Operational Reference Library

Hospital Protocols & ED Policies

Select a protocol to view the embedded document.
๐Ÿ”
๐Ÿฅ Clinical Protocols
Code Blue โ€” Cardiac/Respiratory
Code Blue
Code Sepsis Protocol
Code Sepsis
STEMI Patients โ€” Receiving Centers & Protocol
STEMI Transfer
Code 24 / Code Stroke โ€” BEFAST
Code Stroke Neuro
Trauma Guidelines
Trauma
Trauma Triage
Trauma
MD Restraint Cheat Sheet
Quick Reference
Restraint Orders โ€” Behavioral vs Clinical
Quick Reference Behavioral
Urine GC/Chlamydia Order Guide (<12 yrs)
Pediatric Procedure
Medical Wean / End of Life Management
Palliative
Dementia w/ Behavioral Disturbance โ€” ED Workflow
Geriatric Behavioral
IV Versed โ€” ED RN Scope Clarification
Scope FAQ
Emergency Release & Hemorrhage Protocol โ€” Blood Products
Hemorrhage Blood Bank
Bloodborne Pathogen Post-Exposure Protocol
Exposure Employee Health
๐Ÿ’Š Bedside Mixtures & Procedures
Constipation โ€” Brian Bomb & Pink Lady
Recipe
Occipital Nerve Block (3-2-1)
Recipe Procedure
Peds Multi-System Inflammatory Syndrome (MIS-C)
Pediatric Critical
Priapism โ€” Phenylephrine Prep & Supplies
Procedure Recipe
Peritonsillar Abscess Protocol
Recipe ENT
Stress Tests โ€” PNL Quick Reference
Cardiology
โš™๏ธ ED Operations & Workflows
Last Hour Assignment Protocol
Operations
FMC Shift PSG Assignments
Operations Reference
Rx Sign-Out Workflow
Operations
Inbasket Abnormal Results Workflow
Workflow
Radiology Safety Net Process
Workflow
ED Radiology โ€” Epic Downtime
Workflow Radiology
Overnight IR Procedures
Workflow Radiology
MD-RN Communication Strategy (FMC)
Communication
FMC/OMC ED Operations
Operations
FMC Throughput Changes โ€” Phase 1
Throughput
FMC Throughput Changes โ€” Phase 2
Throughput
Fluorescein Strip Replacement โ€” OMC Drops
Operations Ops Note
Funduscopic Images โ€” Viewing Workflow
Operations Ops Note
๐Ÿš‘ Transfer Processes
Kaiser โ†’ Loma Linda Neuro Radiology
Transfer Process
Fontana Regional Neonatal Transport
Transfer Process
๐Ÿ“‹ Policies & Legal Reference
CA Minor Consent & Confidentiality Laws
Legal Reference
Chaperone Guidelines for Physicians
Policy
Documenting Acute Kidney Injury
Clinical Reference
Safe Prescribing Guidelines
Prescribing
๐Ÿ“Š NEDOCS Tools
NEDOCS 2.0
Crowding Tool
NEDOCS 3.0
Crowding Tool
NEDOCS โ€” FMC
FMC Protocol
NEDOCS โ€” OMC
OMC Protocol
๐Ÿฅ

Select a protocol from the list to view the embedded document.

Code Blue โ€” Cardiac/Respiratory
Emergency Medicine ยท Hospital Medicine ยท FMC & OMC
๐Ÿ”ด Code Blue
Open Document
Word ยท Office Online
๐Ÿ“ Code Blue โ€” Cardiac and/or Respiratory (Fontana/Ontario)
Open in Word โ†—
Code Sepsis Protocol
Emergency Medicine ยท Internal Medicine
๐Ÿ”ด Code Sepsis
Open Document
Word ยท Office Online
๐Ÿ“ Code Sepsis Protocol
Open in Word โ†—
STEMI Patients โ€” Receiving Centers & Protocol
Emergency Medicine ยท Cardiology ยท Kaiser Fontana / Ontario ยท ICEMA
โค๏ธโ€๐Ÿ”ฅ STEMI
KP Fontana & Ontario are STEMI Referral Facilities (SRF) โ€” patients with STEMI must be transferred to a designated STEMI Receiving Center. Goals: door-in to door-out <30 minutes, EKG within 10 minutes.
๐Ÿ“ž STEMI Receiving Centers โ€” Call in this order
1. St. Bernadine's Hospital
Main: 909-883-8711
ER Fax: 909-881-4500
ER Phone: 909-881-7140
Cath lab: x3474
Direct line: 909-881-4320
House Supervisor: 909-881-4338
โš ๏ธ Fax EKG ASAP, wait for confirmation
2. Loma Linda Hospital
Main: 909-558-4000
Fax: 909-558-4054
ER: 909-558-4444
Interfacility transfers: x83111
(in place of house supervisor)
Cath lab: 909-558-4473
3. San Antonio Community Hospital
Main: 909-985-2811
Fax: 909-920-4731
ER: 909-920-4798
Direct Dr. Line: 909-920-4777
House Supervisor: 909-920-6120
Cath Lab: 909-920-4761
๐Ÿฅ Clerk Workflow
  1. CLERK FAXES EKG ASAP, waits for confirmation. F/U with phone call to St. B's ER to notify that EKG has been faxed to them. Once we receive fax confirmation:
  2. CLERK CALLS St. B's ER physician & transfers call to our ER Dr. to discuss. (make sure you have St. B's ER Dr. name)
  3. If our Dr. indicates to ACTIVATE A "STEMI":
    CLERK DIALS "911":
    "I'm calling from Kaiser Fontana Emergency Room. We have a patient that needs to be transported to St. Bernadine's for a STEMI."

