Medstaff Provider Manual

Online Provider Education

Radiation Safety

• At Orlando Health we base our policies and procedures on the ALARA

principle – As Low As Reasonably Possible.

• Most radiology equipment only poses a danger when in use. Rooms contain

signage to show when safe to enter.

• Orlando Health uses three kinds of radiation warning signs to mark the use

of ionizing radiation in restricted areas.

• Consult the appropriate department (Nuclear Medicine, Radiology or

Radiation Oncology) before entry to confirm required safety measures.

MRI Safety

• D ue to the dangers of having metallic objects near the

MRI magnet, all persons entering the MRI scan room
must be screened.

• Only MRI-Safe and nonferrous items may be brought into the

scan room.

• Orlando Health has MRI Safety Zones to ensure everyone’s safety.

Z one 1: General Public Access

Zone 2: Patient Holding/Screening area

Zone 3: Access only with MRI staff – Non-MRI safe items
removed

Zone 4: Entry ONLY with MRI Technologist

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Code Red (Fire): Act Quickly

Call for help! Please call the operator Activate the pull station
1. Remove Patients, Visitors and Staff

2. Activate the Pull Station

Know where the pull stations are in your area!
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3. Alert the Operator Online Provider Education
4. Confine
22 for Orlando Health ORMC, Orlando
Health UF Health Cancer Center – Lewis
Pavilion, Ambulatory Care Center,
Orlando Health Arnold Palmer, Orlando
Health Winnie Palmer and Orlando
Health Dr. P. Phillips

111 for Orlando Health South Seminole
911 for non-hospital buildings

Make sure to close all doors in the affected area. Squeeze Sweep
5. Extinguish the Fire: Hospital (PASS)

Pull Aim

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5. Evacuate: Non-Hospital

Evacuate Everyone

Proceed to your
assembly point

Smoke Compartments (Hospital only)

Code Red Stat: Fire resulting in horizontal evacuation. Proceed to the next smoke compartment by passing
through a door with the red ‘Fire/Smoke Door’ tag below.

Fire Drills
• To be familiar with response procedures
• Must follows all RAACE procedures and react as if the fire is a real event

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Online Provider Education

Fire Safety in the Operating Room
• Fires in the operating room (OR) are a genuine risk to patient safety. There are an estimated 200-240 surgical

patient fires in the United States per year (AORN, 2015). More than half of those fires occur on the head,
neck, upper chest and airway of the surgical patient. Fires that occur in the operating room can result in a
disfiguring, disabling or sometimes fatal outcome for the patient and are often preventable.

• There are three components necessary to complete the fire triangle (ignition source, oxidizer and fuel). Each

component makes a significant contribution to the risk for fire and prevention is a team effort.

Ignition Source Oxidizer Fuel

Electrosurgical Unit Oxygen Drapes

Argon Beam Coagulator Oxygen-rich Environment Gowns

Power Tools (e.g. drills, burrs) Nitrous Oxide Sponges

Laser Endotracheal Tubes

Fiber-optic Light Alcohol Based Skin Preparations

Defibrillator Personnel

Electrical Equipment Linens

• All personnel present during the surgical procedure have a responsibility to implement safety measures that

will reduce the risk of fire reaching the surgical patient. For example, the electrosurgical unit (ESU) hand
piece is the most commonly used ignition source and should be placed in a holster when not in use during the
procedure. Likewise, lasers can ignite any dry materials they contact. Thus, the person controlling the laser
beam should be the only person activating the laser, and wet towels or sponges should drape the area. When
using a fiber optic light source, the light should be placed in standby mode when not in use. All alcohol-based
skin preparation solutions should be used according to the manufacturer’s written instructions. These solutions
should be allowed to completely dry and fumes to dissipate prior to draping, and the circulator should remove
any towels used to prevent pooling. In an effort to prevent the incidence of surgical fires, Orlando Health has
adopted a fire risk assessment tool to be used for all surgical procedures.

• The fire risk assessment is a score attached to a surgical case to determine the level of risk for a fire to occur

in the operating room and offers appropriate interventions to be implemented by the surgical team. The
circulating nurse will assess for an open oxygen source, an available ignition source, and whether or not the
surgical site is above the xiphoid or within twelve inches from the oxygen source. If the risk is present, a score
of one (1) is applied. If the risk is not present a score of zero (0) is applied. The numbers are then added to
achieve the Fire Risk Assessment score.

Fire risk score of 0-2 indicates a low-level risk of fire. The routine fire safety protocol will be initiated.

F ire risk score of 3 indicates a high risk of fire. The high-risk fire safety protocol will be initiated.

• Completing a fire risk assessment along with implementing determined fire prevention safety measures will

reduce the risk of the occurrence of fires in the operating room and help surgical patients achieve their most
optimal outcome.

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References

• AORN, Inc. (2018), Standards for Perioperative Practice, Guideline for a Safe Environment of Care, Part 1.

AORN Publications

• Centers for Medicare & Medicaid Services. State Operations Manual. Appendix A—Survey Protocol,

Regulations and Interpretive Guidelines for Hospitals.
http://cms.gov/manuals/Downloads/som107ap_a_hospitals.pdf. Accessed January 28, 2015.

