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NURSING AFFAIRS (IN COLLABORATION WITH CLINICAL SERVICES) 

STANDARDS OF CARE FOR PATIENTS ACCESSING SERVICES IN THE AMBULATORY CARE SETTING PEDIATRIC CLINIC:

I.  Patient Assessment/Patient Problems:

   A.  The patient can expect that his/her health status will be assessed in a holistic and comprehensive manner and

         documented throughout his/her association with the health care system.

         1)  Every patient receives a brief assessment by a nurse within 30 minutes of registering at the appropriate

              Specialty Clinic within Ambulatory Care.

             1.1  Basic physical status includes vital signs, height, weight, pain scale and any clinic specific data

                     collection required.

        1.2  Focus assessments are completed in specific clinics.

            1.2.1  Neonatology patients actual and corrected age is determined for developmental assessment of

                               Neurological and growth status.  This is done up to 2 years of age.  The following formulas is used:

                               Standard Age (40 weeks) - Gestational Age (Number of weeks at which the baby is born-Correction factor)

                     1.2.2  Head circumference will be measured and recorded for children 3 years of age and under. A separate

                                Head Circumference  Chart shall be placed in the Medical Record of patients when there is a question

                                regarding head size.  Neurology, Metabolic,  Genetic and Spina Bifada patients always have their Head

                                Circumference checked regardless of age.

                     1.2.3  Blood pressure shall be taken annually on patients 3 years of age and above and each visit in the

                               Nephrology/Renal Transplant, Rheumatology/SLE, Diabetic and Cardiology/Cardiovascular clinics.

              1.3  The chart must go to Pre-registration if there is no blue plate and a note made of this. Any eligibility

                      issues as  indicated by Pre-registration are referred to the Medical Coordinator and the Eligibilit Office.

          2)  Ambulatory Care Initial Visit/Annual Review form to be completed on every patient at initial appointment in

               Ambulatory Care and annually thereafter for patient status review purposes or as indicated by assessment of

               patient.

          3)  Ambulatory care Follow Up Visit form to be completed on every patient for all subsequent appointments,

               unless the patient presents for a medication re-fill or supply re-fill. No medication re-fills can be honored for

               discharged patients.

          4)  Vital signs will be taken on all patients at initial appointments in Ambulatory Care and as dictated by

               Clinic Specific Standards of Care at follow up visits.

             4.1  Cardiovascular patients with COA (Co-arctation of the Aorta) repair or Balloon  Dilatation must have

                       their blood pressure checked on 4 extremities and documented. Indicate in the notes if the patient is

                       crying or agitated when the blood pressure is checked.

               4.2  Pediatric patients will have their height, weight and head circumference checked for each visit and

                      recorded on the appropriate Growth Chart. Patients may be enrolled in the Growth Lab if necessary.

          5)  Pain level will be assessed at every visit.

          6)  Immunization status will be assessed at Initial and at each clinic visit.

      7)  Allergies will be updated at every visit.

      8) Medication list will be reviewed and updated at every visit.

      9)  High Risk Screening will be completed at the initial visit, annually and as indicated. Referrals may be made at

               any time by a physician. The following groups of patients are automatically referred to the appropriate

               nutrition clinic: Metabolic/Endocrine, Renal and Gastro and Failure to Thrive by the Consultant.

 B.  The patient can expect that his/her health data is collected and analyzed by the interdisciplinary health care

       team and used to guide the planning of care.

       A Consultant/Associate Consultant must be present at each clinic.

      1)  Reassessment of patients occurs as follows:

           1.1  If change in presenting status occurs.

           1.2  Patient assessed as having unstable vital signs and/or life threatening condition will be accompanied by a

                  SNI/SNII to the area designated by the clinic physician as appropriate for patient’s condition.

           1.3  During current visit

                  1.3.1  Post treatment procedure

                  1.3.2  Patients/family/Care givers are instructed to inform  the clinic nurse of any changes in patients’

                            response to new medication regimes (Neuro Nurse clinic, Endocrinology etc)

           1.4  Follow up visit to determine:

                  1.4.1  Response to treatment

                  1.4.2  Plan for continued treatment or discharge from system

                  1.4.3  Continuing health care needs, and if so, plan of care is revised accordingly

 II.  Patient Care Planning:

      A.  The patient can expect that their care requirements are assessed, planned, implemented and evaluated in a

            systematic way.

            1)  An interdisciplinary written plan of care is formulated, implemented, evaluated and revised as needed by the

                 interdisciplinary team.

                 1.1  Each clinic has a Primary Nurse who is responsible for coordinating activities to ensure the smooth running

                         of the clinic.

                        There is usually an Associate Nurse who assists the Primary Nurse in the operation of the clinic and

                         assumes responsibility for the clinic when the Primary Nurse is absent. The Associate Nurse is responsible

                         to prepare the rooms, call patient, assist with procedures and in-put data as needed in the computer.

                  1.2  Representatives from different disciplines may attend the clinic.

                         1.2.1  Rheumatology/SLE Clinic a representative from Physical Therapy and Occupational Therapy will

                                   attend the clinic.

                                   -Diabetic Clinic, the Educator and Dietician attend.