    AMR will ask: our address 9961 Sierra Ave., ER โ€” Pod ___ Bed ___; name of ordering Dr. (our ER physician); name of receiving Dr. (St. B ER physician).
  4. What goes with patient? Copy of EKG (faxed) ยท Face Sheet (clerk prints) ยท patient chart (RN prints). Put together in lg. white AMR transport envelope.
  5. Give our RN the "STEMI" form to complete (located in QI Tools binder on clerk's desk).
๐ŸŽฏ Goals โ€” Patient arriving non-EMS at Kaiser Ontario or Fontana ED
  1. Door-in to door-out <30 minutes
  2. EKG within 10 minutes
  3. Determination of eligibility for STEMI protocol
  4. Establish that the patient wants invasive treatment
    • Consider potential injury to kidneys
    • Need to rescind any existing DNR standing order
  5. Consider road conditions for transfer (traffic ยท weather ยท availability of transport)
  6. Is the patient stable for transport?
๐Ÿ’Š Pre-Transport Medications & Paramedic Scope
Medications to consider giving prior to transport, and what medics are allowed to use on transport:
ASA
OK
Nitropaste
OK
Heparin
Bolus OK ยท Drips NOT allowed
Dopamine
Drips OK
Lidocaine
Drips OK
Procainamide
Drips OK
All other drips are outside paramedic scope โ€” would require a nurse or physician to go with the patient.
๐Ÿš‘ RN Transport Considerations
  • Fontana: A transport ED RN may go with the patient if other medication is required. RN is responsible for orders from the transferring physician. If patient deteriorates, the paramedic contacts Base Station for orders and any destination change.
  • Ontario: No current method for an Ontario ED RN to go in the ambulance. Securing an RN from AMR will result in further delay โ€” transfers from Ontario will be made without an ED RN and no unapproved medications.
STEMI Receiving Centers list revised 7.26.2014 ยท STEMI Protocol dated 1/23/12 ยท Policy is in concert with County of San Bernardino regarding STEMI.
Code 24 / Code Stroke โ€” BEFAST
Emergency Medicine ยท Neurology ยท TeleNeurology ยท KP Fontana & Ontario
๐Ÿง  Code Stroke
Time is brain. Use the BEFAST screen for any patient with possible stroke symptoms. Code 24 extends the thrombectomy window for select late-presenting patients (LSN 6โ€“24 h with NIHSS โ‰ฅ 6 and confirmed intracranial occlusion).
๐Ÿ…ฑ๏ธ BEFAST โ€” Signs of Stroke
B
Balance changes
E
Eyes โ€” vision changes
F
Face โ€” facial droop
A
Arms / Legs โ€” weakness
S
Speech โ€” slurred
T
Time โ€” don't stall; call
๐Ÿ“ Remember to use the .EDHelp Smartphrase.
๐Ÿ›ค๏ธ Two Pathways
Last Seen Normal 0โ€“6 hours ยท or Wake-Up Stroke
โ†’ Call CODE STROKE
LSN 6โ€“24 hours ยท NIHSS โ‰ฅ 6
  1. Page TeleNeurologist 323-699-4444 to discuss
  2. If discussion yields Code 24: activate Code 24 & order Code24 CTH + Code24 CTA
  3. If CTA reveals intracranial occlusion โ†’ call Code Stroke
๐Ÿ•’ Code 24 Process Summary
  1. Triage โ€” Patient arrives with BEFAST symptoms, last-seen-normal between 6โ€“24 hours.
  2. Physician Assessment โ€” BEFAST symptoms, LSN 6โ€“24 h, NIHSS โ‰ฅ 6.
  3. Physician Calls Code 24 โ€” Page TeleNeurologist at 323-699-4444; discuss case. If candidate, ED physician activates "Code 24" and orders "Code 24 CTH" + "Code 24 CTA".
  4. Radiological Review โ€” Local radiology reviews imaging. If intracranial occlusion is identified, ED physician calls a Code Stroke.
  5. Call Code Stroke โ€” For evaluation and set-up of transfer; TeleNeurologist responds to the Code Stroke.
  6. Prepare Transfer โ€” Use the ETAP form to expedite transfer. ETAP will call the TeleNeurologist for further set-up. Nurse must ensure the patient's chart is closed the moment the patient leaves the hospital doors so the time the patient left is captured accurately.
  7. Transfer to CSC for further treatment.
Trauma Guidelines
Emergency Medicine ยท Surgery ยท Trauma
๐ŸŸ  Trauma Protocol
Open Document
Word ยท Office Online
๐Ÿ“ Trauma Guidelines
Open in Word โ†—
Trauma Triage
Emergency Medicine ยท Surgery ยท Trauma
๐ŸŸ  Trauma Protocol
Open Document
Word ยท Office Online
๐Ÿ“ Trauma Triage
Open in Word โ†—
MD Restraint Cheat Sheet
Emergency Medicine ยท Hospital Medicine
๐Ÿ“‹ Quick Reference
Open Presentation
PowerPoint ยท Office Online
๐Ÿ“Š MD Restraint Cheat Sheet
Open in PowerPoint โ†—
Restraint Orders โ€” Behavioral vs Clinical
Emergency Medicine ยท Behavioral Health
๐Ÿ“‹ Quick Reference
Open Full-Size Image
JPG ยท Print or save
๐Ÿ–ผ๏ธ Restraint Orders โ€” Decision Reference
Open Full-Size โ†—
Restraint Orders quick reference comparing Behavioral and Clinical restraint orders, including criteria, restraint type, point count, face-to-face assessment timing, and order expiration.
Urine GC/Chlamydia Order Guide (<12 yrs)
Emergency Medicine ยท Pediatrics
๐Ÿง’ Pediatric Procedure
Open Document
Word ยท Office Online
๐Ÿ“ How to Order Urine GC/Chlamydia for <12 yrs (Abuse Rule-Out)
Open in Word โ†—
Medical Wean / End of Life Management
Emergency Medicine ยท Palliative Care ยท Critical Care
๐Ÿ•Š๏ธ Palliative
Open Document
Word ยท Office Online
๐Ÿ“ Medical Wean / End of Life Management
Open in Word โ†—
Dementia w/ Behavioral Disturbance โ€” ED Workflow
Emergency Medicine ยท Geriatric ยท Behavioral Health
๐Ÿง  Geriatric Behavioral
Open Document
Word ยท Office Online
