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December, 2016

Influenza Season:
Reminder, at this time, those providers who have declined the flu vaccine are required during recognized flu season: to wear a protective mask while inside SMH AND to wear a RED BADGE on SMH campus.

Hand Hygiene, Coming together on Hand Hygiene:
Hand hygiene (HH) is recognized as the most important safety intervention in infection prevention but must be performed adequately and at the right time. The goal of this program is that hand hygiene at the point of care becomes a reflex action for all healthcare providers. If you have any questions, please contact the Infection Prevention and Control Department or Hospital Epidemiologist.

*Please refer to Clean Your Hands to understand of the following key topics is basic to the success of our hand hygiene program:
  • The concept of two germ zones
  • 4 hand hygiene indications necessary at the point of care
  • Understanding standard precautions and the appropriate use of gloves.

Clinical Documentation Integrity: Hypertensive Urgency/Emergency/Crisis

  • Hypertensive Urgency: BP > 180/110 with or without symptoms such as severe headache, shortness ofbreath and anxiety; no end‐organ involvement
  • Hypertensive Emergency: BP of at least > 180/120, often exceeds 220/140; usually symptomatic withpossible chest pain, neurologic deficits, end‐organ involvement
  • Hypertensive Crisis: Sudden, severe rise in blood pressure that can be dangerous and requires earlyintervention. Can present as hypertensive urgency or as hypertensive emergency

Electronic Query (E‐Query) Process in SCM:
Effective Monday December 19, 2016, Clinical Documentation Integrity (CDI) will be converting to an electronic queryprocess for all physicians. Providers will no longer need to go to ScanDocs to complete outstanding CDI queries.The e‐query is located within SCM under the progress note section of the documents tab. The document name is CDISPhysician Documentation Clarification. The query can be completed through signature manager or the provider’soutstanding query list.

  • CDI team members will be available in the physician lounge on Monday (12/19) and Tuesday (12/20) to assistphysicians with setting up their query list in SCM. More information on how the process works is available in thephysician lounge. For questions, please contact Deb Dallos, CDI Supervisor, at 917‐5447.

*Please refer to Outstanding Query List Set Up Instructions for instructions on how to set up the provider outstanding query list and how to complete the e‐query.

Strategies to Reduce CAUTI:
The duration of indwelling urinary catheters is the most important risk factor for CAUTI. SMHCS is undertaking a comprehensive system‐wide program aimed at reducing unnecessary urinary catheterization and therefore reducing the incidence of CAUTI. There are three new components associated with this initiative- Strategies to Reduce CAUTI.

  • Use of the PureWick external female catheter as an alternative to a Foley catheter for patients with urinary incontinence. For more information, visit the PureWick website.
  • Use of an algorithm for management of patients with inability to void. Click here for a link to view the SMHCS Urinary Retention Algorithm.
  • Revision of urinary retention order sets. Click here for a link to view the SCM Urinary Retention Order set.

For questions related to the Urinary Retention Algorithm, please contact Dr. Manuel Gordillo.


From our families to yours,
We wish you happiness this holiday season ~

Sincerely, Scott Stevens, MD