• Christiana Care Health System. Surgical Fire Risk Assessment. Retrieved 2018 from

https://christianacare.org/forhealthprofessionals/education/fireriskassessment/

• Cristiana Care. Fire safety and fire risk assessment. Retrieved September 2019 from

http//Christianacare.org/documents/firesafety/firesafetyprocedure0510%20%20firesafety.pdf

• Clarke JR, Bruley ME. Surgical fires: trends associated with prevention efforts. Pennsylvania Patient Safety

Advisory. 2012;9(2):130-135.

• ECRI Institute. New clinical guide to surgical fire prevention. Patients can catch fire—here’s how to keep them

safer. Health Devices. 2009;38(10):314-332.

• Guideline for a safe environment of care, part 1. In: Guidelines for Perioperative Practice. Denver, CO: AORN,

Inc; 2015:239-263.

• Guideline for preoperative patient skin antisepsis. In Guidelines for Perioperative Practice. Denver, CO:

AORN, Inc; 2017:51-74.

• Guideline for product selection. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2017:183-190.
• Guideline for safe use of energy-generating devices. In: Guidelines for Perioperative Practice. Denver, CO:

AORN, Inc; 2017:129-156.

• National Fire Protection Association (2015). NFPA 101: Life Safety Code. Quincy, MA: National Fire

Protection Association; 2015.

• http://www.nfpa.org/codes-and-standards/all-codes-and-standards/list-of-codes-and-standards?mode=code&

code=101&tab=editions. Accessed April 4, 2017.

• National Fire Protection Association (2018). NFPA 99® 2012, Health Care Facilities Code. Retrieved from

https://www.nfpa.org/codes-and-standards/all-codes-and-standards/list-of-codes-and-standards/detail?code=99

• Orlando Health Policy #500-8314: Fire Risk Assessment in the Operating Room
• The Joint Commission (2019). 2019 Hospital Accreditation Standards: EC.02.03.01, Oakbrook Terrace, IL:

Joint Commission Resources, Inc.

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Online Provider Education

Security
• Security is a shared responsibility for all team members, physicians and licensed independent practitioners.
• Security can be contacted directly at each facility:

H ospital facilities: Call 4321
Non-Hospital facilities: Call (321) 841-5600

• When to call Security?

Suspicious person/situation
E xterior/security lights not working
Escort to your vehicle
Property damage or stolen property

If you See Something, Say Something

Security: ID Badge
• Part of putting patients first is identifying who we are to patients.
• The primary purpose of your ID badge is to identify you as part of our team – a person our patients can

trust.

• Your badge also authorizes access to work area.
• Your badge must be visible, above the waist, at all times.

If you See Something, Say Something

General Safety
• If you see an unsafe condition or behavior, correct if you can and/or report it to the charge nurse.

For example:
S lip, trip, falls hazards (Note: All patients are assessed for falls risk - Morse Falls Risk Scale for adults and

Humpty Dumpty Scale for peds. Appropriate falls reduction interventions are based on score – Policy #2225)
F loor spills
Obstructed corridors
D amaged equipment, furnishings or physical environment
F ailure to use PPE or hand-washing

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Pain Assessment & Management (Orlando Health Policy #2426)
• Patient’s self-report using a pain rating scale:

o N umeric pain scale of 0-10 (0 = no pain, 1-3 = mild pain, 4-6 = moderate pain, 7-10 = severe pain)
o Pediatric (3 years and older): Numeric pain scale of 0 to 5, (e.g., Wong-Baker Faces Scale or 0 = no pain,

1-2 = mild pain, 3-4 = moderate pain, 5 = severe pain)

• Nonverbal pain behaviors (behavioral and physiological cues):

o C ritical Care Pain Observation Tool (CPOT), adult critical care only
o Pediatrics (4 months to 4 years):
– FLACC (Face, Legs, Activity, Cry or Consolability).
– CRIES (Infants <4 months)

• Proxy Report: Pain report from parent, family/others close to patient.

o https://powerdms.com/client/DocumentViewer.aspx?DocumentID=355618
Acute pain crises (severe, uncontrolled, acute pain episodes) are communicated to the physician or designee and
addressed promptly.

RESOURCES

The following resources are available to help ensure things go right for you and your patients:

• SWIFT – System-Wide Information at your FingerTips is the Orlando Health intranet. Policies and

procedures, call schedules, Medical Staff Bylaws and many other things are available online.

• Department chairs and hospital leadership are available to assist you. Contact information can be obtained

through Medical Staff Services.

PROVIDER ORIENTATION

We hope this presentation is helpful to you as you begin
practicing at Orlando Health.

Please contact Medical Staff Services at (321) 841-5139
if you have any questions.

Again, welcome to the Orlando Health Team!

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Mailing Address:
1414 Kuhl Ave.
Orlando, FL 32806
(321) 843-7000
OrlandoHealth.com

5873-54888 11/19 ©2019 Orlando Health, Inc.