoster immune globulin, VZIG, is given) after last exposure or if varicella occurs until all lesions are dry and crusted.

Herpes simplex

Genital

Whitlows

Orofacial

Employees may work with good hand washing.

Relieved from direct patient care until lesions heal. Must see Employee Health

prior to returning to work

Not able to work in NICU, Pediatrics, Women’s services or with any severely immunocompromised patients. Must be cleared by employee health

Shingles (Herpes zoster)

Localized, in healthy employee

Generalized or localized in immunosuppressed employee

Restrict from patient contact. Non-clinical employees may work outside of patient care areas with lesions covered.

Restrict from patient contact

Measles (Rubeola, hard measles)

Active

Until 7 days after rash appears.

Post exposure

(susceptible employee)

Until 5th day after first exposure through 21st day after last exposure and /or 4 days after rash appears.

Rubella

Active

Post exposure

Until 5 days after rash appears

Until 7th day after first exposure through 21st day after last exposure.

Mumps For 9 days after onset of swelling; less if swelling has subsided.

Influenza like illness (ILI)

Incubation 1-3 days

If exposed and employee has been vaccinated, no antivirals are needed.

If symptomatic and employee has not been vaccinated, employee should not work and antivirals should be initiated.

Influenza vaccination is required when antivirals are indicated unless the influenza vaccination is contraindicated.

Viral respiratory infections, acute febrile Restrict from direct patient care until acute symptoms resolve and respiratory secretions are controlled. NOTE: An employee who has cold symptoms, such as runny nose without fever must wear a surgical mask during patient contact and practice rigorous hand hygiene.

Pertussis

Active

Post Exposure (asymptomatic employee)

Post Exposure (symptomatic employee)

Active Pertussis-Exclude from duty for five days after start of effective antimicrobial therapy or until 3 weeks after the onset of paroxysms if appropriate antimicrobial therapy is not given.

Prophylaxis is required

Exclude from duty until 5 days after start of effective antimicrobial therapy.

Rubella (German measles) Until 5 days after rash appears

Scabies or Lice Until 24 hours after initiation of appropriate treatment and cleared by EHS.

Tuberculosis

Active disease

Until receiving appropriate therapy and clinical improvement. The infectious disease physician shall review the case prior to allowing the employee to return to work.

PPD converter No restrictions after active disease ruled out.

SECTION II. An employee may or may not require work restriction due to specific acute infections or carrier states.

Staphylococcus aureus

Active, drainig skin lesion

Carrier state

Restrict from contact with patients and patients environment or food handling until lesion(s) have resolved.

No restrictions, unless employee are epidemiologically linked to transmission of the organism.

Streptococcal infection, group A Until 24 hours after adequate treatment started.

Acute hepatitis B, HBsAG positive

Acute hepatitis C

HIV positive or AIDS

Consult with EHS

Infection Control Medical Director will evaluate on a case by case basis.

Neisseria meningitidis (meningococcus)

Acute

Post Exposure (close intimate contact with positive patient)

An employee would be too ill to work Exclude from duty until 24 hours after effective therapy.

Prophylaxis required

Hepatitis A, Salmonella, Campylobacter, Shigella, Cholera, Worms/Parasites, Amebiasis

Food handlers are restricted. In other health care workers, evaluation by Employee Health or Infection Control is necessary.

SECTION III. An employee must be evaluated by Employee Health or their health care provider regarding their release to work if they have signs or symptoms of the following:

Any possible or diagnosed infectious condition, such as skin infections, pertussis, C diff, shingles.

EvergreenHealth Policy

Administration of Medications Nursing 761.13 (Rev: 4)Official

PURPOSE:

To safely provide the patient with appropriate medication as ordered by the physician and indicated by clinical condition.

All nurses should understand why a medication is being administered, the action of the medication, normal dosage range for the patient, correct route and adverse reactions the patient might experience. Resources for drug information are located on all units and in Cerner (Micromedex, Up to Date). A pharmacist is available 24 hours at Ext. 2761.

PERSON RESPONSIBLE: Registered Nurse

PROCEDURE: General Guidelines:

1. Prepare medication for a patient in an area free of distractions to minimize risk of error 2. Read the Medication Administration Record (MAR) for medication to be given 3. Read and verify medication label with information on the MAR

General Steps:

1. Before administering a medication, the nurse will: a. Check allergies b. Check for correct medication (based on the medication order and product label) c. Check for correct patient d. Check for correct time and date e. Check for route to be given f. Check for correct dosage g. Visually inspect the medication for particulates, discoloration or loss of

integrity: verify that the medication has not expired h. Verify that no contraindications exist for administering the medication i. Explain the procedure, provide patient information about medications, any

potential clinically significant adverse drug reactions, or other concerns regarding administration of a new medication and answer questions as appropriate

j. Ask patient to notify RN immediately of any side effects of medication after administration

2. Perform hand hygiene 3. Prepare medication 4. Check the patient's name band, verifying two patient identifiers against the patient record.

