REPORT/RECOMMENDATION TO THE BOARD OF SUPERVISORS
OF SAN BERNARDINO COUNTY
AND RECORD OF ACTION
September 9, 2025
FROM
ANDREW GOLDFRACH, ARMC Chief Executive Officer, Arrowhead Regional Medical
Center
SUBJECT
Title
Department of Nursing Policy and Procedure Manual
End
RECOMMENDATION(S)
Recommendation
Accept and approve the revisions of policies in the Arrowhead Regional Medical Center Department of Nursing Policy and Procedure Manual, included in Attachments A through C.
(Presenter: Andrew Goldfrach, ARMC Chief Executive Officer, 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 policies of the Arrowhead Regional Medical Center (ARMC) Operations, Policy, and Procedure Manual are non-financial in nature.
BACKGROUND INFORMATION
The ARMC Operations, Policy, and Procedure Manual are prepared in compliance with County policies, the California Code of Regulations Title 22, Chapters 1 and 5, the Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), and other appropriate regulations and guidelines. Per CMS and TJC, all 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 manual 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 Department of Nursing Policy and Procedures Manual (Nursing Manual) contains policies and procedures regarding department organization, function, and establishes standards of nursing practice. The policies, procedures, standards of patient care, and standards of nursing practice are developed by the Nurse Executives, Nursing Unit Mangers, Registered Nurses, and other nursing staff members as appropriate. The Nursing Manual contains 109 policies, of which nine have major revisions and one added new policy. As evidence-based practice continues to improve, the Department of Nursing is changing product and processes to improve patient care by reducing risks of infections, providing best practice for stroke care, ensuring proper compliance with pressure injury prevention, and implementing state of the art treatment for embolism and thrombus management. The Index has a minor revision to reflect the addition of a new policy.
The Department of Nursing recommends the revisions summarized in Attachment A. The new policy is in Attachment B.
The nine policies with major revisions consist of the following:
- Policy No. 581.20 v6 Central Venous Access Device (Central Line) Insertion Assist - Major changes made include: Updated Physician to Practitioner, removed forms no longer in use. Removed procedural steps: placement of towel roll, hand hygiene, head position, use of clippers, site choice that are located in other resources or are a physician responsibility. Clarified language for generic terms. Updated documentation to reflect the new electronic health record. Updated the resources.
- Policy No. 581.30 v4 Central Venous Access Device (Central Line) Management - Major changes made include: Updated to removed “specialty Registered Nurse (RN)” and replaced with “RN’s with a validated competency”. Updated equipment removed central line dressing kit, removed brand name “bio patch” and replaced with generic terms “occlusive dressing” and added securement device. Updated competency requirements and added dressing changes for RNs with validated competency. Removed specific language for brands and added generic language. Updated references.
- Policy No. 582.00 v8 Peripherally Inserted Central Catheter (PICC) Insertion and Exchange - Major changes made include: Removed assignment for dressing changes of two PICC line RNs, duplicate with another policy, requirement for PICC line dressing change is validated competency. Updated references.
- Policy No. 582.10 v4 Peripherally Inserted Central Catheter (PICC) Access, Complications, Care, Maintenance, and Removal - Major changes made include: Updated dressing change requirements to match central line policy. Added Registered Nurse with validated competency to perform dressing changes in the unit. Added reference to Neonatal Intensive Care Unit policy for their procedures regarding PICC line. Updated reference to department specific policy for Neonatal Intensive Care. Updated references.
- Policy No. 583.00 v3 Intravenous (IV) Dressings: Peripheral and Central - Major changes made include: Removed specific brands and used generic terms. Added dressing changes when integrity is impaired. Changed dressing change at 24 hours to assessed for dressing change needed. Removed Biopatch language. Updated references.
- Policy No. 801.00 v9 Pressure Injuries (PI): Identification, Prevention, and Management - Major changes made include: Changed physician to practitioner. Removed policy reference to administrative policy in the body of the policy. Updated care planning to reflect new electronic health record, changed Braden score to 18 or less. Updated staging guidelines reference. Removed brand names and replaced with generic terms.
- Policy No. 801.01 v4 Wounds in Adults: Identification and Management - Major changes made include: Updated collaboration with negative pressure wound therapy. Updated policy references. Updated care plan for “compromised skin integrity”. Updated wound documentation to reflect new electronic health record. Added wound dressing documentation for each shift. Removed Physical Therapy from wound treatment. Updated weekly Wound Resource Nurse assessment and reporting.
- Policy No. 588.00 v3 Midline Catheter - Major changes made include: Updated criteria for length of therapy. Updated vesicant medication and pH language. Update reference to add evidence-based practices. Updated ordering and consent requirement. Updated dressing changes to match the central line dressing change process. Added removal language. Updated references. Added language for the Neonatal Intensive Care Unit.
- Policy No. 501.02 v8 Guidelines for Administration of Intravenous (IV) Tissue Plasminogen Activator (tPA) in Treatment of Acute Ischemic Stroke - Major changes made include: Updated treatments to avoid while using administering tPA, updated interventions with team approval. Updated references.
The one new policy consists of the following:
- Policy No. 850.00 v1 Ultrasonic Endovascular System for Thrombus Management- This policy establishes guidelines for the proper use, management, and safety procedures of the Ultrasonic Endovascular System in a hospital setting to ensure effective treatment of pulmonary embolism and vascular thrombosis. It details the system’s components, including the Ultrasonic Control Unit, Endovascular Device, infusion pumps, and ultrasonic cart, as well as their functions. The policy outlines indications and contraindications for use, emphasizing physician discretion. It also provides step-by-step procedures for equipment preparation, device setup, insertion, treatment initiation, troubleshooting, and removal, all in accordance with the manufacturer’s instructions. Lastly, it highlights the importance of nurse education and competency validation for patient monitoring and device management.
On August 5, 2025 (Item No. 18), the Board accepted and approved the report of review and certification of ARMC Operations, Policy, and Procedure Manuals listed in Attachment C.
PROCUREMENT
Not applicable.
REVIEW BY OTHERS
This item has been reviewed by County Counsel (Charles Phan, Supervising Deputy County Counsel, 387-5455) on July 8, 2025; ARMC Finance (Chen Wu, Budget and Finance Officer, 387-5285) on August 15, 2025; and County Finance and Administration (Jenny Yang, Administrative Analyst, 387-4884) on August 18, 2025.