General Acute Inpatient Care Unit

217 Pages·2012·7.64 MB·English

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GOBIERNO MINISTERIO
DE ESPAÑA DE SANIDAD, POLÍTICA SOCIAL I REPORTS, STUDIES AND RESEARCH 2011
E IGUALDAD
www.mspsi.gob.es MINISTRY OF HEALTH, SOCIAL POLICY AND EQUALITY
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General Acute

Inpatient Care Unit

Standards and
Recommendations
on Quality and Safety
REPORTS, STUDIES AND RESEARCH 2011
MINISTRY OF HEALTH, SOCIAL POLICY AND EQUALITY
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Edita y distribuye:
© MINISTRY OF HEALTH, SOCIAL POLICY AND EQUALITY
CENTRO DE PUBLICACIONES
PASEO DEL PRADO, 18. 28014 Madrid
NIPO en línea: 860-11-226-0
Catálogo general de publicaciones oficiales
http://publicacionesoficiales.boe.es/
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General Acute

Inpatient Care Unit

Standards and
Recommendations
on Quality and Safety
GOBIERNO MINISTERIO
DE ESPAÑA DE SANIDAD, POLÍTICA SOCIAL
E IGUALDAD
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List of people involved in compiling
the Standards and Recommendations
document on quality and safety in hospital
units: general acute inpatient care units
Management and Coordination
- Inés Palanca Sánchez, Office of Planning and Quality, Quality Agency of
the SNHS, Ministry for Health, Social Policy and Equality, Management
and Technical and Institutional Coordination
- Javier Elola Somoza, Technical Management Board, Elola Consulto­
res S. L.
- Luisa González Cabezas, Scientific Coordinator, Head of the Training
Unit, Catalan Institute of Health, Barcelona
Editing Committee
- Yolanda Agra Valera, Office of Planning and Quality, Quality Agency of
the SNHS, Ministry for Health, Social Policy and Equality
- José Luis Bernal Sobrino, EC Consultoría y Gestión en Sanidad S.L.
- Javier Elola Somoza, Elola Consultores S.L.
- Beatriz Gómez González, Office of Planning and Quality, Quality Agency
of the SNHS, Ministry for Health, Social Policy and Equality
- Luisa González Cabezas, Head of Training Unit, Catalan Institute of
Health, Barcelona
- Inés Palanca Sánchez, Office of Planning and Quality, Quality Agency of
the SNHS, Ministry for Health, Social Policy and Equality
- Dr José León Paniagua Caparrós, architect
Panel of experts
- Luisa González Cabezas, Head of Training Unit, Catalan Institute of
Health, Barcelona
- María del Carmen de la Cruz, Chair of the Spanish Association for
Surgical Nursing, Nursing Supervisor, Functional Area: Outpatient
Consultation/Specialist Centre, Móstoles University Hospital
- Magdalena Díaz Benavente, Supervisor, Clinical Holistic Healthcare
Management Unit, Virgen del Rocío University Hospitals, Seville
- Ana Giménez Maroto, Service Head, Nursing Unit, Professional Regula­
tion, Ministry for Health, Social Policy and Equality
GENERAL ACUTE INPATIENT CARE UNIT 7
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- Elena Martín Pérez, Deputy Secretary of the Spanish Association of
Surgeons, Section Head, Princesa University Hospital
- Dr José León Paniagua Caparrós, architect
- Inmaculada Pérez Castro, Care Coordinator, Liver Surgery Unit, Hospital
Clínic of Barcelona
- Sara Pupato Ferrari, Head of INGESA, Ministry for Health, Social Policy
and Equality
- Asunción Ruiz de la Sierra Martín-Gil, INGESA, Ministry for Health
Social Policy
- Toni Trilla, Quality Coordinator, Hospital Clínic of Barcelona
- Antonio Zapatero Gaviria, Spanish Society for Internal Medicine, Head
of Internal Medicine Unit, Fuenlabrada University Hospital, Madrid
Support
- Alberto Segura Fernández-Escribano, Office of Healthcare Planning and
Quality, Quality Agency of the SNHS, MHSPE
- José de Arriba Enríquez, Office of Healthcare Planning and Quality,
Quality Agency of the SNHS, MHSPE: Publishing Coordinator
- María José Ruiz, EC Consultoría y Gestión en Sanidad S.L.
8 REPORTS, STUDIES AND RESEARCH
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Contents
Executive summary 13

1. Introduction 23

1.1. The aim of this document 25

1.2. Working methods 26

2. The current situation 29

2.1. Stadards and recomendations for GAICUs in Spain 32

2.2. Experience in spain and abroad 35

3. Patients’ rights and guarantees 43

3.1. Information for patients, informed consent 43

3.2. Care for carers 45

3.3. Guarantees of patients’ rights 46

4. Patient safety 49

4.1. Culture of safety 53

4.2. Daily visits to the unit 55

4.3. Communication during patient transfer 55

4.4. Safe drug use 56

4.5. Preventing pressure sores 60

4.6. Fall prevention and injury reduction 61

4.7. Preventing infection 63

4.8. Patient identification 63

4.9. Managing blood products 64

4.10. Epidemiology alert 64

4.11. Involving patients in their own safety 64

4.12. Self-protection plan 65

5. Organisation and management 67

5.1. Admission criteria 68

5.2. Service portfolio 69

5.3. The patient care process in GAICUs 70

5.4. Relationships with other units 78

5.5. GAICU organisation and operation 80

5.6. Patient management 82

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6. Layout and material resources 87

6.1. Functional design 91

6.2. Medical supplies and sterilising 122

6.3. Preventing and controlling contagious diseases 122

6,4. Cleanliness protocol 123

6.5. Hospital waste management 123

7. Human resources 125

7.1. Register of medical staff 125

7.2. Personal files 125

7.3. Posts and duties 125

7.4. Identifying and distinguishing between staff members 127

7.5. Documentation 128

7.6. Ongoing training 128

7.7. Criteria for calculating resources needed 128

8. Quality 133

8.1. Authorisation and registration 133

8.2. Accreditation and auditing 133

8.3. Quality indicators 133

9. Revision and follow-up. Criteria for GAICU standards and recom­
mendations 143

10. Appendices 145

1. Accreditation criteria for acute care hospitals in Catalonia affecting

hospital admission 145

2. Regulations for caring for patients with contagious diseases:

Types of precaution 149

3. Specimen drug reconciliation form 153

4. Levels of care 155

5. Protocol for assessing suitability of admission 157

6. Clinical pathway for time spent in a GAICU 161

7. Modified early warning system 169

8. Hospital discharge plan 171

9. GAICU sizing criteria 181

10. Functional design of GAICU sections 185

11. Professional framework for the post of nursing supervisor 189

12. Recommendations for GAICU nursing staff levels 195

10 REPORTS, STUDIES AND RESEARCH