                                   -Renal Transplant, a Transplant nurse, Clinical Pharmacist and Dietician attend.

       B.  The patient’s plan of care is revised when indicated by a change in the patient’s condition or when patient’s

            needs change.

       C.  The patient can expect that the plan of care promotes continuity of care.

             1)  All care provided by the interdisciplinary health care team shall be clearly documented in the patient’s record

                  and available to all health disciplines.

        D.  The patient/family can expect to have an opportunity to participate in the care process.

III. Psycho Social/Cultural/Religious Needs of the Patient:

     A.  The patient/family can expect support for their psychosocial, cultural, and religious well-being using the

           following interventions:

           1)  Upon request, referrals to Social Services and/or Patient Relations may be made for appropriate support.

           2)  Inform patients of their rights in a language and method they will understand.

           3)  Identify, protect and promote patient rights in the following ways:

                3.1  Utilizing translators and bilingual staff when necessary to enhance communication.

                3.2  Maintaining privacy during delivery of care (single patient exam rooms, assessment rooms, locks on

                       doors, waiting areas).

                3.3  Ensure confidentiality of written, verbal and electronic communication.

                3.4  Explaining tests and procedures before occurrence.

                3.5  Providing an environment that allows the patient/family to practice their cultural religious beliefs.

                       (prayer rooms, separate waiting rooms).

                3.6  Coordinate with other departments including, but not limited to Patient Relations, Social Services

                       and other specialties as indicated.

IV.  Safety Needs of the Patient:

      A.  The patient can expect that infection control and prevention measures be implemented according to

            Hospital Infection Control policies:

            1)  Nursing care is provided according to Infection Control Policies and Procedures.

                 1.1  Patients who present with a rash/possible communicable disease are immediately placed in a

                        designated room in the clinic.

                 1.2  During a dressing change, if an exudates is noted, prior to cleansing the wound, a swab should be

                        taken and sent for C&S

             2)  Patients, families and sitters are given pertinent information regarding infection control and personal hygiene

                  as it applies to them.

       B.  The patient can expect that safety needs are addressed by the following:

            1)  Patients will be correctly identified prior to any treatment, procedure or any dispensing of medications.

            2)  Informed consent is obtained according to policy.

            3)  Providing environmental safety measures utilizing Infection Control policies include:

                 -Wiping the exam table and work desk with disinfectant solution (Portion Pack)

                 -Suction tubing is to be changed between patients

                 -Suction liners when used are to changed daily.

                 -The Sharps containers are to be changed when they are 3/4 full

            4)  The patient is properly secured on stretcher, in wheelchair, or reclining chair.

            5)  Electrical outlets are covered in pediatric areas (including treatment areas and waiting rooms).

            6)  Children are not left unattended

            7)  Emergency medications and equipment are available in immediate area. Crash carts and anaphylactic kits are

                 available in all clinic areas. A schedule will be posted monthly to assign a nurse to check these. This duty will be

                 rotated between all units on the 2^nd floor.

            8)  Medication re-fill prescriptions and take-home supply requisitions for pick-up after the clinic, are to be kept

                 at the Registration Desk in a brown envelope. These will be given out upon request utilizing the patients MRN.

                 The  person picking up the medication re-fill prescription must sign for it. The brown envelopes are kept in a

                 locked drawer after clinic hours.

            9)  MSDS information is available and current and spill kits are available for hazardous material clean up.

          10)  Scheduled preventative maintenance of equipment through Clinical Engineering Services is up to date and

                 includes proper tagging of equipment

          11)  Any malfunctioning equipment should be reported immediately to the Head Nurse or Charge Nurse.

          12)  The nurse will assess, intervene and document safety needs of a patient on an individual basis.

                  Family and sitters are instructed on safety needs and are cautioned to remain with the patient.

           13)  Information is posted in all waiting areas instructing patients on how to receive immediate attention

                  if required.

           14)  Waiting areas will be monitored at assigned intervals.

     C.  The patient can expect that his/her comfort, rest and pain alleviation needs are identified and supported.

V.   Patient Education/Discharge Planning:

      A.  The patient/family can expect education towards self-care and/or adaptation to their holistic well-being.

           1)  Patient educational needs are assessed at each visit.

           2)  Patient education is provided based upon identified needs and is documented.

           3)  All teaching is documented by all health care providers and is accessible through the Interdisciplinary

                Patient/Family Education Record.

           4)  Parents are to be instructed to bring all medications with them for each clinic visit.

      B.  The patient/family can expect that an individualized discharge plan is assessed, established and implemented.

           1)  High Risk Screening will be completed to identify any ongoing health care needs. Referrals are made by

                physicians/nurse.

           2)  Visit Discharge Plan is completed at each visit.

           3)  Discharge planning demonstrates a multidisciplinary collaboration including necessary referrals.

           4)  Refer the family to Social Services as necessary for lodging, oxygen cylinders, travel or financial assistance.

           5)  For medication re-fill, schedule the patient on a day when the primary physician has a clinic.

           6)  If the patient is admitted directly from the clinic, the Primary Nurse must call the unit and give a

                report to the Charge Nurse.

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