Acceptable patient identifiers include: a. Printed patient name on ID band

b. Printed medical record number on ID band c. Printed Financial Information Number (FIN) on ID band d. Printed birth date on ID band e. Patient's verbal verification of name f. Patient's verbal verification of birth date g. Family member/caregiver verbal verification of name h. Family member/caregiver verbal verification of birth date

5. Scan the patient's armband and scan the medication, if unit is using bedside scanning devices a. Be aware that certain medications require a 2 nurse or nurse and

pharmacist witness: IV heparin, PCA narcotic syringes, chemotherapy and insulin 6. Administer medication to the patient 7. Wait at the bedside until patient has taken the medication or the medication has started

infusing. (Medication may not be left at bedside unless ordered by the physician) 8. Complete details of documentation as necessary: document medication given on paper MAR if

this is unit's practice 9. Perform hand hygiene

INJECTIONS: See chart for maximum volumes per age and site

Muscle group and/or

Injection route

Birth to 1.5 years

Maximum dose in mL

1.5 – 3 years Maximum dose in

mL

4 to 6 years

Maximum dose in mL

7 to 14 years

Maximum dose in mL

15 years to adult

Maximum dose in mL

Deltoid (IM)

Not recommended

Not recommended. If no other site, 0.5

mL

0.5

0.5

1

Vento gluteal

(IM)

Not recommended

Not recommended. If no other site, 1 mL

maximum

1.5

2

3

Vastus lateralis

(IM)

0.5 - 1

1

1.5

2

2.5

Intradermal

0.1

0.1

0.1

0.1

0.1

SQ

0.5

1

1

1.2

1.5

INTRAMUSCULAR INJECTIONS: Injection into a muscle: see chart for recommended intramuscular needle length and gauge selections per age

Age Location of injection Needle length Needle

gauge Infants < 18 months Vastus lateralis 7/8"-1" 25-27 G

Children > 18 months and walking to 18 years

Deltoid Ventro gluteal Vastus lateralis

7/8"-1 1/4" 22-25 G

Adults > 18 years

Deltoid Ventro gluteal Vastus lateralis

1"-1 1/2" (up to 3" for large adults) 19-25 G

1. Obtain equipment:

a. Appropriately sized syringe per chart above b. Select a needle long enough to reach deep into the intended muscle per chart above c. Alcohol wipe d. Gloves

2. Prepare medication:

a. Fill syringe with exact amount of prescribed medication b. Don gloves

3. Choose injection site:

a. Deltoid site: deltoid muscle, just below the acromion process (i.e., the small curved structure on the lateral edge of the shoulder blade; it articulates with the clavicle to form a joint, the “point” of the shoulder). The injection site is 1–2 inches below the acromion process. Be sure to administer the injection into the upper third of the deltoid.

b. Vastus lateralis/Anterior thigh site: the anterior lateral portion of the thigh, about midway between the top of the greater trochanter and the lateral femoral condyle (i.e., the outer side of the knee). The injection site is the middle third of the lateral aspect of the thigh.

c. Ventro gluteal site: ventro gluteal site refers to the ventral (side) of the patient at the upper portion of the gluteal muscle group between the top of the iliac crest and the greater trochanter. It is located by placing the heel of the non-dominant hand over the greater trochanter with the thumb toward the patient’s groin. Form a “V” with the index and middle fingers by spreading the index finger so that it is pointing toward the anterior iliac spine and the middle finger is pointing toward the bony ridge of the iliac crest. The injection site is within the “V” area

***Injection sites should be rotated and should be selected so as to be appropriate for the amount of solution to be administered. Use divided doses in different muscle masses if indicated.

4. Clean the injection area with alcohol wipe

5. Spread skin taut by spreading skin at site of injection with one hand and insert needle rapidly at 90-degree angle

6. Withdraw the plunger slightly. If blood appears, withdraw the needle and repeat procedure with a new needle

7. Inject the solution slowly and remove needle from injection site. Activate the safety device on the needle

8. Cover the injection site with gauze or a bandage and apply light pressure until bleeding stops

9. Immediately discard the syringe and needle in sharps container in the patient's room

SUBCUTANEOUS INJECTIONS: Injection into tissues just below the dermis of the skin

1. Obtain equipment: a. Appropriately sized syringe containing correct amount of medication; at room

temperature if possible (not cold) b. 25 gauge 3/8-5/8 inch needle c. Alcohol swab d. Gloves

2. Choose site/and solution amount in mL per chart above based on age and build of patient: a. Outer aspect of upper arm b. Thigh c. Abdomen: Do not inject within 1 inch/2.54 cm of the umbilicus

3. Injection sites should be rotated and should be selected so as to be appropriate for the amount of solution to be administered

4. Don gloves and clean the area with an alcohol swab 5. Gently pinch and elevate the skin around the injection site and insert the needle at a 90º angle

unless the patient has little subcutaneous tissue, if so, insert the needle at a 45º angle. (When using an insulin pen, administer the injection at a 90º angle because insulin pens have shorter needles)

6. Do not aspirate for blood return before administering heparin, insulin, immunizations, or vaccines. In these cases aspiration is not necessary and/or may damage small blood vessels and cause hematoma

7. Inject the solution slowly and remove needle from the injection site. Activate the safety device on the needle

8. When administering heparin or Low Molecular Weight Heparin (LMWH) consider the following: a. Select a site at least 2 inches/5 cm from the umbilicus b. Administer the injection over 30 seconds to produce less bruising c. Aspirating to detect blood prior to injection may damage small blood vessels and

cause bleeding and hematoma d. The injection site should not be massaged following injection because this can

promote bleeding at the site and irritate the skin and tissues e. Withdraw the needle at the same angle that it was inserted, and apply gentle

pressure to the injection site using a sterile gauze pad or alcohol swab 9. Apply gentle pressure with an alcohol swab, then discard the swab 10. Immediately discard the syringe and needle in sharps container in the patient's room

