REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
April 9, 2024
FROM
WILLIAM L. GILBERT, Director, Arrowhead Regional Medical Center
SUBJECT
Title
Arrowhead Regional Medical Center Emergency Department/Trauma Services Policies and Procedure Manual
End
RECOMMENDATION(S)
Recommendation
Accept and approve the revisions of policy, report of the review, and certification of the Arrowhead Regional Medical Center Emergency Department/Trauma Services Policy and Procedure Manual (included and summarized in Attachments A through D).
(Presenter: William L. Gilbert, Director, 580-6150)
Body
COUNTY AND CHIEF EXECUTIVE OFFICER GOALS & OBJECTIVES
Improve County Government Operations.
Provide for the Safety, Health and Social Service Needs of County Residents.
FINANCIAL IMPACT
Approval of this item will not result in the use of Discretionary General Funding (Net County Cost). Revisions of Policy and Procedure Manuals of the Arrowhead Regional Medical Center (ARMC) Emergency Department are non-financial in nature.
BACKGROUND INFORMATION
The ARMC Operations, Policy, and Procedure Manuals are prepared in compliance with County policies, California Code of Regulations Title 22, Chapters 1 and 5, Centers for Medicare and Medicaid Services (CMS), The Joint Commission, and other appropriate regulations and guidelines. Per CMS and The Joint Commission, all ARMC Operations, Policy, and Procedure Manuals are reviewed and revised, as necessary a minimum of every one, two, or three years, depending on the type of manual, and require Board of Supervisors (Board) acceptance and approval.
The manuals and policies are necessary to maintain compliance with policy and regulatory bodies. Adherence to the standards set forth in these manuals will improve County government operations and provide for the safety, health and social service needs of County residents by ensuring policies and procedures are in place for hospital operations and quality patient care.
ARMC policy manuals are reviewed, as applicable, by the Department Manager, Medical Executive Committee, Quality Management Committee, and ARMC Administration. The ARMC Operations, Policy, and Procedure Manuals reviewed include the following:
Emergency Department/Trauma Services Policies and Procedure Manual - Review and Certification
The Emergency Department/Trauma Services Policy and Procedure Manual (Manual) contains hospital-wide policies and procedures regarding quality of patient care within this specialty. The Manual contains 115 policies, which includes one new policy, 11 policies with major revisions (including nine that are deleted), 59 policies and the Index with minor revisions, and 44 policies reviewed with no revisions.
ARMC completed the 2022 review of the Manual and recommends the revisions in Attachment A. Review and update of this Manual is certified in Attachment B.
The one new policy added to the Manual are included in Attachment C, and consist of the following:
• Policy No. 513.00 v1, Orthopedic Admissions and Transfers - The new policy was created to ensure trauma patients with orthopedic injuries receive the necessary care from the appropriate service and that transfer of care between services occurs without issues. A detailed admission procedure was needed to prevent inappropriate admissions or delays of admissions to appropriate service. The new policy was also needed for compliance with the requirements of the American College of Surgeons, which designates ARMC as a Level 1 Trauma Center.
The major revisions to the 11 policies include:
• Policy No. 102.00 v4, Mission - Deleted. Refer to Administrative (ADM) policies 300.03 or 600.01 for Mission Statement.
• Policy 319.00 v4, Transportation of Emergency Department Patients to Behavioral Health - Major revisions to make Behavioral Health transport match current process.
• Policy 404.10 v9, Emergency Severity Index (ESI) Triage Category Principles and Medical Screening Examination (MSE) - Adjustments to current flow.
• Policy 407.00 v3, Chart Checks of Emergency Department Labs, EKG, and X-ray results - Deleted. Based on Meditech processes.
• Policy 408.00 V2, Routine Cerebral Spinal Fluid (CSF) Orders - Deleted. No need for policy on order set.
• Policy 411.10 V3, Point of Care Testing-Urine Multistix-Siemsn Clinitek - Deleted. Change to Department of Nursing Policy.
• Policy 412.00 V1, Urine Pregnancy Test - Deleted. Change to Department of Nursing Policy.
• Policy 426.00 V5, Management of 5150 Patients - Deleted. Combined with Administrative Policy No. 610.34.
• Policy 602.10 V3, Code of Ethics - Deleted. Redundant with Administrative Policy No. 1000.18.
• Policy 603.00 V2, Continuing Education - Deleted. Redundant with policy 602.00 V4.
• Policy 604.00 V1, Committee Participation - Deleted. Redundant with policy 601.00 V2.
The minor revisions to the 59 policies and Index include minor grammatical revisions, specifications of acronyms, reference updates and wording changes to match current references. The new policy was added, and the deleted policies were removed from the Index.
On March 26, 2024 (Item No.20), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment D.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Deputy County Counsel, 387- 5455) on March 8, 2024; ARMC Finance (Chen Wu, Finance and Budget Officer, 580-3165) on March 15, 2024; Finance (Jenny Yang, Administrative Analyst, 387-4884) on March 20, 2024; and County Finance and Administration (Valerie Clay, Deputy Executive Officer, 387- 5423) on March 20, 2024.