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CENTRAL STATE HOSPITAL PROCEDURE SUBJECT: CARDIOPULMONARY RESUSCITATION CODE BLUE ANNUAL REVIEW MONTH: RESPONSIBLE FOR REVIEW: LAST REVISION DATE: August Chief Nurse Executive (CSH) May 2008

Page 1 of 4 No.: 5.20A

This procedure provides guidelines to ensure staff competency and compliance with the CSH Cardiopulmonary Resuscitation Policy. Participants: Service Chief Service Clinical Director Service Nurse Executive Trained Staff Director, Staff Development and Training (SD&T) Department Performance Improvement Staff/Designee

Service Chief 1. 2. 3. 4. Ensure all direct care staff are trained and certified in the recommended American Heart Association (AHA)Cardiopulmonary Resuscitation (CPR) Course. Establish routine Code Blue Drill practices, per Service Area, to include one drill per shift, per building, per quarter, to be conducted by a certified CPR instructor. Ensure staff compliance with CHS Respiratory and/or Cardiac Arrest Code Blue procedure during both actual and/or drill codes. Ensure each drill evaluation is reviewed and recommendations for improvement implemented.

Service Area Nurse Executive/designee 1. 2. Ensure scheduling of staff for certification or re-certification training, as recommended by AHA, and per CSH training calendar. Ensure routine checks/maintenance for Emergency Equipment and Crash Cart are conducted and documented.

CPR Certified Staff Members 1. 2.

Page 2 of 4 No.: 5.20A

Respond to practice drills and actual codes according to CSH Respiratory and/or Cardiac Arrest Procedures (Attachment I) and participate as needed and/or assigned. Participate in actual code events as assigned by charge nurse or shift supervisor.

Director, Staff Development and Training Department 1. Provide appropriate CPR courses for service and support areas. · · · · 2. 3. 4. Basic Life Support for Healthcare Providers (BLS) for all licensed medical staff, to include doctors, nurses radiology personnel, dental service personnel, respiratory services, occupational therapists and physical therapists HeartSaver AED plus First Aid for all direct care staff, activity therapy staff, transportation drivers who accompany clients, and other designated staff as appropriate. HeartSaver CPR for Adults for other support service areas, such as maintenance, housekeeping, food service, etc. Advanced CPR courses, such as Advanced Cardiac Life Support (ACLS), if required for designated CSH staff is provided by external services.

Ensure CPR courses include instruction specific to CSH procedures and policy requirements Maintain an up-to-date roster of all staff trained in CPR. Offer CPR and AED Instructor Courses as needed by hospital.

MONITORING: Evaluation of Code Blue Drills: Code Blue Drill Monitor Instructor (CPR Instructor) 1. 2. 3. 4. 5. Conduct Code Blue drills, at a minimum of one drill per shift, per building, per quarter. An `actual' Code Blue event may substitute for practice drills in the area in which it occurred. Evaluate the Code Drill based on responders performance as outlined in criteria listed in CSH Code Blue Procedure (Attachment I) and Code Blue Drill Evaluation (Attachment III). Provide corrective interventions/instruction/demonstration and or prompting during the drill as needed to ensure correct practice is maintained. Ensure Cardiopulmonary Resuscitation Report, CHS 282, (Attachment II) is completed by unit/ charge nurse and retained by the instructor. Complete evaluation forms for each drill conducted to include: · · Service Area Code Blue Drill Evaluation (Attachment III) CSH Training Roster (Attachment IV)

· 6.

Page 3 of 4 No.: 5.20A Code Blue Drill Report (Attachment V), one report for all code drills conducted

The Drill Instructor will complete the Code Blue Drill Report monthly and submit a copy to the CSH Safety Committee chairperson, Service Area Nurse Executive, Service Clinical Director and Service Chief for review. The original copies of all Code drill forms and Code Blue Drill Report will be maintained by the Instructor for three (3) years, keeping it accessible for the Service Nurse Executive as needed.

Service Area Nurse Executive, Clinical Director and Service Chief 1. 2. Review all Code Blue Drill Evaluations, make comments or recommendations and sign. Make recommendations, if appropriate, and refer back to Drill Instructor. Review any specific aspects of Drills with subordinate staff as needed.

Evaluation of Actual Code Blue Events: Unit/Charge Nurse of Actual Code Blue Victim 1. 2. Assigned nurse completes documentation on CSH #282, CPR Report prior to leaving work site or by the end of the shift. The original CPR report, CSH #282, is completed and either 1) provided for inclusion into the client chart prior to the chart being secured by Police, or 2) if unable to complete before the chart is removed from the unit by Police, completes the form prior to leaving the unit and forwards to medical records.

Service Area Nurse Executive/designee 1. 2. Upon notification of actual Code Blue Event schedules a Code Blue debriefing to be held within five (5) work days. The debriefing is coordinated and conducted by the Debriefing Instructor. The Debriefing Instructor shall be a CSH nurse administrator who performs the debriefing on his/her assigned shift as related to the time/shift of the code. The debriefing shall be conducted within five (5) days of the code. Notifies the actual Code Blue responders/participants to the debriefing meeting. (This group includes but is not limited to the staff who participated in the Code Blue Event and the nurse manager/designee). The Code Blue Debriefing/Critique Report is forwarded to Nursing PI/designee for review and data analysis. If AED procedures were implemented during the Code Event, ensure that data is downloaded, the original AED report is placed in the client's medical record and a copy forwarded to the Nursing Performance Improvement staff/designee for review. Ensure AED post-use procedures are completed and all emergency equipment and supplies are replaced appropriately.