INTRADERMAL INJECTIONS: Injection into the dermis just under the epidermis

1. Obtain equipment:

a. 1 mL syringe b. 27-29 gauge needle c. Alcohol swab d. Gloves

2. Choose site/and solution amount in mL per injection site

a. Forearm-0.01-0.1mL

3. Follow steps of administration as above in numbers 3,4, except inject to form a wheal on the skin at 10-15°angle

a. Assist the patient to relax his/her forearm on a tabletop or armrest b. Cleanse the intended injection site with an alcohol swab and allow it to air dry c. Uncap the needle and administer the injection as follows:

i. Using the thumb of the non-dominant hand, pull downward on the skin below the injection site

ii. Verify that the needle is bevel up, and then slowly insert the needle into the skin at a 5–15 degree angle. Advance the needle no deeper than 1/8” inch below the skin’s surface

iii. Push the plunger to slowly inject the medication, while observing the formation of a wheal beneath the skin

iv. Withdraw the needle at the same angle at which it was inserted and apply very gentle pressure to the injection site using a gauze pad or alcohol swab. Activate the safety device on the needle. Do not massage or rub the site

4. Immediately discard the syringe and needle in sharps container in the patient's room

METERED DOSE INHALERS: (MDI) 1. Perform the following steps for use of an MDI:

a. The first time using a new MDI canister, prime the spray by releasing one or two metered doses into the air

b. Shake the MDI to mix the medication and propellant c. Instruct the patient to exhale through pursed lips d. Instruct the patient to place the mouthpiece into the mouth with the lips tightly

around it and with the canister upright e. Instruct the patient to depress the metered dose dispenser to dispense the

medication f. Instruct the patient to inhale for 3–5 seconds slowly and deeply g. Instruct the patient to hold his/her breath for about 10 seconds to allow time for

the medication to be absorbed

h. Instruct the patient to slowly exhale through pursed lips i. If the written order is for more than one puff, instruct the patient to wait 1–2

minutes between inhalations to prevent bronchospasm and to shake the canister between each puff

j. Instruct the patient to gargle and rinse his/her mouth with water and spit the water out after using the MDI

DRY POWDER IINHALERS: (DPI)

1. Perform the following steps for use of a DPI: a. Don gloves. b. Remove the capsule from the package c. Open the outer cap of the inhaler device and the mouthpiece d. Place the capsule in the center of the chamber e. Hold the device upright and leave the outer cap open f. Close the lid until a click is heard and leave the outer cap open g. Press the side piercing button completely and release h. Instruct the patient to exhale completely i. Instruct the patient to insert the mouthpiece and place lips tightly around it j. Instruct the patient to inhale deeply enough and with enough force to hear the

medication capsule vibrate k. Instruct the patient to hold their deep breath for 10 seconds l. Instruct the patient to remove the mouthpiece from the mouth and breathe

normally

TOPICAL MEDICATIONS:

1. Don gloves 2. Wash and dry skin prior to application unless patient has recently bathed 3. Apply the appropriate amount of cream or ointment to the area of skin to be treated 4. Spread the medication with an even circular rubbing motion, continuing until the medication is

evenly spread

TOPICAL PATCHES : 1. Select an area of the skin on the trunk or upper, outer arm (avoid the extremities below the

knee or elbow) 2. Nitroglycerin patches are typically applied to the upper arm or chest, estrogen patches to fatty

areas of the skin such as the stomach or buttocks, and nicotine patches to the upper arm 3. The area should be clean, dry, and hairless. If hair is likely to interfere with system adhesion or

removal, it can be clipped, but not shaved. Avoid areas with cuts or irritations 4. Don gloves and apply patch. Remove and discard old patch per pharmaceutical waste policy

SUBLINGUAL MEDICATIONS: 1. Don gloves 2. Place the medication under the tongue 3. Allow the medication time to dissolve completely: instruct the patient not to swallow before

the tablet/capsule has dissolved

EAR MEDICATIONS: (EAR DROPS/OTIC SOLUTIONS)

1. Obtains the following: a. Medication with medication dropper b. Cotton ball or gauze c. Gloves

2. Don gloves 3. Turn patient's head to the unaffected side 4. Withdraw the appropriate amount of medication into dropper 5. Straighten the ear canal by pulling auricle gently upward and back 6. Instill the medication and place cotton ball or gauze on outer ear opening 7. Instruct the patient to keep head turned to unaffected side for 10-15 minutes

LIQUID AND OINTMENT EYE MEDICATIONS: (OPHTHALMIC SOLUTIONS)

1. Don gloves 2. Instill drops or ointment into the conjunctival sac (pull the lower eye lid down slightly) 3. Ask patient to look down while finger contact on lower lid is maintained. Prevent the patient

from squeezing eye shut 4. Remove finger from lid 5. If ointment is used, instruct the patient to keep his/her eye shut for at least one minute to

allow the ointment to melt

STRIP OR STICK EYE MEDICATIONS:

