Medical Center Policies that were approved in January 2019
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Anticoagulation Reversal for Adult Patients Guidelines (v3) The purpose of these guidelines is to provide recommendations for the reversal of
or management of bleeding associated with anticoagulants. Of note, information provided
in this document is not intended to replace clinical judgment. Recommendations regarding
the management of anticoagulation in the adult perioperative surgical setting can
be found in the Anticoagulation Management Guidelines for the Adult Perioperative
Asepsis Program Policy (v2) All incoming medical residents and medical students, including those who are visiting
AU Medical Center (AUMC) must complete the Asepsis Program. The purpose of the policy
is to assure that the incoming medical residents, medical students, whether a part
of AUMC or visiting from another facility have training in the guidelines for aseptic/sterile
technique utilized at AUMC.
Attendance Policy (v3) AU Health is open to deliver patient care on a 24-hour, 365 day basis. To meet its
mission, regular attendance and punctuality are expected of all employees. Employees
of AU Health are obligated to work the days or shifts for which they are scheduled,
even during times of hazardous or inclement weather conditions. AU Health strives
to be fair, consistent, and maintain appropriate staffing. AU Health incorporates
the no-fault concept of attendance monitoring in order to increase managerial objectivity
and consistency. It eliminates the need for management staff to determine whether
an absence or tardy is excused, unexcused, chargeable or non-chargeable, legitimate
Automatic Therapeutic Interchange Policy (v2) This policy promotes healthcare cost containment while maintaining positive therapeutic
and safety outcomes of patients within AU Medical Center through judicious use of
an automatic therapeutic interchange program. All medications or medication classes
included in the automatic therapeutic interchange program will be reviewed and deemed
appropriate for interchange by the Pharmacy and Therapeutics (P&T) Committee prior
to implementation as well as approved by the Medical Executive Committee (MEC).
Billing and Collections Policy (v2) To establish a systematic process for the billing and collections of medical services
provided by AU Medical Associates (AUMA) and medical services provided at AU Medical
Center (AUMC). The Billing and Collections policy together with the Financial Assistance
policy is intended to meet the requirements of the applicable federal, state and local
laws, including without limitation, section 501(r) of the Internal Revenue Code of
1986, as amended, and the regulations thereunder. This policy applies to all employees
and staff of legal entities of the health system to include AUMA and AUMC, performing
duties within the scope of their employment at any site.
Blood Administration Policy (v5) This is an AU Medical Center (AUMC) policy governing the obtaining informed consent
and administration of blood and blood components.
Bloodborne Pathogen Exposure Control Plan (v2) AU Medical Center (AUMC) shall establish a written Exposure Control Plan (ECP) designed
to eliminate or minimize occupational exposure to blood or other potentially infectious
material (OPIM). The ECP and supporting documents will be reviewed and updated at
least annually and as necessary. This document contains information for all levels
of the AUMC organization and is applicable at all AUMC locations with a potential
for occupational exposure to blood or OPIM.
Credentialing Medical Staff Policy (v6) The Medical Staff Office coordinates the credentialing process of all prospective
members to the Medical and Advance practice providers for AU Medical Center Inc. Collection
of all application forms and supporting documentation, verification of all required
credentials, maintenance of a credentialing database system and communication, are
handled by one office. This one office supports the Credentials Committee review and
recommendations for appointment/reappointment and privileging in each hospital and
clinics within the healthcare system. The AU Medical Center Inc. Medical Staff Office
does not sub-delegate any credentialing functions to an outside source. The recommendations
of the hospital Credentials Committee and Medical Executive Committee (MEC) are reported
to the Board of Directors (Governing Body). Therefore, in order for there to be uniformity
of credentials documentation and information and to reduce the burden of overseeing
the application process, all credentialing information will be shared within AU Medical
Center Inc. Credentialing information is peer review protected and all new members
of peer review committees (such as Credentials Committee, Medical Executive Committee,
PI Peer Review) will be oriented to the confidentiality process and will sign a confidentiality
agreement. All information obtained during the initial and re-credentialing process
is confidential. PHI is not used in the credentialing process but if submitted with
the application, this information is destroyed, returned or blinded.