๐Ÿ“ Dementia with Behavioral Disturbance โ€” ED Work Flow
Open in Word โ†—
IV Versed โ€” ED RN Scope Clarification
Emergency Medicine ยท Nursing Scope ยท FAQ
โœ… Within Scope
Bottom line
IV Versed (midazolam) is within the scope for ED RNs. This kills a recurring floor-level misunderstanding that IV Versed requires an ICU/procedural-sedation-trained nurse.
The one carve-out
  • Contingent workers (travelers / registry / non-competency-signed-off nurses) cannot perform procedural sedation because they are not comp'd for it.
  • That restriction applies to the procedural sedation role specifically โ€” not to routine IV Versed administration for anxiolysis/seizure/etc.
Source
Mike Schwartzwald (Chief, ED) ยท Feb 19, 2026 ยท internal clarification email
Emergency Release & Hemorrhage Protocol โ€” Urgent Need for Blood Products
Nursing Services ยท Intravenous Therapy ยท Transfusion Committee ยท FMC & OMC ยท NS.GNS.IVT.016
๐Ÿ†˜ Hemorrhage
Purpose
Defines the Emergency Release and Hemorrhage Protocol and describes departmental responsibilities when blood products are needed urgently โ€” i.e., the clinical situation is sufficiently urgent to require release of blood before completion of compatibility testing. Patient sample must be sent to Blood Bank STAT; uncrossmatched blood is dispensed until testing is completed.
Effective 6/10 ยท Revised 3/13, 7/13 ยท Reviewed 6/10, 9/11, 1/13, 6/13 ยท 5 pages, 3 attachments
๐Ÿ“ž Activation โ€” Call Blood Bank
OMC Blood Bank
Extension: 42984
FMC Blood Bank
Extension: 28080
๐Ÿ“ฃ Script (verbalize when calling)
"This is (your name) from Labor & Delivery / Emergency Department / OR / etcโ€ฆ the Emergency Release / Hemorrhage Protocol is in effect on (patient name and MRN #). Please use extension (your extension) for call back information."
  1. Verbalize the type of product, and number of units to be released.
  2. Complete the Emergency Release / Hemorrhage Protocol Form (Attachment 1) โ€” take with you to the Blood Bank. The form acts as the order/release in an emergency.
  3. Blood Bank starts release process at the time of phone call โ€” blood ready for pickup within 10 minutes.
๐Ÿฉธ Emergency Release vs. Hemorrhage Protocol โ€” What Blood Bank Issues
โš ๏ธ Emergency Release
  • Up to 2 units RBC within 10 minutes of phone call.
  • Frozen Plasma (FP) thawed only if requested โ€” available within 45 minutes.
  • Platelets โ€” only if specifically requested.
๐Ÿ†˜ Hemorrhage Protocol
Auto-dispenses a full pack โ€” call alone constitutes the physician order.
  • 4 units RBC within 10 minutes of call.
  • 4 units thawed Plasma โ€” thawed immediately, dispensed within 45 minutes.
  • 1 platelets pheresis component โ€” immediately, or ordered STAT if not available.
  • Blood Bank keeps ahead 4 RBC, 4 plasma, 1 platelets until protocol cancelled.
Key: The authorized call to the Blood Bank for a Hemorrhage Protocol constitutes a physician order for RBCs, thawed Plasma and platelets โ€” no separate written order required to start.
๐Ÿ“‹ Provisions / Procedure
  1. Inform Blood Bank of emergency nature โ€” Emergency Release vs. Hemorrhage Protocol โ€” when phoning.
  2. The authorized call to the Blood Bank for a Hemorrhage Protocol constitutes a physician order for RBCs, thawed Plasma and platelets.
  3. A form with the patient's name, MRN, and ordering MD name must be presented to the Blood Bank when picking up blood products (Emergency Release / Hemorrhage Protocol Form โ€” Attachment 1).
  4. The uncrossmatched RBC tag attached to the RBC must have, at minimum: patient name, patient MRN, patient blood type if dispensing non-group O blood, and the word "UNCROSSMATCHED".
  5. Requesting MD must sign and return the Emergency Blood Release Waiver form (Attachment 2 FMC or 3 OMC) โ€” sent with the blood โ€” as soon as possible.
  6. If the patient does not already have a specimen in the Blood Bank, a specimen must be drawn and sent to lab as soon as possible.
  7. If Hemorrhage Protocol was initiated, the physician will cancel the protocol when the patient has stabilized and the immediate hemorrhage situation has subsided. The circulating nurse / communication person will contact the Blood Bank to discontinue.
  8. All orders will be entered into the electronic medical record (HC) for blood products and transfusions once the patient has stabilized.
๐Ÿ‘ฅ Roles & Responsibilities
1. Attending Physician, Surgeon, or Designee
  • Recognizes the need to activate the hemorrhage protocol and ensures its immediate activation.
  • Updates nursing or responsible team of blood product needs.
  • Cancels the hemorrhage protocol as indicated.
  • Signs and returns the Emergency Blood Release Waiver form to the Blood Bank as soon as possible when the crisis subsides.
  • Places orders in HC as soon as possible for lab work, blood products, and transfusions.
2. Charge Nurse or Designee
  • Initiates the hemorrhage protocol.
  • Ensures collection of a Blood Bank specimen and its immediate transport to the Blood Bank if not already obtained.
  • Assigns a person who will communicate with the Blood Bank for the duration.
  • Maintains communication with the physician, surgeon, or designee.
