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06/01/1966 431 RIDULAR MEETmG BOARD OF HEALTH HELD IN OFFICE OF BOARD June 1, 1966 - PreSBIlt: Mayor O. O. Allsbrook, Acling Chairman, Dr. J. C. Knox, Dr. James Smith, Dr. James Tidler, Dr. William Wagoner, Attorney Bradford L. Tillery. Minutes of the May 4, 1966 meeting were approved by motion of Dr. Wagoner, seconded by Dr. Knox. Policies for Nursing Department: The policies for the Nursing Department in Home Health Services were presented to the Board for consideration and approval. These policies were recoDDllended by the newly appointed Advisory Board. This Board is made up of the following people: Dr. C. B. Davis, Health Director, Miss A. Lou Davis, Director of Nurses, Dr. Frank Reynolds, Dr. L. W. Upperman, Miss Ruth Dixon, Physical Therapist, Mrs. Frances Walker and Chairman Dottie Primrise. This committee was appointed by Dr. Davis and approved by the Board of Health by a vote taken by telephone on May :13, 1966 by Mabel B. Price. These policies were discussed and adopted as presented with the exception of Section V, which is on Fees. This was not accepted because it was incomplete since final word from the State Board of Health on Fees has not been received. There will also be a section added on Nutrition and these two sections will be presented to the Board at a later date. Dr. Wagoner made the motion that the policies be accepted with this exception and Dr. Tidler seconded it. The motion carried. (Copy Attached) .~. . Mr. Tillery was asked to look into the matter of who will be legally responsible in case of a suit arising from services given or not given and whether or not it would be advisable for all the nursing staff to be conrad by. MalPractice Insurance. - Contract with Chronic Disease Section (Home Care Budget): This contract was pre- sented to the Board with attention called to the fact that last year this budget supported two nurses but for the year 1966-67 will support only one. This means that unless the County gives us an additional nurse we will lose a nurse on JulJ' 1, 1966. Dr. Smith made the motion, seconded by Dr. Tidler, that the contract be accepted. Motion carried. Transfer of Funds: Request was made to transfer monies from Contingent Fund to the following: Medical Supplies $50.00, TB Clinic $130.00, Laundry $60.00, Minor Maintenance $200.00. Dr. Wagoner made the motion that we transfer these funds. Dr. Knox seconded the motion. Motion carried. Paging System: Dr. Davis presented brochures on a paging system which could be used by the nurses and sanitarians. Since in our Tentative Budget request we mentioned that we would like to have sane kind of a COIlIIIlUIlications System, Dr. Wagoner suggested that we give information as to cost, etc. to the Commissioners and Mr. Love. , Health Occupations Class: Dr. Wagoner told the Board that he has asked for an instructor for a Health Occupations Class for the High Schools. This would be a course for boys and girls who are interested in becoming LPN's, Orderlies, Laboratory Technicians, etc. but who do not plan to go to college. This course would prepare them to enter a trade school such as the Cape Fear Technical Institute and would encourage them to take these courses as soon as they leave High School. It is felt that such a course might help fill the need for this type of employee since there is such a shortage now. Dr. Tidler made the motion that we endorse this program, Dr. Knox seconded and the motion carried. School Dentist: Dr. Smith advised the Board that he had been notified that instead of the one dentist for the school system, that a team of three dentist would COllIe, thereby completing the work in a shorter period of time. 432 There being no further business the meeting was adjourned. Approved ~ ) - Respectfu~ submitted, 7ll ~ kJ_ p~~ ?- 3_ f., & ~ 1 - ~ . ~ Second Draft May 26, 1966 4---c-i~~ ~ /3~~ "'d' N~-;('.() 6-n (, _ 1- (.,,, _ ~('~ ~~Y- ~~A-.; ~, 7[ d C<9--r><-;FL- POLICIES FOR HOME HEALTH SERVICES CONSOLIDATED BOARD OF HEALTH Wilmington, N. C. , - Objective The aim of the home health services of the Consolidated Board of Health is to meet certain nursing and other therapeutic needs of people living in New Hanover County who can be better treated at home, and to make these services available to anyone regardless of age or ability to pay. Such services shall include: 1. Under the direction of a licensed physician or licensed dentist, give direct patient care to patients at home on an intermittent basis. 2. Teaching for the purposes of disease prevention and health promotion. 3. Rehabilitation of the individual to his maximum degree of independence. The policies governing skilled nursing and other therapeutic services will be established with the approval of an advisory committee to the Consolidated Board of Health. Additions or deletions may be made at the discretion ef the Advisory Committee at a regular meeting. The North Carolina State Board of Health recommends that the advisory committee be selected by the agency with approval of the governing board of the agency. The committee shall consist of at least the following representation but may have addi- tional members in accordance with local preferences: One licensed physician, one registered professional nurse, preferably a qualified public health nurse, one other health professional, and two interested citizens, and the local health director. The chairman will be elected by the committee. In order to effect a pattern of rotation, these members may initially serve terms as follows: The health director will be a permanent ex-officio member ef the committee. Physician and public health nurse --- three years, other health profession --- two years, two interested citizens --- one year. Thereafter, the terms of all members of the advisory ~ . v committee would be for three years. A member may succeed himself for a second term but should go off the committee for at least one year after each two consecutive terms of service before being considered fer reappointment. - 2 - The functions of