3. 4. 5.

Code Blue Debriefing/Critique Monitor

Page 4 of 4 No.: 5.20A 1. Conduct Code Blue debriefing within five (5) working days of actual Code Blue Event with responding code team members. Include all appropriate staff to include those staff that witnessed the event, discovered the victim, those initiating treatment and any other participants. Discuss any issues for opportunities for improvement identified and develop potential strategies for improvement. Complete the Code Blue Event Debriefing/Critique Report (Attachment VI) with opportunities for improvement outlined. During the Code Blue Debriefing the team reviews data and trends, identifies opportunities for improvement, and recommends opportunities for improvement strategies. Forward the original Code Blue Debriefing/Critique Report to the Nursing Performance Improvement staff/designee with a copy to the Service Nurse Executive.

2.

3.

Nursing Performance Improvement Staff/designee 1. 2. 3. 4. 5. 6. Input data into spreadsheet from Code Blue Event Debriefing/Critique Report. Review data and opportunities for improvement from service analysis of Code Blue and identify trends as well as hospital-wide opportunities for improvement. Prepare NPI analysis and present report to Nursing PI Committee and Safety Committee. Check the AED test logs monthly for quality control, if applicable. Coordinate resolution of any problems identified with biomedical staff. Maintain a file of the test logs. Ensure that an accurate listing of the location of AEDs is maintained and provided to the Safety committee. Provide training in the AED software and download of the data as needed.

Approved: This procedure was approved by the CMO and CEO in April 2008

Attachment 1 Page 1 of 2 Central State Hospital

Respiratory and/or Cardiac Arrest Code Blue Procedure

Definition:

Immediate medical attention is needed for a person who is not breathing and/or does not have a pulse; or has a serious condition which could rapidly progress to cessation of breathing and/or pulse. Unresponsiveness Absence of respirations and/or heartbeat

Signs and Symptoms: I. PROCEDURE:

Person discovering victim: 1. 2. Establish unresponsiveness. Call for help; when help arrives, tell them to · Announce "code blue in (state location) ____________" three (3) times. · Call 911# for Ambulance Service, give location · Call CSH Police, ext 4169 Begin CPR UNLESS there is a Do Not Resuscitate (DNR) order Obtain Barrier device for breathing Implement Automated External Defibrillator (AED) Announce three (3) times over the intercom: Code Blue, ____________.

State location

First rescuer: 1. 2. 3. Available personnel: 1. 3. 4. 5. 6. 7. Code Blue leader:

Call ambulance service (911# ), indicating code blue situation and state location. Notify the Campus Nurse Administrator, pager: 451-2025 Notify the CSH Police Department, ext 4169 Notify physician Check DNR status if unknown. If DNR order exists, cease CPR and notify physician.

Must be a licensed nurse/medical staff 1. 2. 3. Assumes charge of the scene. Ensures proper basic life support/cardiopulmonary resuscitation (CPR) procedures are being performed. (per AHA guidelines) Ensures necessary equipment is on the scene and is being properly implemented: 1. Crash Cart 2. Automated External Defibrillator (AED) 3. Oxygen 4. Emergency drug kit

Attachment II Page 2 of 2 4. 5. Suction machine Assigns personnel as appropriate: 1. To ensure cardiac arrest is managed by appropriate staff trained and competent to recognize the need for and use of resuscitative equipment. 2. To ensure medications are administered properly, if ordered; 3. To ensure that one (1) staff member serves as the event recorder and completes appropriate documentation (CPR Report and Progress note in the medical record). This person shall choose the official time piece; 4. To ensure additional staff are obtained, if needed, or excessive staff are dispersed from the scene.

II.

III.

Designated ACLS certified personnel managing the code situation and those using the Conscious Sedation Crash Cart in the absence of or upon request of a physician : Only designated ACLS qualified staff may perform the following ACLS and other procedures: 1. Defibrillation 2. EKG rhythm recognition 3. Cardiac monitoring 4. Start and maintain IV of Normal Saline to keep vein open, unless contraindicated by medical condition. Continuation of Code Blue Procedures: Continue until: 1. Return of spontaneous pulse and/or respirations; 2. The victim is pronounced dead by a physician; 3. EMS arrives and assumes charge of the Code Blue: or 4. The victim is transported by ambulance to another facility. 1. If the victim is pronounced, the CSH Police immediately secure the medical record, the scene, and notify the coroner.