1. Don gloves 2. Moisten end of strip or stick (or follow manufacturer's recommendations) 3. Place the moistened strip at the fornix in the lower inner corner of the eye 4. Remove the strip from the eye after contact (or follow manufacturer's recommendation)

NASAL MEDICATIONS:

1. Obtain the following: a. Medication in bottle or nasal spray bottle b. Medicine dropper, if needed c. Tissue d. Gloves

2. Nose drops:

a. Place a pillow under the shoulders of the patient so that the head will drop back and forehead will be lower than chin. (If the patient is sitting in a chair, instruct the patient to hold his/her head well back)

b. Don gloves c. Brace patient's head if necessary to avoid damage to nasal tissue should head move d. Instill prescribed number of drops into the specified nostril, directing flow toward

floor of nasal cavity. Avoid touching the nostril with the dropper; use tissue under the nos

e. Instruct the patient to maintain position for about five minutes f. Raise patient to a sitting position to allow medication flow to the lower part of

nose. Supply tissues 3. Nasal Spray:

a. Gently shake the container b. If using a pump bottle for the first time, prime the pump by holding it upright and

away from you, and spraying a small amount into a piece of sterile gauze c. If not contraindicated, assist the patient in tilting his or her head forward slightly d. Don gloves e. Ask the patient to close his/her mouth and breathe out, then inward slowly through

the open nostril f. As the patient begins to inhale, place the container tip no more than ¼ inch/0.635

cm away from the exterior opening of the nostril–avoid contaminating the container. Point the tip toward the back of the nostril—aim straight toward the back of the head, not upward into the nasal turbinates. Press down on the canister delivery button to administer the medication

g. Supply tissues

ORAL MEDICATIONS:

1. Sit the patient in a near 90o, head up position in order to avoid aspiration. 2. Offer the patient the medication in a medicine cup, staying with the patient until the

medication is taken. 3. May use an oral syringe in lieu of a medicine cup for liquid medication when the patient has a

potential for aspiration, if liquid medications are allowed per speech pathologist recommendations

a. Place the patient in a 90o, head up position b. Don gloves c. Administer the medication slowly into the side of the patient's mouth to avoid

aspiration, monitor carefully

RECTAL SUPPOSITORIES:

1. Obtain the following: a. Suppository of prescribed medication b. Gloves c. Lubricant

2. Assist the patient to a left side lying position with the knees flexed and the right leg in front of the left leg

3. Remove packaging of suppository 4. Don gloves and apply lubricant to the suppository 5. Separate the buttocks and insert the suppository gently into rectum beyond internal sphincter 6. If necessary, apply pressure to the anus or hold the buttocks together until the desire to expel

suppository has passed

IV MEDICATIONS:

1. See Peripheral Intravenous Therapy Guidelines 2. See Central Line Policy

DOCUMENTATION:

1. Chart the medication on the Medication Administration Record (MAR) or via the electronic medical record per unit procedure

2. Observe for and document patient's reaction to medications 3. Document patient teaching related to medication administration. Medication information for

patients is available through Micromedex, Up to Date and Krames, accessible from the patient's electronic chart

4. If additional or in depth medication teaching is indicated, consult with pharmacist

REFERENCES:

Administration of Medication: Administering Skin/Topical Medications By: Caple C, Schub E, Pravikoff D, CINAHL Nursing Guide, June 21, 2013

Nursing Reference Center

Administration of Medication: Subcutaneous Injection By: Caple C, Richards S, Pravikoff D, CINAHL Nursing Guide, October 12, 2012

JCAHO 2004 Medication Management Standard MM 5.10

Evidence - Based Competency Management, 2nd Edition; 2008. HCPro., Inc.

Potter and Perry; Clinical Nursing Skills and Techniques;6th Edition, 2006.

CINAHL Nursing Guide, Smith, N, Caple, C, Pravikoff, D; 05/06/2011.

EvergreenHealth Policy

Exposure to Blood and Body Fluid Management Infection Control & Employee Health

12201 (Rev: 5)Official

POLICY

Post-exposure follow up and treatment is provided for all employees, physicians, students, and volunteers when any exposure to blood or body substances considered potentially infectious material (OPIM) for HIV, Hepatitis B and C has occurred.

This policy covers post-exposure management of exposures to blood or OPIM and for HIV, Hepatitis B and Hepatitis C testing. This document includes policy for consent for testing in post-exposure situations and guidelines for initiating post-exposure prophylaxis (PEP) medications when appropriate.

PURPOSE

To provide a consistent approach in the assessment and treatment of occupational exposures to blood or OPIM.

Exposures include but are not limited to:

1. Puncture wound from a needle or sharp instrument contaminated with blood or other potentially infectious material (OPIM)

2. Inoculation of conjunctivae with blood or OPIM (eye splash)

3. Inoculation of oral mucosa with blood or OPIM

4. Cutaneous contamination with blood or OPIM

5. Human bites

PROCEDURE

All EvergreenHealth employees with an occupational exposure to blood or OPIM must report the incident immediately to Employee Health Services at 425-899-2278, 0730-1600 or if unavailable/after hours to the Nursing Supervisor at 425-890-4328.

Employee/Physician/Volunteer

1. Immediately report the incident to the manager/designee and Employee Health Services on pager 206-989-6897. If after hours contact the Nursing Supervisor at 425-890-4328. Managers/designee must ensure coverage is provided to the employee on a timely basis so they can proceed with the exposure follow up.

