KINGDOM OF SAUDI ARABIA

Ministry Of Higher Education

Najran University Hospital

NAJRAN UNIVERSITY HOSPITAL

INTERNAL POLICY AND PROCEDURE

IPP – DEPARTMENT: Nursing Service ORIGINAL DATE :

Department
NUMBER: IPP-NSO-000 EFFECTIVE DATE :
TITLE : SCHEDULING REVIEW DATE :

1. STATEMENT OF PURPOSE
1.1 To describe the policies and procedures for completing the unit staff schedule and making
changes in the schedule once it is posted and there by ensure patient safety.

2. APPLICABILITY
2.1 This policy applies to all nursing staff on all hospital units.

3. DEFINITIONS

3.1 Scheduling: It's on going implementation off staffing pattern by assigning individual personal
to work specific hours & days in a specific unit or area

4. POLICIES
4.1 STAFFING
The Head Nurse shall be responsible for staff coverage within the assigned unit per twenty-four
hours. Staffing needs for each unit must be projected on a (8*3=24)twenty-four-hour basis.
Emergency shift assignments will be made as needed to provide adequate ward coverage. Other
methods of providing coverage are through use of Per Diem staff and overtime.
Emergency coverage will be made by the Head Nurse/Designee. It will be based on patient needs,
patient appointments, and ward activities. Safety of patients and staff must not be compromised.

4.2 II. SCHEDULING

A. The Head Nurse has the responsibility to schedule staff in such a way as to provide
coverage for the unit, as well as to develop alternative ward staffing plans to be implemented if a
shortage is anticipated or occurs unexpectedly (with unforeseen absences, inclement weather,
etc.). The alternative ward staffing plan may include change of shifts and the use of available
nursing staff from non patient care areas. Scheduling must be even across the week. Days off will
be adjusted so that no weekday is scheduled heavier than any other.

B. Holidays must be scheduled and taken during the month the holiday is assigned by the
office of Personnel.

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C. The Head Nurse will be responsible for submitting each schedule 15 days in advance. The
schedule will be posted two weeks in advance.

D. Core shifts are morning shift- 8:00am to 4:00 pm, evening shift- 4:00 pm to 12:00 mid night
and night shift -12:00 mid night to 8:00 am, for ICU, ER and Surgical ward.
For OPD and OR morning shift- 8:00am to 4:00 pm.
12 Hours duty: morning shift- 8:00am to 8:00 pm, evening shift- 8:00 pm to 8:00 am.
Special shift hours must be approved by the Director of Nursing and indicated on the schedule.

E. All schedules will include shift, employee’s last then first name, specific classification to
include HN,CN,SN etc., Head Nurse and Charge Nurse designation in that order. It will also include
holiday, personal leave, emergency leave days used and scheduled classes before being submitted.
Schedules will also include totals for each shift of the total number of staff on duty (in that order).

F. Schedules shall not be submitted with less than minimum staffing on each shift unless all
efforts to cover have been made to include changing shifts and reassigning staff.
G. When scheduling individuals for classes and meetings, indicate whether they are AM or PM
or the entire shift by drawing a line to divide the block. Then place the code in the appropriate half
of the block. If a class is the entire shift, place the code in the entire block. Note the time of the the
schedule. All classes will be indicated by the following scheduling codes, and specific titles of
classes, meetings at the bottom of schedule with date and time:
1. Mandatory Inservice
a. CPR
b. Fire Orientation
c. Infection Control
d. Prevention and Management of Aggressive Behavior
e. Claires Pharmarnlngy
f. Patients Rights
g. Other (Specify)

Continuing Education/Inservice Training

All on grounds non-mandatory workshops, Inservice Training, and classes other than educational
leave. (Specify)

3. Outservice Training
All off-grounds workshops and classes other than educational leave. (Specify)

4. Special Meetings
a. Nursing Leadership Council
b. Discipline Group Meeting (Specify)
c. Committee Meetings (Specify)
d. Other (Specify)

5. Education Leave
Work-study: A program that provides the opportunity to work twenty (20) hours a week and be
released from duty the other 20 hours to attend school as a full-time student Release Time: A
program that provides the opportunity to attend school

for up to six (6) hours per week for courses that are not offered during the employees off duty

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time. This is approved only for work related classes/seminars.