  • Ensures cancellation of the protocol as directed and prompt return of unused blood products to the Blood Bank.
  • Maintains all transfused bags for later reconciliation of products transfused โ€” placed in the patient medical record.
  • Ensures HC orders are placed for all lab work, blood products, and transfusions.
  • Coordinates a debriefing once the crisis subsides and/or the protocol has been cancelled.
3. Person Assigned to Communicate with Blood Bank (e.g., unit secretary or transporter)
Calls the Blood Bank and provides them with:
  • Their contact name and phone extension for Blood Bank to call back.
  • Patient Name and MRN.
  • Physician Name.
  • Location where blood is to be transfused.
  • Confirms order: 4 units RBC, 4 units thawed plasma, 1 unit platelets.
  • Completes orders for blood products (electronic or manual) and prints the Blood Release Verification (if ordered in HC), or manually completes either the Emergency Release Waiver form or Hemorrhage Protocol Form to pick up blood product(s).
  • Transports Blood Bank specimens, or ensures they are transported immediately.
  • Receives blood products from the Blood Bank and delivers to patient location immediately.
  • Maintains close communication with the Blood Bank and informs them when additional blood products are needed.
  • Waits for additional instructions from the charge nurse or team leader.
4. Blood Bank Technologist (CLS)
  • Initiates the emergency release or Hemorrhage protocol as soon as the call is made.
  • Assesses need for assistance and immediately informs Lab supervisor.
  • Prepares RBCs for immediate dispense โ€” may be:
    • Uncrossmatched group O neg or O pos (depending on supply).
    • Uncrossmatched ABO compatible IF a current sample exists with at least an ABO/Rh test performed, and the ABO/Rh has been confirmed by historic or serologic testing or it was drawn using the KPPI process.
    • Crossmatched RBCs if available.
For Hemorrhage Protocol Only
  • If thawed plasma is not available, 4 units will be thawed immediately โ€” available within 45 minutes.
  • Platelets dispensed if available, or ordered from a blood supplier or alternate source.
  • Keeps ahead 4 RBC, 4 plasma, and 1 platelets until protocol is cancelled.
For Emergency Dispense and Hemorrhage Protocol
  • If uncrossmatched blood was dispensed, Blood Bank completes the type and screen (if needed) and the crossmatch(es) ASAP. Any positive or unexpected results are immediately called to the MD or contact person.
  • Sends with blood products the Emergency Blood Release Waiver form to the emergency site for the ordering physician to sign when crisis subsides โ€” ensures form is signed and returned.
  • Reconciles all blood components issued to ensure they are dispensed in the Blood Bank's computer, and that HC orders have been placed.
5. On-Site Lab Supervisor
  • Ensures the policy and procedures are followed.
  • Ensures adequate staffing in the Blood Bank while protocol is in effect.
  • Provides assistance as needed.
  • Updates the Blood Bank director of the protocol status as needed.
  • Examines the process after the Emergency or Hemorrhage protocol to determine if all procedures were followed and if there are ways to improve the process.
๐Ÿ“ Attachment 1 โ€” Emergency Release / Hemorrhage Protocol Form
FONTANA / ONTARIO MEDICAL CENTER ยท Policy NS.LD-F.C.2392 ยท Worksheet โ€” not a permanent part of the medical record
Process
  1. CALL THE BLOOD BANK โ€” OMC ext. 42984 ยท FMC ext. 28080
  2. Say "this is (your name) from Labor & Delivery, Emergency Department, OR, etcโ€ฆ the Emergency Release / Hemorrhage Protocol is in effect on (patient name and MRN #). Please use extension ___ (your extension) for call back information."
  3. Verbalize the type of product, and number of units to be released.
  4. Complete this form and take with you to blood bank โ€” acts as order/release in an emergency.
  5. Blood bank starts release process at phone call; blood ready for pickup within 10 minutes.
โ˜ Emergency Release
Packed Red Blood Cells: ____ units
Platelets: ____ units
Fresh Frozen Plasma: ____ units
โ˜ Hemorrhage Protocol
Packed Red Blood Cells: 4 units
Fresh Frozen Plasma: 4 units
Platelets Pheresis Component: 1
Note: Blood bank will determine the appropriate type of blood for the patient โ€” either Type O or Type compatible. Form requires Ordering Physician and RN signatures.
๐Ÿ“Ž Attachments / References
  • Attachment 1: Emergency Release / Hemorrhage Protocol Form (transcribed above)
  • Attachment 2: Emergency Blood Release / Waiver Form โ€” Fontana Medical Center
  • Attachment 3: Emergency Blood Release / Waiver Form โ€” Ontario Medical Center
Accountable: Transfusion Committee ยท SMEs: Registered Nurses, Medical Staff, Blood Bank, Emergency Medicine
Open Original Document
Word ยท Office Online
๐Ÿ“ Emergency Hemorrhage Protocol โ€” Source Document
Open in Word โ†—
Bloodborne Pathogen Post-Exposure Protocol
Employee Health ยท Occupational Medicine ยท Kaiser Fontana / Ontario
๐Ÿฉธ Post-Exposure
โš ๏ธ Treatment must be administered within 2 hours of exposure. Wash affected area for 15 minutes ยท Notify supervisor ยท Report to KOJ or ED immediately
๐Ÿ“‹ BBP Exposure Algorithm โ€” What Next?