2. Immediately report to the Evergreen Emergency Department for:

Exposure to known HIV positive or high risk patient

An injury that requires medical attention

3. Home Health staff should be directed to report to the nearest hospital emergency department if they require immediate medical attention; otherwise, See Attachment "E" for Home Health or Outpatient Exposure Management.

4. The Emergency Department (ED) provides treatment as warranted by the injury. See Policy for Chemoprophylaxis after Occupational Exposure to HIV: PEP (Post Exposure Prophylaxis for Blood and Body Fluid Exposures) Exposures requiring medical intervention are workers compensation claims. When the employee requires medical treatment such as chemoprophylaxis or injury is severe enough for intervention, ED registration will inform employee of Labor and Industries and Self Insured Employers claim information. See Attachment “C”

5. Within the first two hours after exposure, the person managing the exposure (e.g. Employee Health or Nursing Supervisor) is responsible for reporting the rapid HIV test result to the employee and providing additonal instructions for follow up action. If Employee Health or Nursing Supervisor does not receive timely results, Microbiology can be called at extension 2732. Post-exposure Chemoprophylaxis (PEP) medications work best when started within 1-2 hours from exposure.

a. The employee must stay at work until the source patient’s HIV test result has been determined.

b. If “rapid HIV” result is positive the employee needs to report to the Emergency Department immediately.

c. If employee has not had tetanus vaccine for greater than five years, employee is to contact Employee Health Services within 48 hours to receive tetanus vaccine. If the employee is seen in the ED, vaccination will be provided, if indicated.

d. After hours the ED or Nursing Supervisor must notify Employee Health Services of the exposure by leaving a message at 425-899-2278 and fax the exposure worksheet to Employee Health Services 425-899-2277.

e. Bring all documentation of exposure (Employee Report of Accident form, Epinet survey, consents and completed exposure worksheet) to Employee Health Services. If after hours, leave in confidential drop box next to office door.

Consent and Test

HIV counseling and consent are obtained from the employee and source patient using the “HIV Antibody Blood Consent” form. If the source patient is less than 18 months old, it is optional for their mother to be tested instead. Informed consent must be obtained before the HIV test is performed. Verbal consent is allowed but must be documented. The person who has legal authority (power of attorney) for the source patient can authorize the test if the source patient is not able. All HIV test results are confidential to the patient and employee and may only be disclosed to the authorized individuals. Health care workers may exchange confidential medical information related to HIV testing, the HIV test results and confirmed HIV (or other transmitted disease) diagnosis and treatment, only when necessary, in order to provide health care services to the patient or employee.

If the source patient refuses to have HIV testing then notify Public Health. See Attachment C. HBsAG and HCV can be tested on the source patient without consent if blood is available.

If the employee consents to baseline blood collection, but doesn't give consent at that time for HIV serologic testing, the sample must be preserved for at least 90 days. If, within 90 days of the exposure incident, the employee chooses to have the baseline sample tested, it must be done as soon as possible. Employee Health will send written orders to the lab to hold the blood for 90 days.

All testing is charged to the Employee Health Services account with no cost to the employee or patient. If medical care is sought, expenses will be paid by workers' compensation.

Employee and Source Patient Blood Test Identifier

Exposure packets containing the pre-marked laboratory requisitions are located in Employee Health and the Nursing Supervisor office. Sticker identification numbers located on each laboratory requisition are used for the employee and patient identification for the initial blood tests during a post-exposure follow up. The sticker identification must be placed on every blood tube to match the appropriate laboratory requisition.

Source Patient Testing

Source Patient Baseline Testing: Rapid HIV, HepC Ab, HepBs Ag

1. Rapid HIV testing is used. The purpose of performing the rapid test is to provide the exposed employee quick information about the exposure and to determine if chemoprophylaxis should be started for the employee.

2. The Employee Health Nurse/designee or Nursing Supervisor must call the laboratory staff to come to the unit to draw the source patient’s blood and the lab tech must be given the laboratory requisition at the time of the blood draw. The Employee Health Nurse or Nursing Supervisor must inform the laboratory staff at 3898how to contact them by pager for timely reporting of source patient rapid HIV test results.

3. If the source patient is less than 18 months old, it is optional for their mother to be tested instead.

4. "Source Patient” and “Rapid HIV” test are pre-marked on the laboratory requisition in the exposure packet.

5. Report the Rapid HIV test result immediately to Employee Health Services or after hours to the Nursing Supervisor.

6. Lab will report the the source patient HIV test result to the person managing the exposure. If the HIV result is positive the person managing the exposure will contact the employee in person to report the results and instruct the employee that PEP medication is needed.

7. If the rapid HIV test is positive, escort the employee to the Emergency Department immediately

Disclose test results only to the exposed employee, ED physician, Employee Health Services and Infectious Disease Physician

Positive HIV tests must be confirmed by Elisa and western blot prior to notifying the source patient's attending physician

The Hepatitis B surface antigen and Hepatitis C tests are sent to PACLAB. The results of these tests will be available within two days and will be sent to Employee Health Services

Employee Testing

Employee Baseline Testing: HIV 1/2 Abs, HepBs Ab, Hep C Ab

1. Written or verbal informed consent must be obtained before the HIV antibody test can be performed. If verbal consent then must be documented.