H. Weekend coverage:
1. Weekend days are defined as Friday and Saturday for the day and evening shifts. Friday
and Saturday or Saturday and Sunday for the night shift, based upon the unit staffing needs.
For OPD,OR and NSO staff can take week end off. Remaining staffs take off after working 5 days or
3 working day can take one off then work 2 days can take 1 day off as per HN/CN/nursing
supervisor decision or according to patient service need.

2. Head Nurses are scheduled off three weekends in a 28-day schedule and work one
weekend in a 28-day schedule. Head Nurses work half of the major holidays and may be scheduled
to provide staffing coverage in their unit or in the Nursing service Office as determined by the
nursing supervisor or DON. Head Nurses are required to work one off shift per schedule in order to
meet with the shift staff to address issues, concerns and supervise off shift activities.

3. All staff (to include per diem staff) will be scheduled to work every other weekend or two
weekends per schedule.

4. To facilitate a request for additional weekend, leave the employee may trade off days with a
staff member of the same classification, by providing a memo of the proposal with both parties
signature to the Head Nurse.

III. SCHEDULE CHANGES

Scheduled changes must be submitted 5 business days in advance to the respective nursing
supervisor for consideration of approval.
A. After the projected schedule has been submitted by the Head Nurse, changes should be
minimal. Request for schedule changes in the posted schedule should be minimal and only be
submitted for doctor’s appointments, within the designated work week, court appointments, jury
duty, even exchange of days among staff of same classification and/or for unforeseen events.

B. Requests for schedule changes must be submitted to the Head Nurse in writing for
approval.
1. The Head Nurse must receive approval from NS/DON and then make the changes on the
unit schedule and initial each change.
2. The NSO Nurse Supervisor or DON will make the approved changes on the NSO schedule
and initial each change.

C. No changes should be requested which take the staffing below minimum, or which result in
the use of overtime or pulling.

D. Requested changes should not conflict with regularly scheduled ward activities.

E. Two nursing personnel of the same classification may exchange days by providing a memo
of the proposal with both parties signatures to the Head Nurse.

F. Nursing Administration Office schedule is the official correct schedule.

G. Head Nurses will be held accountable for all inaccuracies in the schedule. Discrepancy

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forms will be initiated by NSO and sent to the Head Nurse and ADON.

H. The DON/ADON must review all schedules to assure that all criteria have been met and
initial the top of each schedule before it’s posted on the unit.
I. In the event that a nurse who is schedule for duty is absent or on sick leave,emergency
leave, a reliver must be arrange by the HN/NS. Nurse who going for sick leave or emergency leave
must inform to the HN/NS 2 hours before her/his duty.

In cases wherein, the staff is absent without notyfying the HN/NS must take disciplinary action to
the subject.
On call nurse schedule also preper by the HN/NS.

4.4 OVERTIME GUIDELINES

Overtime is any time in a worked in a week which exceeds the schedules 48 hours.
Over time will be closely monitored and controlled by HN/NS/ADON/DON. In case of sever
shortage of manpower, over time must approved by hospital leaders hospital director or medical
director through NSO.
Over time may be paid back in terms of extra days off in case financial remuneration is not
applicable/approved.

SHIFT DUTY:
All Shift duty staff must do MORNING DUTY: 7_ 8 days, EVENING DUTY: 7-8 days and NIGHT DUTY:
5-7 days (according to patient service need and shortage of staff it may be increase) per month

5. RESPONSIBILITIES
HEAD NURSE AND NURSING SUPERVISOR: for make schedule as per patient need and
staff availability.
ASSISTANT DIRECTOR OF NURSING: review the schedule
DIRECTOR OF NURSING: for approval the schedule

6. PROCEDURES
6.1 head nurse prepar the monthly schedule based on the policy.
6.2 .
6.3 Set up the O2 delivery system that will be utilized post-extubation. If no specific order has
been written for post extubation O2 the RCP will initiate oxygen utilizing an aerosol
mask or cannula system at a FiO2 estimated to be 10% higher than the pre-
extubation level while monitoring O2 saturation.
6.4 Explain the procedure to the patient. You should also instruct the patient as to the
importance of deep breathing, coughing, and about any systems that will be applied post
extubations such as the O2 delivery device or incentive spirometer.
6.5 The ICU Nurse will document the following parameters on the ventilator flow sheet
as part of the pre and post extubation assessment:
6.5.1 O2 saturation
6.5.2 Heart rate