Discharge Planning Policy (v3) Each patient admitted to AU Medical Center (AUMC) will have an individualized evaluation
of continuing care needs following discharge from the hospital. AUMC staff will work
closely with the patient/patient’s representative and appropriate community agencies
to ensure continuity of care is addressed and regulatory requirements are met. This
policy provides a process that addresses the patient’s need for continuing care, treatment,
and services after discharge or transfer.
Empiric Precautions Policy (v2) All patients will be assessed for infectious diseases or pathogens upon presentation
in all settings. Proper transmission-based precautions will be initiated based on
clinical presentation and likely pathogens; then, maintained until a diagnosis is
confirmed or ruled out.
Infection Prevention and Control Annual Risk Assessment and Plan (v6) Annually, AU Medical Center (AUMC) documents a risk assessment which describes the
infection risks unique to Augusta University Medical Center’s hospitals and clinics
used to determine the Annual Infection Prevention and Control Plan. Monitoring the
on-going status of infection risks and occurrences involves a systematic review of
patient outcomes using Surveillance Indicators.
Informed Consent Policy (v3) AU Health will obtain informed consent for all patients (for pediatric patients, see
below III A.3) regarding any surgical or invasive procedure performed under general
anesthesia, spinal anesthesia, or major regional anesthesia or an amniocentesis diagnostic
procedure; or a diagnostic procedure which involves intravenous injection of a contrast
Laryngoscope Processing Policy (v3) AU Medical Center (AUMC) reprocesses laryngoscope blades as semi-critical devices
between each patient use and in accordance with the manufacturer’s instructions. Laryngoscope
blades are packaged and stored in a manner to prevent recontamination. As manufacturer’s
instructions for the handles vary from low level disinfection to sterilization, manufacturer’s
instructions for reprocessing laryngoscope handles will be followed and handles will
be stored and managed in a manner to prevent contamination. Devices such as laryngoscope
blades and handles, may be exposed to potentially infectious material during indicated
use, and can become contaminated through direct contact with the patient’s skin, mucous
membranes, secretions, and blood. To reduce the risk of infection, the importance
of standardizing the reprocessing and storage of laryngoscope blades and handles is
emphasized. This policy will provide provisions for reprocessing, handling and storage
of laryngoscope blades and handles to ensure that they are safe for use.
Monitoring for Hazardous Air Contaminants Policy (v2) It is the policy of AU Health to minimize air contaminants exposure to employees by
providing for proper monitoring of air contaminants. Contaminants monitored include,
but are not limited to, waste anesthesia gases, formaldehyde, glutaraldehyde, and
Name Entry and Changes Policy (v2) The purpose of this policy is to establish a standardized process for patient name
and demographics entry into the IDX Enterprise Scheduling and Visit Management Systems
which will feed all other downstream systems.
Ordering Radiology/Imaging Studies Policy (v3) In order to perform a Radiology/Imaging study for Inpatients and Outpatients at AU
Medical Center (AUMC), an appropriate clinical indication and a signed order are required
from a physician or other provider.
Organ Donation After Cardiac Death and Imminent Death Potential Organ Donation Policy
(v2) This policy outlines the procedure for referral, authorization, medical management,
and recovery of organs for transplantation through donation after cardiac death (DCD).
This policy highlights the rights of patients and their families related to options
for organ donation and decision making regarding these options when timing of death
is determined by withdrawal of mechanical support. With the reality of individuals
dying every day awaiting organs for transplantation, AU Medical Center (AUMC) will
make reasonable efforts to identify potential organ donors and to cooperate in the
procurement of anatomical gifts.