IV. Role of Police Approved:

Scott Van Sant, M.D. Chief Medical Officer

Lee Ann Molini, RN-BC Chief Nurse Executive

Marvin Bailey Chief Executive Officer

Revised: 3/08

Attachment II Page 2 of 2

Cardiopulmonary Resuscitation Report

Central State Hospital

Milledgeville, Georgia Date _________________ Time Victim Found:___________ Time Code Blue Announced______:_____ AM/PM

Time Notified Time Arrived

911# ________________ Police Department ________________ Physican/APRN ________________ Initial Condition: Conscious yes Event Witnessed: yes no Time Initiated _____________ _____________ _____________ no Breathing yes

________________ ________________ _________________ no Pulse yes no

Mouth-to-Mouth/Microshield Chest Compressions Connected AED

Time CPR Discontinued: _______________ N/A Time Transported:______________________________ Transported To:________________________________ Time Death Pronounced:________________ N/A

Bag/mask Resuscitator (Ambu) with O2 at 10 Liters/Min. ___________ ROSC (Return Of Spontaneous Circulation) No Yes Time_______ Non Rebreather Mask with O2 at 10 Liters/Min. _____________ only if ROSC (Return Of Spontaneous Circulation)

TIME

SEQUENCE OF EVENTS / THERAPEUTIC ACTION (meds, shock) / RESPONSES / DISPOSITION

OVER

CSH-282 (Revised 3/08)

Stamp Plate

Attachment II Page 2 of 2

TIME SEQUENCE OF EVENTS / THERAPEUTIC ACTION (meds, shock) / RESPONSES / DISPOSITION

Recording Nurse: ___________________________________________ Date: _____________ Physician: ___________________________________________ Date: _____________ Medication Nurse: ___________________________________________ Date: _____________

CODE BLUE ATTENDANCE ROSTER

Employee ID number

Name Last

First

M. I.

Code Participation Yes No

Duties

Attachment III Page 1 of 2 CENTRAL STATE HOSPITAL CARDIOPULMONARY RESUSCITATION DRILL EVALUATION Date ___________ Time __________am/pm Location ______________________

Scenario: CPR Choking Adult Child

Code Blue Action/Response 1. Discoverer of victim responded appropriately? (Non- Certified) · Recognizes emergency, shouts for help 2. First CPR certified responder: · Establishes unresponsiveness, shouts for help to call Code Blue, 911-#, CSH Police Dept. · Start CPR immediately and correctly. Ask for barrier device. 3. Assisting staff: Making Code Blue Calls : · Dial # (key) 24 on telephone Announce, " Code Blue and Location" x 3 · Telephones EMS 911 # (key) [or 9-911 if unable to access 911#] and give information · Telephones CSH Police @ 4169 4. Responding code team members took active rolls in Code Blue activities 5. First Licensed Nurse responder took Charge roll · Ensured CPR being done (self performed or designated ) correctly to include: airway management, adequate chest compressions (depth, rate, placement) · Ensured calls made · Established official time piece for code and someone to document/take notes 6. Responding nurses · Provide assistance with CPR, Bag /mask ventilations (Ambu) O2 at 10 L/min, suction as needed; Crash Cart/ Emergency Drug Box to scene, call to Physician, assign CPR documentation, AED implementation · Assign designee for other duties ( i.e. meeting EMS, police, MD, crowd control, swap out of staff during CPR) 7. CPR continued without unnecessary delays or pauses until AED procedures implemented (pauses less than 10 seconds) 8. Certified staff implements AED immediately upon its arrival to the scene if the victim is unresponsive and breathless, nurses should check for presence of pulse. AED arrived in 3-5 min. of announcement and implementation within 90 seconds of arrival) 9. Follows AED prompts as indicted 10. On initial assessment if victim is found to be choking · Staff makes Code Blue calls ( refer #3) · Provide abdominal thrusts 11. If choking victim became unconscious were appropriate actions taken · Check victim's mouth , remove any visible objects · Start CPR until airway is cleared or EMS arrives 12. If victim returns to spontaneous circulation apply either of the following · Non Rebreather mask at 10 L/min: · Nasal cannula at 2 to maximum of 4 L/min 13. Staff assist EMS as directed 14. CSH form 282 (Cardiopulmonary Resuscitation Report) was completed correctly 15. Number of staff present: MD/APRN_______RN_______LPN__________Other CPR certified staff_____________ 16. CPR policy/procedure reviewed 17. Demonstrations done

YES

N/I

Attachment III Page 2 of 2

Time Interval Victim found to Announcement______________ Victim found to start of CPR________________ Victim found to first shock_________________ Victim found to nurse arrival_______________ Victim found to MD arrival_________________ Victim found to EMS arrival________________ Opportunities for Improvement Observations/Comments ___________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ Interventions

Code Blue Drill Instructor:___________________________________________________________________ __________________________________________________________________ Date:_________________ Management Review: Service Division Nurse Executive:_______________________________________________Date:___________ Comments:_________________________________________________________________________________ ________________________________________________________________________________________ Service Clinical Division Medical Director:_____________________________________Date:_____________ Comments:_________________________________________________________________________________ ________________________________________________________________________________________ Service Division Chief:__________________________________________Date:________________________ Comments:________________________________________________________________________________

Rev 3/08

Attachment IV CENTRAL STATE HOSPITAL/TRAINING ROSTER Page ______ of ______

Code Blue Drill/Evaluation (1) COURSE TITLE: (2) COURSE NUMBER: PPRDD-015 (3) HOURS RECEIVED: 0.75 HOURS (4) COURSE DATE/TIME: _____________________ (5) TRAINING SITE: __________________________ Employee ID #