the advisory committee shall be to assist with: 1. program development 2. establishing policies for home health services 3. program evaluation 4. public relations The committee shall meet at least semi-annually. Special meetings may be called at the discretion of the chairman. The purposes of these written policies are: 1. to provide for standard of high quality patient care 2. to promote good professional relationships between the practicing physician and the staff of the Consolidated Board of Health 3. to insure that all staff members engage only in those activities which are recognized to constitute approved practice for their respective position, training and skills I. Medical Supervision A. The patient should be under the supervision of a primary physician who provides and or coordinates orders for his care. / B. The responsibility for seeking medical care belongs primarily to the family. Consolidated Board of Health personnel, while in the home, do not summon a physician except in the case of a real emergency. C. An alternate physician may be named by the family to provide care when the primary physician is not available. D. If the person giving care finds that the patient has changed medical supervision, she may not give further care until new written orders have been obtained. E. If, on first visit, the nurse finds that the patient is not under medical supervision, she should explain to patient and family that medical supervision is essential for continued service, and that she will return upon request of their physician. - 3 - II. Medical Orders A. Request for service and orders for care will be accepted from physicians and dentists licensed to practice in the state of North Carolina and practicing within a reasonable radius of the Consolidated Board of Health. B. Medical orders will be accepted from physicians in hospitals and nursing homes which are beyond reasonable radius of the agency. (Such as Veterans Administration Hospitals and out-patient clinics at Duke and Memorial Hospital in Chapel Hill). If, however, the referring physician is not responsible for the patient's medical care at home, the local family physician should be contacted for approval of orders before, or immodiately, following the first visit. If no local physician has been selected by the family, this should be done before a second visit is made. When possible, the patient or the family will be responsible for securing orders from the physician. C. Written orders for patient care are to be procured from the physician and signed by him. A regist.ered llIu'se may accept verbal orders from a physician in SOUIO instances, but these are to be followed within 72 hours by written orders and before the service is repeated. D. Orders for narcotics and dangerous drugs must be received in writing and signed by the physician BEFORE being administered. E. Verbal orders cannot be accepted from the patient or family. F. When obtaining orders from the physician, specific information shall be requested with regard to: Diagnosis and treatment Medications and dressings Dosage and interval Method preferred for administering medication or treatment Frequency of treatment Precautions, if any - 4 - G. All orders for patient care must be reviewed by the physician and renewed in writing every two months. Renewal fonns will be provided for the physician by the agency at the appropriate time. III. Request for Service A. The agency reserves the right to make discretionary judgment if and when adequate staff is not available. Request from physician for service will be answered with a minimum of delay. Requests received before 9:00 A. M. will be made the same day when possible. Requests received later than 9:00 A. M. will be answered the following day, or on the nurse's first visit to the area. New orders for treatment will not be initiated from Friday after 12:00 noon until Monday at 8:00 A. M., nor on holidays. B. The nursing staff will call the office between 12:00 and 2:00 P. M. to receive calls that need more immediate attention. C. Frequency and duration of visits will be determined according to needs of patient and availability of staff. D. Working hours of the nursing staff will conform to the regular agency schedule -- Monday through Friday. 1. Nursing service on Saturday, Sunday, and holidays will be extremely limited. All orders for medication and treatments will be scheduled for regular working days WHENEVER POSSIBLE. E. The nursing staff will receive compensatory time for week-end and holiday service. They will be expected to take this time the following week. F. A specific hour for visits cannot be given; attempts will be made to follow a practicable schedule for patient and staff. - 5 - IV. Patient and/or family respOnsibility A. Patient will be expected to select a primary physician and to remain under medical supervision. B. Patients will be expected to secure all medications and dressings and as much equipment as is feasible. C. A member of the household must be willing and able to assume responsi- bility for care of the patient between nursing visits. D. The patient, when possible, or a household member will be expected to learn to assume responsibility for procedures which, in the opinion of the physician, can be safely taught the individual. ( V. Payment for Home Health Services A. Philosophy of fee collection 1. The familites financial status does not determine the patient I sneed for home health service. 2. The charge for home visits will be based on an established cost. B. When families are unable to pay full fee and are ineligible for contract services, the fee is adjusted in accordance with the ability of the family to pay. When there is any question, fees are discussed with supervisory personnel of the agency. 'I \ \ \ \ \ ( E. '------- C. Method of determining families ability to pay. D. Cost of home health services (more information from State Board of Health is needed for C, D & E). Method of fee collection VI. Home Health Services A. Nursing Services Nursing care is primarily skilled nursing service which may be supple- mented by services of other personnel whose duties and competencies are carefully delineated. Initial and closing visits will be made by - 6 - a Public Health Nurse. I. Nursing visits will be "1Ilade to catty out specific orders for nursing services. 