Organ, Eye, Tissue Donation Policy (v3) The purpose of this policy to establish guidelines for communication with families
of potential donors and to develop procedures to follow in coordinating the procurement
of eyes, organs and tissues. Recognizing that eye, organ, and tissue donation saves
lives and improves quality of life and that anatomical gifts offer consolation to
the bereaved next-of-kin/guardian of a donor, AU Medical Center (AUMC) actively participates
in eye, organ, and tissue donation programs. To this end, the next-of kin/guardian
of medically suitable potential eye, organ, and tissue donors will be informed of
the option of making anatomical gifts. Hospital management will maintain a working
relationship with the AUMC’s Tissue and Donor Services, LifeLink of Georgia Organ
Procurement Organization, and the Georgia Eye Bank to facilitate the implementation
of next-of kin/guardian desires regarding eye, organ, and tissue donation.
Personal Appearance Policy (v5) AU Medical Center (AUMC) employees are expected to maintain a high standard of neatness
and personal hygiene. Personal appearance must meet safety and cleanliness standards
to ensure patient and staff protection. If an employee is uncertain about dress requirements
in his/her department, the employee should consult with his/her immediate supervisor.
Portable Medical Gas Policy (v2) This policy establishes procedures to be followed when cylinders are required to be
store on a unit or smoke compartment for emergency or transport use.
Serious Reportable Events Policy (v2) The NQF-Endorsed® Serious Reportable Events are an ongoing effort to enable healthcare
quality and safety improvement through introduction of tools for assessing, measuring,
and reporting organizational performance. The purpose of the NQF-endorsed list of
Serious Reportable Events in Healthcare is to facilitate uniform and comparable public
reporting to enable systematic learning across healthcare organizations and systems
and to drive systematic national improvements in patient safety based on what is learned—both
about the events and about how to prevent their recurrence. AU Medical Center (AUMC)
is committed to reducing and eliminating Serious Reportable Events. As such, this
policy is intended to standardize AUMC’s response to a potential Serious Reportable
Event and to facilitate the investigation, response to the patient and reporting of
Surgical Attire Policy (v2) Personnel working in an operating room (OR), OR-like, Hybrid suites will wear the
appropriate surgical attire relative to each traffic zone and personnel status as
listed below while adhering to AORN Recommended Guidelines.
Temperature and Humidity Monitoring in Operating Suites Policy (v2) It is the intent of AU Medical Center (AUMC) Facilities Support Services to provide
all Operative Services with proper HVAC equipment and controls to monitor temperature
and humidity levels. Facilities Support Services will reference the following guidelines
for temperature and humidity ranges, AIA Guidelines for Construction, The American
Institute of Architects, and AORN - Association of Perioperative Registered Nurses.
Transfer of Patient via AUMC Transfer Center Policy (v2) All requests from outlying hospitals for transfer of patients to AU Medical Center
(AUMC) are managed in accordance with the Emergency Medical Treatment and Labor Act
(EMTALA), 42 U.S.C., Section 1395, all applicable Federal regulations and interpretive
guidelines promulgated thereafter, and/or the tenets of this policy. All transfer
requests are managed by the AUMC Transfer Center or AUMC Emergency Communications
Center (ECC), both available at 706-721-5600. The Transfer Center and ECC are staffed
24 hours per day, seven (7) days a week. AUMC does not determine a patient's stability
for transfer. The transferring physician does. Transfer Center and ECC calls include
Attending Physician to Attending Physician discussions regarding referrals for care,
e.g., inpatient, procedures, consults, inquiries, etc. Transfer Center and ECC calls
are recorded for quality assurance and training purposes.
Use and Disclosure of Protected Health Information for Fundraising Purposes (v3) The medical center will inform patients through its joint Notice of Privacy Practices
that it may use patient demographic information and limited health information to
contact patients for fundraising purposes or to share with an institutional related
charity foundation and that all patients have a right to opt out of receiving fundraising
communications. Any and all fundraising efforts activities involving the use or disclosure
of patient information may only be undertaken after being approved by the Office of
Advancement (Advancement). Any fundraising material or oral communications to patient
will contain language in a “clear and conspicuous manner” that allows the patient
to opt out from receiving further fundraising communications. The medical center will
refrain from conditioning treatment or payment on an individual’s choice regarding
Vascular Access Device Policy (v1) This policy provides a framework to guide clinical practice as it relates to vascular
access devices. It provides the actions to be followed to provide for appropriate
and safe patient care.'