๐Ÿ‘ค Injured Employee

  1. Immediately wash affected area for 15 minutes. If eyes exposed, use eye-wash station or saline flush.
  2. Notify supervisor or manager of the injury.
  3. Immediately report to Kaiser on the Job (KOJ) Monโ€“Fri 8:30 am โ€“ 5:30 pm or the Emergency Department. Treatment must be administered within 2 hours of exposure.
  4. Return completed BBP Exposure Report and DWC-1 form to direct supervisor or DA on duty.
  5. Follow up with Employee Health (909) 427-7060. Completed BBP Exposure Report must be returned to Employee Health within 48 hours.

๐Ÿฉบ Medical Provider

  1. MD orders appropriate labs (see BBP forms).
  2. Evaluates injured employee. Order appropriate prescriptions (call in Rx on stat Rx line).
  3. Completes MD portion of BBP Exposure Report. Returns report to employee.

๐Ÿง‘โ€๐Ÿ’ผ Manager / DA

  1. With the injured employee, complete the top portion of the BBP Exposure Report. Form must accompany the employee to the provider. Include device type, manufacturer, and body part exposed.
  2. Send the employee to the appropriate treatment location (KOJ or ED) immediately. Give employee the DWC-1 form.
  3. Inform source patient of incident and need for blood testing. Once consent received, arrange blood testing on source patient โ€” order by MD immediately.
  4. Email source patient information to Employee Health: Teresa.X.Gwinn@kp.org or Sherri.L.Fuchs@kp.org.
  5. Complete the Supervisor's Report of Injury (SRI) within 24 hours. Fax or email all completed forms to Employee Health and Sedgwick.
๐Ÿ“ Where to Report โ€” Treatment Locations
FMCFontana KOJ โ€” Occupational Medicine
MOB-3 Basement
Office hours: 8:30 am โ€“ 5:00 pm
(909) 427-3917
FMCFontana Emergency Dept
Located in Main Hospital
After 5 pm: Report to triage nurse โ€” triage nurse will notify the MD.
OMCOntario KOJ โ€” Occupational Medicine
MOB-A: Check in at the front desk on the first floor.
Occupational Medicine: 4th floor, Suite 404
Office hours: 8:30 am โ€“ 5:00 pm (closed for lunch 12:10โ€“1:10 pm)
(909) 724-2332 ยท if no answer call (909) 427-3917
OMCOntario Emergency Department
Located in Main Hospital, First floor.
After hours (5 pm โ€“ 8:30 am): Inform triage nurse of BBP exposure โ€” triage nurse will notify the MD. May call ED Charge Nurse in advance: (909) 724-5860.
Reminder: Employees should be seen within 2 hours of exposure in the ER by an MD in case PEP is indicated.
๐Ÿงช Lab Orders โ€” Source Patient & Health Care Worker

Source Patient Labs

HBsAG HepC Rapid HIV
Inform source patient immediately and request permission for lab draw. If unable to discuss, may add lab order to blood already drawn.
Who may order: MD at time of incident; Nurse Manager / Charge may contact the patient. Contact source PCP or Attending to request lab order.

Health Care Worker Labs

HBsAb HIV HepC
PEP: The MD will evaluate risk of exposure, educate staff, and determine if prophylaxis is warranted. Provider completes the BBP report and sends to Employee Health.
Non-medical departments (lab, environmental services, diagnostic imaging): notify the manager of the department or charge nurse where the incident occurred immediately. Also inform the HCW manager.
Be sure to complete required BBP form fields and a callback number. Indicate type of sharps and manufacturer โ€” vital for the regional data log. Employee Health will contact the HCW to review labs once available and inform if further follow-up is needed. The source patient's PCP should report lab results to the patient.
๐Ÿ“Š Estimated Per-Act Risk for HIV Acquisition
Exposure routeRisk per 10,000 exposures
(infected source)
Blood transfusion9,000
Needle-sharing injection-drug use67
Percutaneous needle stick30
Mucous membrane exposure9
Source: HCW Information Sheet โ€” Fontana / Ontario Occupational Exposure
๐Ÿ“ž HCW Follow-Up & While Waiting for Lab Results

Follow-Up Instructions

  1. Call Employee Health โ€” Teresa Gwinn @ tie line 8-250-7060 or Sherri Fuchs @ tie line 8-250-6057 for lab results before running out of medications.
  2. Call Employee Health if you develop: fatigue, lightheadedness or dizziness, abdominal discomfort, vomiting, yellowing skin or eyes, dark urine, or muscle aches.