Or Last 4 SS#

(6) INSTRUCTOR/MONITOR 1._______________________________ 2._______________________________ 3._______________________________ 4._______________________________

NAME

Last First

Job Title

Task Attend done in Inst.Initial drill

Unit / work area

CPR certified Yes | No

| | | | | | | | | | | | | | | | | | | | | | | | |

4/08 CPRDrillRoster

_____________________________

Entered By Date

Central State Hospital

Monthly Cardiopulmonary Resuscitation Drill Report

Attachment V

Division: ________________ Number of Drills: Actual Codes: Total:

Month/Year:

Note: Submit to Chief Nurse Executive's office the first work day of each month for the prior month. Date Time Location Actual Type Drill Improvement Opportunities Code Yes No Choking CPR

Interventions

Status

Rev 4/08

Attachment VI Page 1 of 3 CENTRAL STATE HOSPITAL CODE BLUE EVENT DEBRIEFING/CRITIQUE

EVENT DATE: _____________ DEBRIEFING/CRITIQUE DATE: ____________ UNIT LOCATION: __________________ NAME: ___________________________ DOB: _________ AGE: ________ M ___ F ___ ADMISSION DATE: _________________ CHART NUMBER: ______________________ TIME LAPSE INTERVAL TABLE

TIME EVENT WITNESSED TIME CLIENT FOUND

ISSUES MONITORED CPR IMPLEMENTED AED IMPLEMENTED CODE BLUE ANNOUNCED EMS NOTIFIED CSH POLICE DEPARTMENT NOTIFIED PHYSICIAN / APRN NOTIFIED EMS ARRIVED PHYSICIAN / APRN ARRIVED VICTIM TRANSPORTED TO ACUTE CARE FACILITY VICTIM TRANSPORTED TO FUNERAL HOME VICTIM OUTCOME:

TIME

TIME LAPSE

REVIVED ___ EXPIRED ___

OPPORTUNITIES FOR IMPROVEMENT: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________

Attachment VI Page 2 of 3

DEBRIEFING QUESTIONS:

1. Were there any issues or problems encountered during the Code Blue Event? _________________________________________________________________________________________ _________________________________________________________________________________________

_________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Based on participant response, were there any opportunities for improvement identified? _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 2. Were there any equipment or supply problems? _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Any suggestions for opportunities for improvement concerning equipment or supply problems identified? _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ CRITIQUE SUMMARY: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ CODE BLUE DEBRIEFING / CRITIQUE MONITOR: ______________________________ DATE: ______________________________

Attachment VI Page 3 of 3

PARTICIPANTS IN CODE BLUE DEBRIEFING/CRITIQUE MEETING: NAME TITLE

Rev. 4/08

Page 1 of 3 No: 5.20B CENTRAL STATE HOSPITAL PROCEDURE SUBJECT: MAINTENANCE AND CONTROL OF EMERGENCY DRUG KITS AND CRASH CARTS August Chief Nurse Executive (CSH) May 2008

ANNUAL REVIEW MONTH: RESPONSIBLE FOR REVIEW: LAST REVISION DATE:

This procedure provides guidelines to ensure Emergency Drug Kits and Crash Carts are readily available, appropriately stocked, and operational in the event of a medical emergency, thus providing a safe and therapeutic environment for clients. Participants: Pharmacy Services Service Clinical Director Service Nurse Executive Trained Staff Nurse Administrators

Location and Security Emergency Drug Kits and Crash Carts are strategically located throughout the campus. (Attachment A). All Emergency Drug Kits and Crash Carts will be secured with a numbered plastic twist-off lock to assure the integrity of the contents is maintained. Control of emergency Drug Kits locks will be under the supervisions of the Service Pharmacist. Control of Crash Cart locks will be under the supervision of the Service Nurse Executive (NE) or a designated staff member. Emergency Drug Kits and Crash Carts are stocked in accordance with the guidelines established and approved by the Division Medical Executive Committee and Pharmacy and Therapeutics Committee. Emergency Drug Kits The Emergency Drug Kit contains emergency drugs used during a Code Blue or other medical emergency. (Attachment B) The Emergency Drug Kits are stocked by the Pharmacy and distributed to crash cart locations. They are secured inside the crash cart with a numbered plastic twist-off lock assuring the integrity of the contents.