2. Employees may have their blood drawn by the main laboratory in Client Services Purple 1-368 during normal business hours or in their department after hours.

3. The HIV antibody test (EIA), Hepatitis B surface antibody, and Hepatitis C antibody are performed at PACLAB for the employee on a non urgent basis and will be available within two days

4. “Employee”is pre-marked on the lab requisition

5. PACLAB will send the hard copy of the lab results to the Employee Health Services confidential printer

Attachments for these procedures follow at the end of this document:

Attachment A: Recomended post exposure prophylaxis for exposure to Hepatitis B virus

Attachment B: Health Department Assistance with Source Patient Consent

Attachment C: Counseling Instructions

Attachment D: Workers Compensation Information

Attachment E: Exposure at Home Health or Outpatient Setting

DOCUMENTATION

All documentation and lab results are kept in Employee Health Services in exposure files that are separate from the employee health file.

Exposure packets contain:

1. Exposure Checklist

2. Exposure algorithm

3. HIV consent forms for the employee and source patient

4. Laboratory requisitions for the employee and the source patient with pre-assigned identifiers

5. Exposure worksheet

6. Employee Injury/Incident Report

7. Epinet survey

8. Employee Health Services business card

9. Envelope marked "Confidential" for returning forms to Employee Health Services

FOLLOW UP SERIAL TESTING FOR HIV, HEP B AND HEP C

Every effort is made to reach the employee by phone to notify them of test(s) results as soon as the results are made available. The Employee Health Coordinator will send a written follow up medical report to the employee within 15 days. The report will indicate whether Hepatitis B vaccination is or is not indicated.

1. If the source patient's initial test results are negative for HIV, Hepatitis B surface antigen (HBs Ag) and Hepatitis C antibody (HCAb), follow up testing is not recomended for the employee.

2. If follow up testing is needed, Employee Health Services will send follow up testing packets to the employee through the hospital mail system. Additional testing will be provided at no charge to the employee. The employee is informed of the follow up recommendations when counseled during the follow up for the incident.

POST EXPOSURE PROPHYLAXIS (PEP) AND TESTING SCHEDULE

Source Patient Testing

(At time of exposure)

Post Exposure Prophylaxis (PEP) for

Employee

Employee Initial

Testing

Employee Follow up Testing

3 weeks

Employee Follow up Testing

6 weeks

Employee Follow up Testing

3 months

Employee Follow up Testing

6 months

Source patient unknown

Determined case by case

(Employee Health or designee, ID physician or ED

physician to determine)

HIV

HBsAb

HCV

HCV RNA

HIV antibody

HCV antibody

HIV antibody

HCV antibody

HIV antibody

HCV antibody

HIV,HCV,HBsAg negative PEP-No

HIV

HBsAb

HCV

None None None None

HIV positive PEP-Yes

HIV

HBsAb

HCV

None HIV antibody HIV antibody HIV

antibody+

HCV positive PEP-No

HIV

HBsAb

HCV

ALT

HCV RNA HCV Ab

HCV Ab

HCV Ab

ALT

HBsAg positive*

PEP-No

If employee HBsAb titer is positive

HIV

HBsAb

HCV

None None None None

PEP-Yes

If employee HBsAb titer is negative**

HIV

HBsAb

HBsAg

HCV

None

HBsAg

HBsAb++

HBsAg

HBsAb

HBsAg

HBsAb+++

* If source patient positive for HBsAg and employee is a known non-responder then administer HBIG x 1 and initiate revaccination or administer HBIG x 2. Refer known non-responders who have completed 2 series or 6 total doses of vaccine to Infectious Disease for alternative Hep B vaccination protocols.

**If source patient is unknown and employee HBsAb is negative, revaccinate.

+ If source patient is HIV positive and hepatitis C positive, additional testing for HIV is recommended at 12 months.

++ If HBIG is given, do not test for HBsAb at 6 weeks.

+++ If employee still has a negative HBsAb after 2 series of vaccine or 6 total doses, refer them to Infectious Disease for alternative Hep B vaccination protocols.

If the source patient is HIV positive, employee HIV testing schedule is baseline, 6 weeks, 3 months, and 6 months.

If the source patient is Hepatitis C positive, a baseline antibody will be done on employee and a PCR will be performed at 3 weeks on the employee. Hep C antibody will be checked again on the employee at 6 weeks, 3 months and 6 months.

ATTACHMENT A

RECOMMENDED POSTEXPOSURE PROPHYLAXIS FOR EXPOSURE TO HEPATITIS B VIRUS

Vaccination and Antibody Status of exposed

workers*

ANTIBODY RESPONSE STATUS

Source HBsAg

Positive

Source HBsAg

Negative

Source unknown

or not available for testing

Unvaccinated

HBIG§ x 1 and initiate HB vaccine series¶

Initiate HB vaccine series Initiate HB vaccine series

Previously Vaccinated

Known responder**

No treatment No treatment No treatment

Known non-responder€ HBIG x 1 and initiate

revaccination or HBIG x 2+ No treatment

If known high risk source, treat as if source were

HBsAg positive

Antibody Response Unknown

Test exposed employee for anti-HBs ≈

1. If adequate,** no treatment is necessary

2. If inadequate,€ test exposed person for HepBsAg and if negative administer HBIG x 1 and vaccine booster

No treatment Test exposed person for anti-Hbs

1. If adequate, ¶no treatment necessary

2. If inadequate, ¶test exposed person for HepBsAg and if negative administer vaccine booster and recheck titer in 1 – 2 months

* Persons who have previously been infected with HBV are immune to reinfection and do not require post-exposure prophylaxis.