While Waiting for Lab Results

  • Take medications as prescribed (if medications given).
  • Practice safe sex.
  • Do not breastfeed.
  • Do not share toothbrushes, razors, or other devices that could be contaminated with blood.
โ˜Ž๏ธ Key Contacts
Employee Health (FMC & OMC)
(909) 427-7060
Fax: (909) 427-4240
Kaiser on the Job (KOJ)
(909) 427-3917 โ€” FMC & OMC
Environmental Health & Safety / Workplace Safety
(909) 427-7300
Christine Petrovick โ€” Injury Prevention Coordinator
Employee Health ยท MOB2 Basement
(909) 427-6057
Kaiser Fontana: (909) 427-4191
HIV PEP Information
Dr. M. Perez โ€” (909) 427-4198
Source: Kaiser Permanente โ€” Bloodborne Pathogen Post Exposure Protocol ยท Southern California Permanente Medical Group ยท Kaiser Foundation Hospital ยท Fontana / Ontario ยท Employee Health
Last Hour Assignment Protocol
Emergency Medicine ยท Operations
โš™๏ธ Operations
Open Document
Word ยท Office Online
๐Ÿ“ Last Hour Assignment Protocol
Open in Word โ†—
FMC Shift PSG Assignments
Fontana Medical Center ยท ED Operations ยท Patient Scoring Guide
โš™๏ธ Operations Reference
Hour-by-hour point assignments by shift block. Each cell shows the PSG point value a provider should take for new patients starting at that hour. Values taper from 3 (start of shift) down to 1, then to X (no new patients / wrap-up).
3 / 2 / 1 โ€” points to pick up at that hour 1* โ€” any ESI level, longest waiting X โ€” no new patients
๐Ÿ“‹ Standard Shift Blocks
5aโ€“3p
HourPts
05:003
06:002
07:002
08:002
09:002
10:002
11:001
12:001*
13:00X
14:00X
*Any ESI level, longest waiting
6aโ€“4p
HourPts
06:003
07:002
08:002
09:002
10:002
11:002
12:001
13:001*
14:00X
15:00X
*Any ESI level, longest waiting
12pโ€“10p
HourPts
12:003
13:002
14:002
15:002
16:002
17:002
18:001
19:001*
20:00X
21:00X
*Any ESI level, longest waiting
1pโ€“11p
HourPts
13:003
14:002
15:002
16:002
17:002
18:002
19:001
20:001*
21:00X
22:00X
*Any ESI level, longest waiting
2pโ€“12a
HourPts
14:003
15:002
16:002
17:002
18:002
19:002
20:001
21:001*
22:00X
23:00X
*Any ESI level, longest waiting
8pโ€“8a
HourPts
20:003
21:002
22:002
23:002
00:002
01:002
02:002
03:001
04:001
05:001*
06:00X
07:00X
*Any ESI level, longest waiting
9pโ€“7a
HourPts
21:003
22:002
23:002
00:002
01:002
02:002
03:001
04:001*
05:00X
06:00X
*Any ESI level, longest waiting
10pโ€“8a
HourPts
22:003
23:002
00:002
01:002
02:002
03:002
04:001
05:001*
06:00X
07:00X
*Any ESI level, longest waiting
๐Ÿฅ Mod Pod Shifts
8aโ€“8p Mod Pod
HourPts
08:003
09:002
10:002
11:002
12:002
13:002
14:002
15:002
16:002
17:001*
18:00X
19:00X
*Any ESI level, longest waiting
1pโ€“1a Mod Pod
HourPts
13:003
14:002
15:002
16:002
17:002
18:002
19:002
20:002
21:002
22:001*
23:00X
00:00X
*Any ESI level, longest waiting
6pโ€“6a Mod Pod
HourPts
18:003
19:002
20:002
21:002
22:002
23:002
00:002
01:002
02:002
03:001*
04:00X
05:00X
*Any ESI level, longest waiting
๐Ÿ“‹ Alternate Sheet โ€” Shift Point Assignments
Same schedule using 3-digit hour notation (e.g. 500 = 5:00, 1400 = 14:00).
5aโ€“3p
HourPts
5003
6002
7002
8002
9002
10002
11001
12001*
1300x
1400x
*Any ESI lvl, longest waiting
6aโ€“4p
HourPts
6003
7002
8002
9002
10002
11002
12001
13001*
1400x
1500x
*Any ESI lvl, longest waiting
8aโ€“8p
HourPts
8003
9002
10002
11002
12002
13002
14002
15001
16001
17001*
1800x
1900x
*Any ESI lvl, longest waiting
10aโ€“10p
HourPts
10003
11002
12002
13002
14002
15002
16002
17001
18001
19001*
2000x
2100x
*Any ESI lvl, longest waiting
12pโ€“12a
HourPts
12003
13002
14002
15002
16002
17002
18002
19001
20001
21001*
2200x
2300x
*Any ESI lvl, longest waiting
3pโ€“1a
HourPts
15003
16002
17002
18002
19002
20002
21001
22001*
2300x
2400x
*Any ESI lvl, longest waiting
4pโ€“2a
HourPts
16003
17002
18002
19002
20002
21002
22001
23001*
2400x
100x
*Any ESI lvl, longest waiting
8pโ€“8a (1/2)
HourPts
20003
21002
22002
23002
24002
1002
2002
3001
4001
5001*
600x
700x
*Any ESI lvl, longest waiting
10pโ€“8a
HourPts
22003
23002
24002
1002
2002
3002
4001
5001*
600x
700x
*Any ESI lvl, longest waiting
Mod Pod 3pโ€“3a
HourPts
15003
16002
17002
18002
19002
20002
21002
22002
23002
24001*
100x
200x
*Any ESI lvl, longest waiting
Rx Sign-Out Workflow
Emergency Medicine ยท Pharmacy
โš™๏ธ Workflow
Open Presentation