Page 2 of 3 No: 5.20B

The earliest expiration date of the drugs is noted on the outside of the kit and on the outside of the Crash Cart. Prior to the expiration date of the drugs, the kit will be returned to the pharmacy for replenishment and a new Emergency Drug Kit will be obtained for use in the crash carts. Crash Carts The Crash Cart contains supplies used during a Code blue or other medical emergency situation. (Attachment C). · The Crash Carts are under supervision of the Service Nurse Executives or other designated staff member. · The date of the earliest expiration date of medical supplies will be noted on the outside of the cart. In addition the date of the earliest expiration date of supplies in each package will be noted on the package. These supplies are placed individually in designated drawers when replaced. · Prior to the expiration date of supplies, a new package(s) will be obtained. Extra packages are available in each Service areas for timely replacement. Replacements are also located in each Service area and the Campus Nurse Administrator's Office. · A new lock for the cart will be obtained from the Service Nurse Executive or the designated staff member. The Moderate Sedation Crash Cart contains emergency supplies used during a code blue or other medical emergency situation requiring ACLS only. IV fluids and intubation supplies are stocked on the stand alone crash cart. (Attachment D) A monthly checklist shall be maintained on the laryngoscope handles and blades. (Attachment E) Inspection of Emergency Drug Kits and Crash Carts At the change of each shift staff should inspect the Crash Cart and Emergency Drug Kit located in their areas to assure that locks are intact. Check previous lock numbers and ensure that no drugs or supplies are out of date. If the lock on the crash cart is broken, complete a total inventory of the cart, replace used/expired items and replace lock. Check the emergency drug kit. If the emergency drug kit lock is broken or the drug kit has been removed or compromised, call the pharmacist on duty to report that the drug kit has been opened or removed. Notify the pharmacy, and return the Drug Kit to the pharmacy for replacement during normal work hours. If the Emergency Drug Kit has been opened and needs to be replaced on weekends, after hours, holidays, etc, there are extra replacement drug kits located in the nurse administrator's office. Notify the CSH Nurse Administrator for replacement of all crash cart materials after normal working hours and holidays.

Page 3 of 3 No: 5.20B

If the locks are not intact or supplies are in need of replacing follow above procedures for corrective action. · · Ensure that the AED and electrode pads are on the cart and that an extra charged battery is available for use (if applicable) Check and record the oxygen psi (pounds per square inch) every night on 11-7 shift. The tank should be changed if it reads 500 psi or less. Note: If a tank needs to be replaced, one of the extra tanks in the building should be used (Each building will have access to replacement tanks). Replacement tanks are obtained from Respiratory Services, which have tanks delivered directly to them from contracted company. Additional tanks may also be obtained from the campus nurse administrator after hours, weekends, and holidays. Check the suction machine every night. If the suction machine is battery operated unplug and run for 15 minutes every Wednesday night. For all types of suction check for vacuum. Vacuum check: Make sure that the regulator is pushed in to the high vacuum position. If the units stops or slows during the testing time, notify the nurse manager/designee who will report the malfunction to the biomedical engineer. Documentation will be completed on the Emergency Drug Kit and Crash Cart Inspection Check form (Attachment F) Quality control of AEDs is monitored monthly through Clinical Consultative Services.

·

· ·

Attachment A Crash Cart with AED Location for Central State Hospital

ALLEN BLDG (3) 2-WEST-------Room 207-West AED ZOLL 3-WEST-------Room 307-West AED ZOLL 4-WEST-------Room 407-West AED ZOLL Extra Pouches-------------------Room 158-East from hallway/inside Room/ # 160-East. PHOENIX CENTER (4) 1-EAST--------Room 160-East AED ZOLL 2-EAST--------Room 207-East AED ZOLL 3-EAST--------Room 307-East AED ZOLL 4-EAST--------Room 407-East AED ZOLL Extra Pouches-------------- Room 158-East from hallway/inside Room/ # 160-East DDS/HOUSES (5) BROAD-11-----No room number located in dining area behind curtain. AED ZOLL BROAD-13---- No room number located in dining area behind curtain. AED ZOLL BROAD-14---- No room number located in dining area behind curtain. AED ZOLL BROAD-15---- No room number located in dining area behind curtain. AED ZOLL BROAD-16---- No room number located in dining area behind curtain. AED ZOLL 286 Jones Road---Room (Nurses Station Area) AED ZOLL Extra Pouches---------------Room 158-East from hallway/inside Room/ # 160-East BOLAND BLDG (7) 1-SOUTH-------Room 162-South-East AED ZOLL 1-NORTH-------Room 120-South-East AED ZOLL 2-EAST----------------Room 120-South AED ZOLL 2-WEST---------------Room 152-South AED ZOLL 4-----------------Room 119-North-West AED ZOLL 5-EAST----------------Room 119-North AED ZOLL 5-WEST---------------Room 151-North AED ZOLL Extra Pouches----------------------------Room 154-C EWAC (1)------------------Room 126 AED ZOLL Extra Pouches--------------------------Room 135 CRAIG CENTER (7) CRAIG-1-----------Room 120 North-West AED ZOLL CRAIG-2-----------Room 154 North-West AED ZOLL CRAIG-3-----------Room 169 North-East AED ZOLL CRAIG-4-----------Room 119 North-East AED ZOLL CRAIG-5-----------Room 128 South-East AED ZOLL CRAIG-6-----------Room 168 South-East AED ZOLL CRAIG-7-----------Room 144 South-West AED ZOLL Extra Pouches----- Room 101SW (Top Drawer of Filing Cabinet)

