10. GOVERNING RULES OF PROFESSIONAL NURSING ORGANIZATION

6. Visiting Regulations

Patient Visitation PS 2.04

7. Volunteer Services

Volunteers at University Hospital, ACRC and Outpatient Service participate indirectly in patient care through clerical duties, and errands. They are assigned from Volunteer Services and are responsible to the Care Delivery Facilitator on the inpatient-nursing unit or the Clinic Manager. Any volunteer who provides direct patients must have orientation provided by Staff Education or nursing unit personnel. Further clarification of volunteer responsibilities may be found in the Volunteer Manual.

8. Resuscitation / 333 Code Policy for Nursing Personnel

a. Patient Care Personnel Responsibilities. It is the Employee’s responsibility to initiate CPR and call the Code Blue Team in any life-threatening situation, unless a Do-Not-Resuscitate (DNR) order is in effect . (Clinical Programs Policy ML 3.03)

b. Intensive Care Nurse Responsibilities. The extended role of the Intensive Care nurse in the base unit carrying the Code Blue beeper is to have such an assignment as to be able to respond immediately to a code situation. Sometimes patient assignments must be altered until the Code Blue nurse returns to the unit. The intensive care nurse’s responsibility as a member of the Code Blue team is to respond as a team member, utilizing A.C.L.S. procedures and protocols. This nurse is responsible for assuring arrival of the drug box and portable defibrillator at the code scene area in which emergency equipment is not readily available

c. Code Blue Policy. Clinical Programs Policy PS. 1.04.

4. CPR Training / ACLS. The Intensive Care Unit nurse member of the Code Blue team is trained as, and must maintain, cardiac training as an Advanced Cardiac Life Support (ACLS) provider. All employees having direct patient care are required to be trained in CPR and maintain current training. Training for Executive Council and Assistant Directors of Nursing is optional (Addendum J. 18 and J.19).

e. Do-Not-Resuscitate Policy. The Professional Nursing Organization follows the Clinical Programs Policy, Care of Hopeless/Moribund Patients, which delineates different levels of restricted life support. This policy addresses physician responsibility in writing the order, documentation of supporting data and communication with appropriate persons. (Clinical Programs Policy ML.3.03)

f. Limitations of Nursing Staff. Notifying families of major changes in the patient’s condition and pronouncement of death are the responsibilities of the physician. General nursing staff are not allowed to defibrillate or intubate patients.

g. General Policies on Death. After a patient is pronounced dead by a physician the physician completes his/her portion of the death certificate, autopsy forms, and organ request forms as outlined in Clinical Programs Policy. ARORA must be notified of all patient deaths by hospital personnel. Clinical Programs Policy ML.3.05 and ML.3.06.

h.     Coroner Notification: In defined instances it is the responsibility of the physician or any other person with knowledge of the circumstances of death to notify the county coroner. Nursing staff should address any concerns regarding this process to their supervisor prior to coroner notification. Specific are described in Clinical Program Policy ML 3.05

i.     Cardiac Telemetry Monitoring. See Addendum J.20 and Procedure #97 (Telemetry Monitoring).

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