+ Hepatitis B surface antigen.

§ Hepatitis B immune globulin; dose is 0.06 mL/kg intramuscularly.

¶ Hepatitis B Vaccine.

** A responder is a person with adequate levels of serum antibody to HBsAg (i.e., anti-HBs ≥10 mlU/mL).

€ A non-responder is a person with inadequate response to vaccination (i.e., serum anti-HBs < 10 mlU/mL).

± The option of giving one dose of HBIG and rei-nitiating the vaccine series is preferred for non-responders who have not completed a second 3-dose vaccine series. For persons who previously completed a second vaccine series but failed to respond, two doses of HBIG are preferred.

≈Antibody to HBsAg

Any person who is persistently Hep BsAb negative after completing 2 full Hep B vaccine series or 6 total doses should be referred to Infectious Disease for alternative Hep B vaccination protocols

ATTACHMENT B

Health Department Assistant with Source Patient Consent

When a health care provider, person working in a health care facility, firefighter, or law enforcement officer has been exposed to another person’s blood while on the job, you may need to know that source person’s hepatitis B virus (HBV) or HIV serostatus.

If you are unable to obtain voluntary consent from either the source, guardians, or next of kin, call Edith Allen at 206-731-4377 Disease Prevention Specialist with public health HIV AIDS Program Prevention.

The Department of Public Health can order testing if:

1. A report is filed with the health department within seven days of the incident

2. Reasonable attempts were made to obtain voluntary consent; and

3. The exposure meets the criteria established by the State Board of Health (e.g. parenteral, mucous membrane, or non intact skin exposure to blood, semen or vaginal fluids).

ATTACHMENT C

HIV Informed Consent

In January 2010, The Washington State Board of Health adopted new rules for HIV testing, counseling, and partner services. Under the new rules healthcare providers are still required to obtain informed consent to test for HIV. These changes to Washington Administrative Code (WAC 246-100) align the state rules with recomendations from the U.S. Centers for Disease Control and Prevention (CDC).

1. HIV testing consent may now be verbal but must be documented.

2. Health care providers are no longer required to counsel patients prior to HIV testing.

3. Patients must be provided the opportunity to ask questions or decline the test.

4. Patient counseling and partner services for persons testing HIV positive are now the responsibility of local public health.

ATTACHMENT D

Workers Compensation Information

You are required by Washington State Law to disclose personal health information to the Department of Labor and Industries or a self-insured employer when you are treated under a workers’ compensation claim.

Physicians can disclose personal health information to an employer without an authorization from you.

You can not object to or request to restrict disclosures of your personal health information to the department or self-insurer because it is required by law.

ATTACHMENT E

Exposure at Home Health or Outpatient Lab Setting

Wash the wound or flush the exposed area (eyes, mouth) IMMEDIATELY

If source patient known to have HIV or if medical care required (tetanus or wound care), employee should report to Emergency Department immediately.

Otherwise:

Obtain exposure packet. If employee does not have a Exposure packet contact supervisor.

Consent patient for HIV testing, letting source patient know this is confidential testing using a number only. There is no charge for the patient.

Draw patient’s blood (one lavender and gold top), label with E number and call PacLab Client Services at 425-899-3900 option 2. Inform them of STAT pickup for exposure.

Notify manager and Employee Health Services 425-899-2278. If after 4:00PM, notify Evergreen’s Nursing Supervisor at 425-890-4328. Give phone number/cell phone where you can be reached to receive rapid HIV results. Give requisition number of source patient.

If source patients HIV test is positive, employee must report to Emergency Department immediately to consider PEP medications.

If source patient HIV test is negative then Employee signs HIV consent and employees blood to be drawn at site or go to EHMC main lab (purple 1-368) NOT URGENT

Fill out exposure worksheet and fax to Employee Health at 425-899-2277 immediately.

Fill out remainder of exposure packet, copy of lab requisitions, and copy of consents and send exposure information in confidential envelope to Employee Health Services Mail stop #42 or drop in confidential drop box located outside the EH office (Blue 1-164).

PURPOSE

EvergreenHealth expects the appearance of every employee to reflect a positive and professional image while on duty. Personal appearance including dress, grooming and cleanliness contributes to the overall business image presented to patients, customers, visitors, physicians and other staff.

SCOPE

All Evergreenhealth employees, physicians, contractors, volunteers and students.

PROCEDURE

EvergreenHealth employees and others affected should dress in a manner which is both personally and professionally appropriate.

Attire and shoes should be appropriate for the employee's role and work performed and meet department, safety and occupational standards. Clothing should be neat, clean, conservative and in good repair. Torn or dirty clothing is considered inappropriate. Extreme (defined as going far beyond what is reasonable, moderate or normal as determined by the manager):

Clothing styles,

Cosmetics,

Hair Color,

Jewelry,

Tattoos,

Body Piercings

are also considered inappropriate and not acceptable in the work environment.