Attachment A

CHILDREN & ADOLESCENT (1)----------Room 132 #1 AED 500 Model Room 132 #2 AED 500 Model Extra Pouches---------------------------------------------------------Room 138 BINION BLDG (3) 1-SOUTH----------Room 123- South AED 500 Model 2-SOUTH----------Room 213-South AED 500 Model 2-NORTH----------Room 220-North AED 500 Model Extra Pouches--------------------------------Room 203-C FREEMAN BLDG (4) 2-EAST-------------Room 209 East AED 500 Model 3-EAST-------------Room 309 East AED 500 Model 4-EAST-------------Room 409 East AED 500 Model Freeway--------------Room 209 West AED 500 Model Extra Pouches--------------------------------Room 307 East POWELL BLDG (5) 2-WEST------------Room 210-West AED 500 Model 3-WEST------------Room 310-West AED 500 Model 3-EAST-------------Room 333-East AED 500 Model Temp Observation Unit -------Room 146-W AED 500 Model HOPEWAY---------------Room 215-E AED 500 Model Extra Pouches------Room 210-C inside of Red Cart (Radiology DEPT.) (1)-------Room 2-116 (Moderate Sedation) Extra Pouches---------------------------------------------------------Room 2-116 Radiology (KIDD BLDG) (1)---------Room 2-116 AED 500 Model Extra Pouches-----------------------Room 2-116 Dental Clinic (1)------------------------Room 110 AED 500 Model Extra Pouches-----------------------Room 111 Admissions/Evaluation Area (2) Standard Crash Cart------------------Room 146W------ AED 500 Model Mobile Crash Cart--------------------Room 128 B-W--- AED 500 Model Extra Pouches------------------------Room 210C (No Crash Cart-AEDs Only) NDI------------------------------------------------------------- ---Room 102 AED 500 Model Extra Pouches-----------------------Room 102 Bobby E Parham Cafeteria (2) East Cafeteria AED 500 Model West Cafeteria AED 500 Model OHIS (Yarbrough)---------------------------------------------Room 1-054 AED 500 Model Police Department------------------------------------------------------------- AED 500 Model Extra Pouches and Emergency Drug Kits are located at the Police Dept. Annex Building in the Campus Administrator's office Room 113.

Attachment B

Central State Hospital Emergency Drug Kit Contents

Generic Name Aspirin Diphenydramine Epinephrine Liquid Glucose Naloxone Nitroglycerine

Ref. Name Aspirin Benadryl Adrenalin Insta-Glucose Narcan NitroQuick

Strength 325 mg 50 mg/ml 0.3 mg 30 Gm 1 mg/ml 0.4 mg

Dispensed Size 100 tablets 1 ml syringe 0.3 mg auto-injector 1 tube 2 ml syringe 25 tablets

Quantity Expiration Dates 1 2 2 2 2 1

Unit_________________________ Date Inspected_________________ Next Inspection Due_____________

Lock #______________________ By:_________________________ Next Drug Exp Date____________

Attachment C

CRASH CART ­ 4 Drawer

#

TOP OF CART

AED Machine with 1 razor/electrode pads Suction Machine with suction gauge Clipboards with Forms 1 CLIPBOARD, 3 FORMS Microshield Adult Ambu Bag with Mask and Tubing (check expiration) Pediatric Microshield (Craig 1, Admissions, C&A, Dental Clinic and Radiology) Pediatric (Child) Ambu Bag with Mask (check expiration) (Craig 2, Admissions, C&A, Dental Clinic and Radiology)

DRAWER #1

1 1 3 1 1 1 1

Blood Pressure Cuff/Stethoscope Pediatric Cuff (Craig 2, Admissions, C&A, Dental, Radiology)

DRAWER #2

1 1

Sponges 4x4 Alcohol Pads Tape Scissors

DRAWER #3

10 10

Oral Airways (small & medium) 02 Mask & Tubing Nasal Cannula Non-Rebreather Mask Yankauer Suction Catheter

DRAWER #4

1 1 1 1 1

Exam Gloves (small, medium, large) Flashlight PPE(barrier bag) Red Bio Bag Extension Cord Emesis Basin Emergency Drug Kit

1 1 2 1 1

Revised 4/08

Attachment C

CRASH CART-5 Drawer

#

TOP OF CART

AED Machine with 1 razor/electrode pads Suction Machine with suction gauge Clipboards with Forms 1 CLIPBOARD, 3 FORMS Microshield Adult Ambu Bag with Mask and Tubing (check expiration) Pediatric Microshield (Craig 1, Admissions, C&A, Dental Clinic and Radiology) Pediatric (Child) Ambu Bag with Mask (check expiration) (Craig 2, Admissions, C&A, Dental Clinic and Radiology)

DRAWER #1

1 1 3 1 1 1 1

Blood Pressure Cuff/Stethoscope Pediatric Cuff (Craig 2, Admissions, C&A, Dental, Radiology)

DRAWER #2

1 1

Sponges 4x4 Alcohol Pads Tape Scissors

DRAWER #3

10 10

Oral Airways (small & medium) 02 Mask & Tubing Nasal Cannula Non-Rebreather Mask Yankauer Suction Catheter

DRAWER #5

1 1 1 1 1

Exam Gloves (small, medium, large) Flashlight PPE(barrier bag) Red Bio Bag Extension Cord Emesis Basin Emergency Drug Kit