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 6.5.3 f/Vt or respiratory rate
6.5.4 Respiratory pattern
6.5.5 Breath sounds
6.6 Ensure a functioning bag-mask system with patient label is connected to a flow meter is
ready at the bedside for use if needed.
6.7 Hyperoxygenate the patients at 100% for at least 60 seconds.
6.8 Prepare suction equipment as per suction procedure and suction below then thoroughly
above cuff.
6.9 Remove tape from patient’s face while holding ETT in place.
6.10 Utilize a new suction catheter and insert the catheter just beyond the distal tip of the ET
tube.
6.11 Apply suction while totally deflating the ET cuff. The patient will likely be stimulated to
cough at which time the ET tube as a unit with the suction catheter should be
withdrawn while applying suction. The clinician that is deflating the cuff should pull the
tube as they will have a better perspective of when the air is totally evacuated from the
cuff.
6.12 If possible the ET should be pulled out at the point of end inspiration followed by
coached coughing to clear secretions.
6.13. The ability of the patient to maintain a patent airway should be immediately
assessed and
adverse findings reported to the physician. The ICU Nurse will specifically:
6.13.1 Look, listen, and feel for air movement.

6.13.2 Auscultate for the presence of stridor.

6.13.3 Assess vital signs and work of breathing. (i.e. paradoxical, agonal)
6.13.4 Observe for retractions in which the diaphragm moves down and chest wall
and/or intercostals spaces move in.
6.13.5 Be receptive to patient’s complaints.
6.13.6 If the post extubation saturation falls below 92%, or the saturation limit
specified by the physician, notify the physician.

6.14 The ICU Nurse will document the following on the ventilator flow sheet and in
Respiratory care treatment sheet:
6.14.1 Procedure
6.14.2 Airway assessment
6.14.3 O2 delivery system
6.15 Notify ICU Physician if the following changes occur DURING or AFTER the procedure:
6.15.1 Changes in Oz saturation
6.15.2 Heart rate
6.15.3 Respiratory rate of greater than 10%
6.15.4 Presence of a change in respiratory pattern or breath sounds (i.e. stridor,

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 wheezing, etc.)
6.16 Extubation is best accomplished with ICU Physician, Nurse and respiratory technician at
the bedside. The patient's nurse should be present.
6.17 In emergent situations in which the ICU Nurse is unable to adequately ventilate a
patient through the ET (tube obstruction or significant air leak), and the ICU Nurse
foresees imminent respiratory/cardiac arrest, the ICU Physician should be notified
immediately.

7. MATERIALS AND EQUIPMENTS

7.1. Intubation equipments
7.2. Mechanical ventilator
7.3. Cardiac monitor
7.4. Nebulizer
7.5. Ambubag

7. REVIEW
This IPP entitled Extubation and numbered IPP-ICU-022 , has been written by:

ASWATHY C.G.
ICU HN

Reviewed by:

DR. SALEM FARAG DR. ABDULLAH SHWAIL

ICU CONSULTANT ICU DIRECTOR

8. APPROVALS :
This This IPP, entitled Extubation and numbered IPP-ICU-022, is approved effective 28-10-2019 and
shall be included in the Policies and Procedures Manual of Najran University Hospital, and shall
be reviewed every 2 years.

DR. HASSAN ALSHAMRANI

TQM DIRECTOR

DR. AWAD AL SHAHRANI

HOSPITAL DIRECTOR

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9. REFERENCES

9.1 American Association of Respiratory Care, AARC Clinical Practice Guideline-

Endotracheal Suctioning of Mechanically Ventilated patients with Artificial Airways
http://www.rcjournal.com/online_resources/cpgs/cpg_index.asp

9.2 American Association of Respiratory Care, AARC Clinical Practice GuidelineRemoval of the
Endotracheal Tube. http://www.rcjournal.com/online_resources/cpgs/cpg_index.asp
9.3 Egan’s Fundamentals of Respiratory Care Scanlon, Spearman and Sheldon, 8th edition,
Mosby publishing, pgs 612-14.

10. ATTACHMENTS

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