High standards of personal hygiene are essential for every employee. This includes general cleanliness and clean, neatly-styled hair. Body odor should not be apparent. The smell of tobacco on clothing is unacceptable (see Smoke and Tobacco Free Environment policy, HR-WS213).

Fragrances (including perfume, cologne or other scented items) should be avoided due to sensitivities of employees, patients and visitors.

In order to protect the safety and maintain the security of all employees, every employee is required to wear an EvergreenHealth issued photo I.D. badge at all times. Employees may not loan their badges to anyone, including other employees.

Each manager has the discretion and authority to establish and enforce appropriate dress standards for his/her departments. The above policy will apply unless specifically exempted by a department’s own policy for work unique to that area. See HR policy Corrective Action, HR-LA1002 for failure to adhere to EvergreenHealth's dress code.

EvergreenHealth Policy

Dress Code, HR-WS214 HR - Workplace Standards

HR-WS214 (Rev: 3)Official

PERSONAL PROTECTIVE EQUIPMENT AND NAIL HYGIENE

EvergreenHealth provides Personal Protective Equipment to staff that may be exposed to body substances or hazardous materials (as required by law).

Personal Protective Equipment includes, but is not limited to, gloves, impermeable gowns, eye protection, procedure masks or respirator, hats and shoe covers.

It is the responsibility of each staff person to wear appropriate Personal Protective Equipment to prevent exposure to blood or body fluids or infectious disease. All employees must follow Standard Precautions and Transmission Based Isolation Precautions policy and Blood-borne Pathogen Organizational Exposure Control Plan as it pertains to each patient. Transmission Based Isolation Precautions.

Nails of employees, who provide patient care or prepare sterile products for patient care, such as Pharmacy IV preparation, sterile processing and other similar areas working directly with patients or sterile patient products, may not be more than ¼ inch from the end of the nail bed. Additionally, artificial nails or extenders may not be worn, and nail polish, if allowed by departmental policy, may not be chipped.

HOSPITAL-PROVIDED LAUNDERED "SCRUBS"

Hospital-provided laundered "scrubs" (scrub suits) are to be worn only by staff working in hospital-designated clean, sterile, or controlled environments.

Hospital-provided "scrubs" are washable pantsuits of a uniform color and design, purchased and maintained by the hospital, and worn only within the confines of the hospital environment. The sole purpose of hospital-provided laundered "scrubs" is infection control. "Scrubs" are to protect the patient from exposure to potential sources of infection by limiting the introduction of pathogens from the external environment. "Scrubs" are not Personal Protective Equipment.

EvergreenHealth will make available hospital-provided laundered "scrubs" to staff who work directly with patients at high risk for infection, in areas which the hospital has designated as being clean, sterile, or controlled areas. Staff whose job requires them to wear hospital provided laundered "scrubs" will:

put on this clothing upon arrival for their workday;

remove it at the close of the workday and

wear this clothing exclusively on the premises of EvergreenHealth. ("Scrubs" may not be taken home and/or worn outside the hospital grounds.)

prior to going outside the hospital, Evergreen Professional Center (EPC),Evergreen Surgical and Professional Center (ES&PC) or Redmond campus, employees must change into street clothes and change back into scrubs upon return to work areas.

staff and physicians authorized to wear hospital supplied scrubs per the Linen policy must arrive and depart the facility in their own personal clothing, changing into or out of scrubs on the premises. Scrubs are not to be taken off site.

Examples of areas requiring a change of attire:

Parking garages

Courtyard

Perimeter of hospital

Outlying buildings

If in the judgment of the supervisor/manager, an employee does not meet the standards described above, the supervisor/manager is accountable to clarify standards with the employee and follow the progressive corrective action process. The supervisor/manager has the discretion to send the employee home without pay to change clothes and return to work immediately, or to return to work for the next scheduled shift.

EvergreenHealth Policy

Cell Phones Usage and Requirements, HR-WS203 HR - Workplace Standards HR-WS203 (Rev: 3)Official

PURPOSE

This policy outlines the use of personal cell phones at work, including special issues related to use of the camera on cell phones, the personal use of business cell phones and the safe use of cell phones by employees while driving.

SCOPE

All persons employed by EvergreenHealth, non-employed physicians, students, temporary employees, and vendors.

RESPONSIBILITIES

Personal cell phone activities which interfere with an individuals work performance or the work of other employees could result in an individual’s access privileges being taken away or other disciplinary action, up to and including dismissal. Reference Policy HR-WS202 Telephone & Voice-mail Standards and Electronic Communication & Technology and Environment of Care Policy 6-004.02 Radio Frequency Interference.

EvergreenHealth prohibits the inappropriate use of camera phones in the workplace, as a preventative step believed necessary to assure employee privacy and the confidentiality of patient information and other business information. Violations as outlined in Policy HR-WS202 may subject employees to discipline, up to and including dismissal.

Where job or business needs demand immediate access to an employee, EvergreenHealth may issue a business-owned cell phone for work-related communications as per the Cell Phone Agreement (District Owned) policy. Individuals in possession of company equipment such as cellular phones are expected to protect the equipment from loss, damage or theft.

Employees whose job responsibilities include regular or occasional driving and who are issued a cell phone for business use are expected to refrain from using their phone while driving.