1 1 2 1 1

Revised 4/08

Attachment C

CRASH CART ­6 Drawer

# TOP OF CART

AED Machine with 1 razor/electrode pads Suction Machine with suction gauge Clipboards with Forms 1 CLIPBOARD, 3 FORMS Microshield Adult Ambu Bag with Mask and Tubing (check expiration) Pediatric Microshield (Craig 1, Admissions, C&A, Dental Clinic and Radiology) Pediatric (Child) Ambu Bag with Mask (check expiration) (Craig 2, Admissions, C&A, Dental Clinic and Radiology)

DRAWER #1

1 1 3 1 1 1 1

Blood Pressure Cuff/Stethoscope Pediatric Cuff (Craig 2, Admissions, C&A, Dental, Radiology)

DRAWER #2

1 1

Sponges 4x4 Alcohol Pads Tape Scissors

DRAWER #3

10 10

Oral Airways (small & medium) 02 Mask & Tubing Nasal Cannula Non-Rebreather Mask Yankauer Suction Catheter

DRAWER #5

1 1 1 1 1

Exam Gloves (small, medium, large) Flashlight PPE(barrier bag) Red Bio Bag Extension Cord Emesis Basin

DRAWER #6

1 1 2 1 1

Emergency Drug Kit

Revised 4/08

Attachment D

MODERATE SEDATION CRASH CART (KIDD BLDG)

# TOP OF CART

AED Machine Drug Box Suction Machine Clipboards with Forms Pocket Mask with One-Way Valve Adult Ambu Bag with Mask (check exp) Sharps Container

1 1 1 3 1 1 1

DRAWER #1 Nasal Pharyngeal Airways: Oral Pharyngeal Airways:

Size 32 Size 34 Small Medium Large

12 ml Syringe with Christmas Tree Adaptor O2 Flow Meter with Plastic O2 Connector Laryngoscope Handle (with Battery) The following blades will be checked 3 times each on each of the handles to ensure that the bulbs are bright and the batteries are good. When this check is completed, initial and date. Laryngoscope Adult Curved Blade #4: Initial _____ Laryngoscope Adult Curved Blade #3: Initial _____ Laryngoscope Adult Straight Blade #3: Initial _______ Laryngoscope Adult Straight Blade #2: Initial _______ Laryngoscope Straight Blade # 1: Initial_______ Laryngoscope Straight Blade # 0: Initial ______ Lidocaine Jelly, one tube (check expiration date) Endotracheal Tubes (check expiration date on each): Size 5 Size 6 Size 7 Size 7 ½ Size 8 Size 9 CO2 Detector (check expiration date) Endotracheal Tube Holder Endotracheal Guide ­ Copper Wire McGill Forceps

1 1 2 2 2 1 1 2

1 1 1 1 1 1 1 1 1 2 2 2 1 1 1 1 1

Revised 4/08

Attachment D DRAWER #2 Blood Pressure Cuff Stethoscope Tongue Blades Razor Blades Bandage Scissors DRAWER #3 Non-Rebreather Mask Tracheostomy Mask Nasal Cannula Oxygen Tubing Suction Tubing Yankauer Suction Tip Suction Catheter Kit (check expiration) 4X4 sponges Oxygen Meter (check for function with every use) Oxygen Tubing Connectors DRAWER #4 Safety Needles: (check exp) 1 1 10 1 1

1 1 2 1 1 1 1 10 1 1

Luer Lock Syringes:

18 gauge 20 gauge 22 gauge 3 ml 6 ml 12 ml 35 ml

3 3 3 2 2 2 2 6 6 6

Safety Syringes with Needle: (check expiration dates) 3 ml with 1 ½ inch needle 5 ml with 1 ½ inch needle 10 ml with 1 ½ inch needle

Revised 4/08

Attachment D DRAWER #5

IV Fluids: (check expiration dates) 1000 ml 0.9 NaCl 1000 ml 0.9 NaCl

1 1 2 2 2 2 2 3 3 3 10 1 2 1

IV Start Kits Lever Lock Cannula Interlink Injection Site IV Solution Sets IV Extension Sets IV Catheters: (check expiration dates)

18 gauge 20 gauge 22 gauge

Alcohol Prep Pads 2 inch Adhesive Tape Heparin Lock (check expiration date) NaCl 30 ml Vial (check expiration date)

DRAWER #6

Medium Gloves Large Gloves Barrier Bag Waterless Hand Cleaner (check expiration date) Suction Gauge with Canister (When cart is being restocked after use, check suction to ensure proper function.)

1 box 1 box 1 1 1

SIDE OF CART

Backboard Oxygen E-cylinder

1 1

Revised 4/08

Attachment E

Laryngoscope Handles and Blades (Moderate Sedation Crash Cart)

(Kidd Bldg)

MONTHLY CHECKLIST

(Fibro-Optic)-LARYNGOSCOPE HANDLES AND BLADES Date:______________________________ Signature___________________________ Location____________________________ The following blades will be checked 3 times each on each of the handles to ensure that the bulbs are bright and the batteries are good. When this check is completed, initial and date. Procedure for checking handles and blades: Gloves are to be worn when checking blades. Make sure each blade is checked three times before going to the next blade. Check the bulb to ensure that it is tight. If handles have any rust or erosion inside, you are to return back to Medical Supply Management immediately so that it may be exchanged.