PowerPoint ยท Office Online
๐Ÿ“Š Rx Sign-Out Workflow
Open in PowerPoint โ†—
Inbasket Abnormal Results Workflow
Emergency Medicine ยท Operations
โš™๏ธ Workflow
Open Document
Word ยท Office Online
๐Ÿ“ Inbasket Abnormal Results Workflow v3
Open in Word โ†—
Radiology Safety Net Process
Emergency Medicine ยท Radiology
โš™๏ธ Workflow
Open Document
Word ยท Office Online
๐Ÿ“ Radiology Safety Net Process v5
Open in Word โ†—
ED Radiology โ€” Epic Downtime
Emergency Medicine ยท Radiology
โš™๏ธ Workflow
Open Document
Word ยท Office Online
๐Ÿ“ ED Radiology Epic Downtime
Open in Word โ†—
Overnight IR Procedures
Emergency Medicine ยท Interventional Radiology ยท FMC & OMC
โš™๏ธ Workflow
While IR is available 24/7, for those non-emergent cases that arise in the middle of the night that can be done the next day, please have the ED physician place the order and call and leave a message for the IR charge RN (include the patient's name and MR#). The charge RNs arrive early in the morning and can begin working on scheduling.
๐Ÿ“ž IR Charge RN Extensions
Fontana (FMC)
#24044
Ontario (OMC)
#45210
โœ… ED Physician Steps
  1. Place the order in the chart.
  2. Call and leave a voicemail for the IR charge RN at the appropriate site extension above.
  3. Include the patient's name and MR# in the message.
MD-RN Communication Strategy (FMC)
Emergency Medicine ยท Nursing ยท FMC
๐Ÿ’ฌ Communication
Open Document
Word ยท Office Online
๐Ÿ“ MD-RN Communication Strategy โ€” FMC
Open in Word โ†—
FMC/OMC ED Operations
Emergency Medicine ยท Operations ยท FMC & OMC
โš™๏ธ Operations
Open Document
Word ยท Office Online
๐Ÿ“ Fontana/Ontario Emergency Department Operations
Open in Word โ†—
FMC Throughput Changes โ€” Phase 1
Emergency Medicine ยท Operations ยท FMC
โš™๏ธ Throughput
Open Document
Word ยท Office Online
๐Ÿ“ FMC Throughput Changes โ€” Phase 1
Open in Word โ†—
FMC Throughput Changes โ€” Phase 2
Emergency Medicine ยท Operations ยท FMC
โš™๏ธ Throughput
Open Document
Word ยท Office Online
๐Ÿ“ FMC Throughput Changes โ€” Phase 2
Open in Word โ†—
Fluorescein Strip Replacement โ€” OMC Drops
Ontario Medical Center ยท ED Operations ยท Ophthalmic Supplies
๐Ÿ’ง Ops Note
What changed
OMC is replacing fluorescein strips with Altafluor-Benox ophthalmic drops. FMC is mirroring.
Key workflow points
  • Order the drops in HealthConnect โ€” not the strips โ€” so RNs can pull from Pyxis.
  • Drops must be stored in the refrigerator.
  • Each bottle is single-use only โ€” cannot be shared between patients.
  • Altafluor-Benox = fluorescein + benoxinate (topical anesthetic combo).
Source
Chris Sanine / OMC pharmacy ยท Mar 19, 2026 ยท internal ops email
Funduscopic Images โ€” Viewing Workflow
Emergency Medicine ยท Ophthalmology ยท HealthConnect ยท PACS
๐Ÿ“ท Ops Note
What changed
The workflow for viewing fundus camera images after they're sent has changed. Use the steps below to pull images from PACS through HealthConnect.
Steps
  1. In the patient chart, click Chart Review.
  2. Click the Eye tab.
  3. Select the Fundus Photography of Both Eyes test that you ordered.
  4. Below, you'll see PACS Images and Reports and a hyperlink "View images and PDF report" โ€” select it and PACS will open.
Source
Sonya Sandhu ยท Mar 23, 2026 ยท internal workflow email
Kaiser โ†’ Loma Linda Neuro Radiology Process
Emergency Medicine ยท Neurology ยท Radiology
๐Ÿš‘ Transfer Process
Open Document
Word ยท Office Online
๐Ÿ“ Kaiser to Loma Linda Neuro Radiology Process
Open in Word โ†—
Fontana Regional Neonatal Transport Service
Emergency Medicine ยท Pediatrics ยท NICU ยท FMC
๐Ÿš‘ Transfer Process
Open Document
Word ยท Office Online
๐Ÿ“ Fontana Regional Neonatal Transport Service
Open in Word โ†—
Chaperone Guidelines for Physicians
Emergency Medicine ยท Policy
๐Ÿ“‹ Policy
Download PDF
PDF ยท Direct Download
๐Ÿ“„ Chaperone Guidelines for Physicians
Open PDF โ†—
Documenting Acute Kidney Injury
Emergency Medicine ยท Internal Medicine
๐Ÿฉบ Clinical Reference
Download PDF
PDF ยท Direct Download
๐Ÿ“„ Documenting Acute Kidney Injury โ€” Summary
Open PDF โ†—
Safe Prescribing Guidelines
Emergency Medicine ยท Pharmacy
๐Ÿ’Š Prescribing
Download PDF
PDF ยท Direct Download
๐Ÿ“„ Safe Prescribing Scripting Guidelines
Open PDF โ†—