2. Procedures will be carried out according to accepted practice. 3. The Public Health Nursing Manual of the State Board of Health will be used as a guide. 4. 'ilhen indicated and feasible, and with the consent of the attending physician, many procedures may be taught to a member of the family, or other responsible person in the household. 5. A report of the patient's condition, nursing care given and the results of treatment will be made to the attending physician in person, by telephone or in writing as indicated by the patient's condition or the physician's order. 6. Examples of Nursing Care: a. Examples of nursing care which the agency will provide are: (1) subcutaneous and intramuscular injections (exluding drugs for the treatment of allergies, immunizing agents, and first injections of penicillin). (2) catheterization of female patients (except first catheteri- zation when there is a history of obstruction or tumor) (3) irrigation and care of retention catheter (4) dressings (5) colostomy care ( 6 ) enema (7) (8) (9) skin care (10) (ll) douche bed or tub bath feeding positioning - 7 - (12) simple exercises (13) care of tracheotomy (14) blood pressure b. Examples of nursing care which the agency does not provide: (1) giving blood transfusions (2) giving intravenous fluids (3 ) giving fluids by hypodermoclysis (4) removing sutures (5) catheterization of male patients (until services of a male nurse or aide is available) (6) insertion and removal of outer tracheotomy tube (7) first injection of penicillin (8) immunizing agents and drugs for the treatment of allergies (9) visits to potentially violent patients (10) enemas for male patients (until services of a male nurse or aide is available) c. The following nursing activities are a part of all public health nursing visits and will be continued in the home nursing care program: (1) instruction and guidance in relation to disease (2) instruction and guidance in general health promotion (3) emotional support and guidance in accepting and adjusting to illness and its limitations (4) guidance in use of community resources 7. Standing orders a. Purpose: Standing orders are authorized by the Health Director. These orders guide the nursing staff of the agency in giving nursing care when: (1) There is an emergency and no physician is in attendance C~'_~"~____'_~___"_ ..... ~___~,~^,.~,~.~,., - 8 - (2) The nurse has been unable to reach the physician for orders (3) The nurse in making a first visit finds the patient is not under medical supervision (further bedside nursing service will be given only on direct medical orders from the physician in charge). b. The standing orders for bedside nursing service are as follows: (1) S"i'v.i"",,, wbi"h may be l'eudered witbout a medical order on a first nursing visit include: (a) temperature, pulse, and respiration (b) sponge bath or partial care if not contr~jndicated (no tub bath without physician's order) (c) care of pressure sore - cleanse well with soap and water - relieve pressure - instruct in keeping area clean and dry - change position (2) Emergency orders for severe drug reaction (a) the public health nurse will contact the patient's physician for emergency orders if possible (b) if physician cannot be reached, or if reaction is so sudden and severe that delay is not feasible, the public health nurse will administer 3 - 5 minims of adrenalin chloride 1:1000 solution, which she will carry in her nursing bag. (c) the nurse will contact supervisory personnel at the Health Department as soon as possible to notify them of the emergency and action taken. Supervisory personnel will help obtain or advise about emergency medical supervision for the patient if this has not been arranged for. - 9 - (d) in an emergency the nurse should remain with the patient until medical supervision can be obtained. In some instances, the most practical means of obtaining emergency medical supervision may be having the patient moved to the hospital emergency room. The nursing staff, however, does not transport patients and/or families. , tflO~ C. B. Davis, M.D. Health Director Phy_sic:~l ThQraJl.'LService s: Physical therapy servic.es will be provided by the Wilmington Physical Therapy Clinic under a contract. Physical therapy will be administered only by a person registered to practice physical therapy in the state of North Carolina. 1. Physical therapy visits will be made to carry out physician's orders. 2. Procedures will be administered a.c,.cording to accepted pwsical therapy practices. 3. When indicated and feasible, and with the consent of the physician, many procedures may be taught to a member of the family or other responsible person in the household. 4. A written report of visits will be maintained in the agency office and periodic reports will be transmitted to the physician. Examples of procedures which the physical therapist must administer: 1. muscle testing, joint range, ambulation and other physical evaluation procedures. 2. therapeutic exercise. 3. selecting and teaching proper gait pattern(s). 4. determining progression of treatment plan. - 10 - 5. application of any modality involving the therapeutic use of electricity. Examples of procedures which the physical therapist may teach and supervise: 1. application of heat or cold. 2. positioning. 3. therapeutic program of passive and active exercise. 4. supervise practice of transfer and ambulation activities. 0..OllS'lli t~'l.t.ion anti C()()pcl'at,; OH in platud He aud implmn8uti ng services: 1. participation on advisory committees. 2. establishment of loan closets. 3. assist with training and utilization of non-professional ].>ersonne1. Nutrition Services The Nutrition Section of the State Board of Health has been asked to draft a statement to incorporate in these Policies.