Laryngoscope Curved Blade #4: Initial _____ Laryngoscope Curved Blade #3: Initial _____ Laryngoscope Curved Blade #2: Initial _____ Laryngoscope Straight Blade #3: Initial _______ Laryngoscope Straight Blade #2: Initial _______ Laryngoscope Straight Blade # 1: Initial _______ Laryngoscope Straight Blade # 0: Initial _______ Laryngoscope Handles (with Battery)____________ NOTE: LARYNGOSCOPE HANDLE AND BLADES ARE TO BE CHECKED MONTHLY AND THE BATTERIES ARE TO BE CHANGED OUT YEARLY. 1 1 1 1 1 1 1 2

Revised 4/08

Emergency Drug Kit and Crash Cart Inspection Check

Month:__

Attachment F

NOTE: Documentation on this sheet indicates that inspection of the following has been completed every shift in consumer living areas and every day (on normally scheduled work days) in non consumer living areas. ALL SHIFTS: must complete and document the following: Check locks for security and verification of numbers, check tubing (suction and 02) is in place DAY SHIFT: Check expiration for batteries and electrodes, complete down loads, change batteries at end of the month for Lifepack 500, or check for green check () light on Zoll, as applicable. NIGHT SHIFT (11-7): all of the above, plus perform daily suction machine check and record the O2 psi WEDNESDAY NIGHT: perform the 15 min suction machine check.

Crash Cart Lock # AED battery in machine for 500s, OR green check () light appears on Zolls. Electrodes connected Day Lock # 7-3 3-11 11-7 7-3 3-11 11-7 11-7 Document O2 PSI-EVERY NIGHT 11-7 Suction--Turn on & test vacuum daily on 11-7. For battery operated, run for 15 min every Wednesday 11-7 shift Daily Wed 11-7 11-7 Drug kit expiration dates checked on form COMMENTS

7-3

3-11

11-7

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

psi psi psi psi psi psi psi psi psi psi psi psi psi psi psi psi psi psi psi psi psi psi psi psi psi psi psi psi psi psi psi

** Lifepak 500 only: Charge the battery from machine for at least 10 hours or until LED light on charger is green.

AED (Lifepak has 2 exp dates, Zoll has 1 exp date) batteries expiration date(s): #1 __________________ #2__________________ AED electrodes expiration date(s) #1_________________ Ambu Bag expiration date: __________________ #2, indicate NA if not applicable:___________________________ _________________________________ Signature

Revised 4/08

Attachment F Emergency Drug Kit and Crash Cart Inspection Check Protocol If the lock on the crash cart is broken: 1) complete a total inventory of the cart, 2) replace used/expired items and replace lock, 3) check the Emergency Drug Kit. If the Emergency Drug Kit lock has been broken, or the Emergency Drug Kit has been removed, notify the pharmacy, and return the Drug Kit to the pharmacy for replacement during normal work hours. If the Emergency Drug Kit has been opened and needs to be replaced on weekends, after hours, holidays, etc, there are extra replacement drug kits located in the nurse administrator's office. Notify the CSH Nurse Administrator if extra crash cart materials are needed after normal working hours and holidays. Routine monitoring of the crash cart include: 1) Check and Record the O2 PSI EVERY NIGHT ON 11-7 shift. The tank should be changed if it reads 500 psi or less. 2) Ensure that the lock is intact and verify the crash cart lock number. 3) Verify the expiration dates of the AED electrode pads. 4) For Lifepak 500, verify the expiration dates of BOTH AED batteries on the form. For Zoll, check to ensure green check () light is on. If red (X) is present, unplug electrodes and check for green check () to appear. If the green check () light does not appear and/or the red (X) continues, tag as "out of order" and notify the supervisor. 5) Check the suction machine every night. If the suction machine is battery operated unplug and run for 15 minutes every Wednesday night for all types of suction check for vacuum. (Vacuum check: Make sure that the regulator is pushed in to the high vacuum position, use occlusion to check suction capability. If the unit stops or slows during the testing time, notify the nurse manager/designee who will report the malfunction to the biomedical engineer) 6) Check the list of emergency drug expiration dates located on the crash cart. Routine monitoring of the AED include: For Lifepak 500: AT THE END OF EACH MONTH THE NURSE/ DESIGNEE WILL DOWNLOAD THE AED and CHANGE THE BATTERY, if applicable. The nurse will: 1) enter a note in the comments section that the battery change out was completed, 2) place the removed battery from the AED on the charger, 3) check the battery charger each shift and remove the battery from the charger when the green LED light appears on the charger and, 4) place the charged battery on the crash cart and enter a note on the comments section of this form to indicate the battery was charged. Reminder: AED batteries expire 2 years from the date on the battery. The unit nurse should contact the nurse manager/ designee for new batteries ONE month prior to expiration. For the Zoll: batteries, have multi-year shelf-life and the expiration date noted on the outside of the AED. Emergency Drug Kit lock broken or Kit compromised

Pharmacy notified: Date__________Time__________Nurse Initials_________ Pharmacy notified: Date__________Time__________Nurse Initials_________ Pharmacy notified: Date__________Time__________Nurse Initials_________ YELLOW LOCK= cart is stocked and medication kit is intact inside of cart

Revised 4/08

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