NEDOCS 2.0
Emergency Medicine ยท Operations
๐Ÿ“Š Crowding Tool
Open Document
Word ยท Office Online
๐Ÿ“ NEDOCS 2.0 โ€” ED Crowding Assessment Tool
Open in Word โ†—
NEDOCS 3.0
Emergency Medicine ยท Operations
๐Ÿ“Š Crowding Tool
Open Document
Word ยท Office Online
๐Ÿ“ NEDOCS 3.0 โ€” ED Crowding Assessment Tool
Open in Word โ†—
NEDOCS โ€” FMC
Emergency Medicine ยท Operations ยท Fontana Medical Center
๐Ÿ“Š FMC Protocol
Open Document
Word ยท Office Online
๐Ÿ“ NEDOCS โ€” Fontana Medical Center
Open in Word โ†—
NEDOCS โ€” OMC
Emergency Medicine ยท Operations ยท Ontario Medical Center
๐Ÿ“Š OMC Protocol
Open Document
Word ยท Office Online
๐Ÿ“ NEDOCS โ€” Ontario Medical Center
Open in Word โ†—
Constipation โ€” Bedside Mixtures
Emergency Medicine ยท GI ยท Bedside Recipe
๐Ÿ’Š Recipe
Brian Bomb (็™ฝไบบ)
  • 60 mL glycerin
  • 133 mL Fleet enema
  • 30 mL docusate
  • 10 mg bisacodyl
Pink Lady
  • 60 mL Fleet enema
  • 100 mL docusate
  • 60 mL mineral oil
  • 60 mL magnesium citrate
Occipital Nerve Block Mixture (3-2-1)
Emergency Medicine ยท Neurology ยท Procedural
๐Ÿ’‰ Procedure Recipe
3 ccLidocaine 1% (without epinephrine)
2 ccMarcaine (bupivacaine) 0.5%
1 ccKenalog 40 mg/mL
Pediatric Multi-System Inflammatory Syndrome (MIS-C)
Pediatrics ยท Emergency Medicine ยท PTAC
๐Ÿ”ด Critical Peds
Consider in any pediatric patient with prolonged fevers, Kawasaki-like features (conjunctivitis, rash, peripheral edema), and GI symptoms (diarrhea, abdominal pain).
โš ๏ธ Cardiogenic Shock Pearls
  • May be hypoxic; if not perfusing, will need a pressor (milrinone or epinephrine โ€” both can run peripherally).
  • In CHF / pulmonary edema โ€” will not respond to IV fluids (will get worse).
  • Antecubital line preferred; a hand 24g is acceptable to begin resuscitation.
๐Ÿงช Recommended Workup (Peds Rheum)
CBC/diff ยท Lytes ยท BUN ยท Creatinine ยท Glucose ยท LFTs ยท Albumin ยท Bagged UA ยท CRP ยท ESR ยท Ferritin ยท Fibrinogen ยท D-dimer ยท Triglycerides ยท LDH ยท Troponin ยท BNP ยท IL-2 receptor
๐Ÿ“ž Disposition
  • Call PTAC immediately for transfer.
  • If unstable, ask to be connected to the Peds Intensivist on call.
  • Request robot evaluation in the ED to assist with resuscitation; PICU attending can guide pressor management via video.
Priapism โ€” Phenylephrine Preparation
Emergency Medicine ยท Urology ยท Procedural
๐ŸŸ  Procedure
Medication Prep โ€” Phenylephrine 1 mg/mL
  1. Using a 3 mL syringe + 18g needle, withdraw and discard 1 mL from a 10 mL vial of 0.9% NaCl.
  2. With the same syringe, withdraw 1 mL of 1% phenylephrine (10 mg/mL) and add it to the remaining 9 mL of NaCl. Final concentration: phenylephrine 1 mg/mL.
  3. Using an insulin syringe, draw up 20 units (0.2 mL) = 200 mcg OR 40 units (0.4 mL) = 400 mcg.
Dr. Lawrence's preference: 1% lidocaine with epinephrine 1:100,000. Draw 100 units (1 mL) in an insulin syringe for the MD.
โš ๏ธ Important
  • Check BP and pulse immediately prior to injection and again 5 minutes after.
  • Inject medication very slowly (over ~1 minute).
  • If patient is hypertensive, consider a different treatment.
๐Ÿงฐ Treatment Supplies
  • Alcohol prep pads (4โ€“6)
  • Phenylephrine 1% 10 mg/mL โ€” 1 vial
  • 0.9% NaCl 10 mL โ€” 1 vial
  • 1% lidocaine w/ epi 1:100,000 (Dr. Lawrence's preference)
  • 3 mL leur-lock syringe (1)
  • 10 mL leur-lock syringe (1)
  • 60 mL leur-lock syringe (1)
  • 18g ร— 1ยฝโ€ณ needle (1)
  • 18g ร— 1.16โ€ณ angiocath (2)
  • 16g angiocath (1)
  • 16g butterfly needle (2)
  • 18g butterfly needle (2)
  • 100-unit insulin syringe (3)
โž• Additional Supplies
  • 1 L bottle normal saline irrigant (ร—2)
  • Large basin for irrigant/clots
  • Sterile gloves (per MD size)
  • Non-sterile gloves
  • Large chux
  • 4ร—4 gauze or kerlex fluff sponges
Peritonsillar Abscess Protocol
Emergency Medicine ยท ENT
๐Ÿ’Š Recipe
  1. Decadron 10 mg IV (or weight-based equivalent)
  2. Rocephin 1โ€“2 g IV
  3. Discharge on oral Augmentin or Clindamycin; PCP follow-up
Stress Tests โ€” PNL Quick Reference
Emergency Medicine ยท Cardiology
๐Ÿซ€ Cardiology
PNL Treadmill
If the patient can exercise.
PNL Lexiscan
If the patient is unable to exercise.
PNL Dobutamine
For asthma patients with active wheezing.